"Let's play with the blocks together." Child: "Okay."  Peer Mediated Peer: "Do you want to build a tower with me?" Child: "Yes."  Peer Initiated Peer: "Look at the castle I made. Want to help me add a moat?" Child: "Sure!"  Adult Facilitated Adult: "Jake likes trains. Do you want to show him your train?" Child: "Here is my train." Peer: "Cool train!"  Child Directed

1. Engaging Autism: Considerations for underserved,
under-represented and under-resourced
Connie
Kasari,
PhD
University
of
California,
Los
Angeles
ASF Science and Sandwiches
December 6, 2012
AIR-B --Autism Intervention
Research Network for
Behavioral Health

2. UCLA Kasari Lab Intervention Studies
 Targeted
Interventions
 Core
deficits
(beyond
dose
and
approach)
 Underserved,
under-­‐represented
 Infants,
toddlers
 Minimally
verbal
 School
aged,
included
in
general
education
 Under-­‐resourced
 Community
based
 Schools
are
where
all
children
can
be
found

3. Engagement
as
Critical
Intervention
Target
 Young
children:
focus
on
joint
attention,
play,
engagement
with
parents
(the
core
de?icits)
 Look
to
behavioral
signs
of
engagement
 Shared
attention
and
affect
 Joint
attention
 Social
play
with
others
 Conversation

4. Targeted
Intervention
Approach
to
Address
Problems
of
Engagement
 To
affect
engagement,
intervention
needs
to
be
targeted,
dense
and
long
term
 The
targets
of
intervention
change
with
development,
and
with
amount
of
impairment
in
individual
children
 Debate
in
the
field
as
to
how
much
direct
teaching
versus
naturalistic
methods
should
be
used

5. JASPER
Joint
Attention,
Symbolic
Play,
Engagement,
Regulation
Joint Attention Initiations:
-Point to share
-Show #
-Symbolic Play

6. Change
in
proximal
outcomes:
Joint
attention
and
play
Joint Attention Initiations
Play Level

7. Why
are
these
targets
important?
They
predict
to
distal
language
outcomes
Follow
up
1
year
later:
JA
and
SP
Follow
up
for
Low
Language
Group:
groups
better
language
JA
group
best
outcomes
Kasari, Paparella, Freeman & Jahromi , 2008, JCCP

8. Pay
off
from
early
focus
on
joint
attention/
joint
engagement
 Follow
up
of
children
in
original
study,
5
years
later
 40
out
of
the
58
children
 32
became
verbal
and
8
minimally
verbal
 Predicting
Expressive
Language:
 Treatment
group
 CA
 IJA
 Play
Level
 Expressive
Language
 DQ
 Gender

9. Pay
off
from
early
focus
on
joint
attention/
joint
engagement
9
 Follow
up
of
children
in
original
study,
5
years
later
 40
out
of
the
58
children
 32
became
verbal
and
8
minimally
verbal
 Predicting
Expressive
Language:
 Treatment
group
 CA
 Initiates
joint
attention
 Play
Level
 Expressive
Language
 DQ
 Gender
Kasari, Gulsrud, Freeman, Paparella,
Hellemann, 2012, JAACAP

10. What
did
we
learn
from
this
study?
 Active
ingredient
to
early
intervention
is
a
focus
on
early
developing
core
de?icits
 Joint
attention
 Play
 Results
suggest
the
mechanism
is
likely
engagement
as
JA
and
SP
interventions
led
to
similar
outcome
 Suggestion
that
APPROACH
also
matters-­‐-­‐-­‐the
fusion
of
developmental
and
behavioral
approaches
JASPER

11. Difference
between
preverbal
and
nonverbal
children
 Most
young
children
are
preverbal…..we
can
get
them
to
talk
 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

12. Access
to
Communication
Important
JASPER-­‐EMT
studies
Boy 5 ½ years; No words or
sounds

13. School
aged
Studies:
What
is
the
Issue?
 For children with ASD:
 More issues about social inclusion/acceptance than academic
support for some children
 Others---issues about intervention in general—minimally
verbal, low verbal, learning
 Level of support needed (or if it is needed)
 1:1 assistant?
 Concerns mostly about feeling connected, belonging for
ASD
 Intervention for ASD---or for those around ASD?

14. UCLA
School
aged
Studies:
Children
have
different
views
about
friends,
relationships
 Important to ask children
 Gives you window into their world
 Provides clues as to what is needed for intervention, and
if intervention is needed

17. Information
gained
from
asking
 How
connected
child
is
to
other
children
in
the
class
 How
popular
(salient)
the
peer
group
is
 If
children
they
nominate
as
best
friends
nominate
them
back
(reciprocity)
 How
many
children
they
nominate
as
friends
 How
many
children
nominate
them
as
a
friend

18. Charlotte (8)
4.5 Erick (6)
Luke (5)
Cori (7) 7.5
Adam (3)
Len (7)
Olive (9)
8
Alex (4)
Ellen (7) 5.5 Leah (4)
Stan (4) Nancy (2)
Thomas (4)
2 Miguel (4)
5 Gerry (6)
Maggie (3) Nora (1)
Alejandro (4)
Lonnie (2)
Isolate: Nick (3), Noel (4)

19. Connection to Social Groups at School—
few children with ASD are isolated!
 First
to
Fifth
Graders
(n=60
ASD;
matched
TYP
Second, Third Graders (n=17 ASD;
matched TYP)
Chamberlain, Kasari, Rotheram-Fuller, 2007, JADD; Kasari et al, 2011, JADD; Rotheram-
Fuller et al, 2010, JCPP

