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Connie Kasari 2012 Science and Sandwiches

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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
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	
  
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	
  
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	
  
JASPER	
  	
  
Joint	
  Attention,	
  Symbolic	
  Play,	
  Engagement,	
  Regulation	
  




                       Joint Attention Initiations:

                       -Point to share

                       -Show #

                       -Symbolic Play
Change	
  in	
  proximal	
  outcomes:	
  Joint	
  attention	
  
and	
  play	
  


                                            Joint Attention Initiations




                                                  Play Level

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Connie Kasari 2012 Science and Sandwiches

  • 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