20. Friends and Reciprocity
Reciprocity is limited ……
Nearly all children can identify a 20 to 34% of children with
friend and/or best friend ASD have a reciprocal
friendship depending on study
Over 90% of children with ASD
can identify a friend during 60% for typical children
elementary ages, but this
drops to less than 50% for
adults

21. What
about
children
who
are
doing
well
(socially
connected)?
 20%
of
children
had
a
reciprocal
friendship
(best
or
top
3)
 These
same
children
had
higher
social
network
status
 Were
they
also
more
engaged
on
the
playground?
 NO…..playground
may
be
just
too
difficult
an
environment

22. UCLA
study
on
peer
intervention
study
in
the
schools

23. Modular,
individualized
approach
 Child
Assisted
 Peer
Mediated
 Observed
child
on
 3
peers
willing
from
the
playground,
obtained
class
teacher
reports,
peer
 Had
peers
identify
some
networks,
self
reports
children
who
had
difficulty
 Determine
top
3
problems
on
playground
for
child
engaging
with
 Had
peers
generate
ideas
peers
to
help
engage
all
children
 Worked
on
1
at
at
time
on
the
playground

24. Summary
of
UCLA
Peer
Study
CHILD
PEER
• PEER
Mediated
(1:1)
(3
peers)
Interventions
>
CHILD
Assisted
Interventions
NO
Treatment
CHILD+PEER
• Primary
Outcome
• Social
Network
Salience
(d=.79)
6 WEEK TREATMENT
(12 SESSIONS)
12 WEEK FOLLOW UP
Kasari, Rotheram-Fuller, Locke, & Gulsrud, 2012, JCPP

25. Social Network Centrality Second Grade –T2
Second Grade - T1 I9 (7) 2.5
G7 (1) A1 (2) H8 (8)
E5 (3)*** C3 (2)
F6 (1) K11 (1) 6.5 8
D4 (6)
B2 (3) 2 I9 (3) 3 J10 (8)
3 N14 (3)
6 L12 (3) N14 (6) O15 (5)
G7 (3) Q17 (6)
M13 (1) R18 (6)
P16 (6) H8 (7) P16 (7)
6 6.5 5 M13 (2)
R17 (5) 6.5 K11 (1)
7 J10 (7)
S18 (6) F6 (2)
2.5
D4 (1) O15 (4) 1.5 L12 (4)
Isolates: A1, C3, E5*** B2 (1)
Second Grade -T3 E5 (3)
G7 (6)
R18 (5) A1 (3) H8 (3)
Q17 (5)
7 8
7 P16 (1)
I9 (9)
C3 (4)
3.5 J10 (3) 1
F6 (1) D4 (2)
K11 (5)
Isolates: L12, M13, N14, S19 T20 (10) O15 (1)

26. Summary
of
UCLA
Peer
Study
CHILD
PEER
• Other
Findings
favoring
Peer
(1:1)
(3
peers)
Mediated
Interventions:
NO
Treatment
CHILD+PEER
• Number
of
Received
Friend
Nominations
(d=74)
• Less
isolated
on
playground
(growth
6 WEEK TREATMENT
curves
over
tx)
(12 SESSIONS)
• Improved
rating
of
social
12 WEEK FOLLOW UP skills
(by
Teachers)
(d=.44)

27. Other
Findings
 Effect
of
the
1:1
assistant
 About
half
of
the
children
had
a
1:1
assistant
 They
were
the
least
engaged
on
the
playground
(with
peers
or
with
the
aide)
 Need
to
think
about
how
to
train
aides
better
 Just
completed
para-­‐educator
intervention
on
the
playground
 Can
change
adult
behavior
and
improve
child
engagement

28. What
Needs
to
Happen
to
deploy
evidence
based
interventions
into
schools
 Researchers
need
to
conduct
research
in
school
settings;
effectiveness
research
from
beginning
not
last
step
 Distillation
and
matching
approaches
to
intervention
 Isolating
active
ingredients
of
intervention
 Matching
to
needs
of
child
in
context
 New
approaches:
Researchers
and
school
staff
need
to
work
together….community
partnered
research
(balance
of
power)
 NEW:
partnered
research
with
LAUSD
for
low
resourced
schools
 Testing
playground
intervention
 Functional
routines
in
special
education
classrooms

29. Next
Steps/New
Studies
 Determine
active
ingredients
of
intervention
 Importance
of
building
adaptive
strategies
(a
potential
sequence
of
interventions
for
particular
children…new
ACE
network
project
as
example)
 Deploying
interventions
into
the
community
that
can
be
sustained
 Preschools
 Teaching
teachers
to
engage
children
in
ways
to
increase
social
and
communication
skills
 Elementary
schools
 Playground
intervention
 Functional
routines
in
special
education
classrooms

30. Acknowledgements
Funding!
NIH,
HRSA,
Autism
Speaks,
Private
donors
Jason
Lee
Current
Caity
McCracken
Gail
Fox
Adams
Charlotte
Mucchetti
Kathleen
Berry
Chris
Osborn
Ya-­‐Chih
Chang,
PhD
Jonathan
Panganaban
Michelle
Dean
Stephanie
Patterson
Amy
Fuller
Wendy
Shih
Lizzy
Fuller
Shawna
Ueyama
Jordan
Gibson
Hilary
Gould
• Community
Kelly
Stickles
Goods,
PhD
Sonia
Dickson-­‐Bracks,
MBUSD
Amanda
Gulsrud,
Phd
Carolyn
Gelfand,
LAUSD
Alison
Holbrook
Nancy
Huynh,
PhD
Eric
Ishijima,
PhD
Dahlia
Kabab
Mark
Kretzmann,
PhD
Kelley
Krueger