10/15/16 1 Early interventions for ASD: Active ingredients and deployment in the community Connie Kasari. PhD SPD Conference, Seattle November 5, 2016 Autism Intervention Research Network for Behavioral Health None Disclosures 1 Introduction b a Summary 3 c 3 issues
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Seattle SPD talk - STAR Institute · SPD Conference, Seattle November 5, 2016 ... ESDM-toddlers 25 hrs/wk vs. fewer ... Slide courtesy of Danny AlmirallMay 16, 2014
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10/15/16
1
Early interventions for ASD: Active ingredients and deployment in the
community
Connie Kasari. PhD
SPD Conference, SeattleNovember 5, 2016
Autism Intervention Research Network for Behavioral Health
None
Disclosures
1
Introduction
ba
Summary
3c
3 issues
10/15/16
2
1
Introduction
ba
Research topractice gap
Summary
3c
3 issues
1
Introduction
No singletreatment
ba
Research topractice gap
Summary
3c
3 issues
1
Introduction
No singletreatment
ba
Research topractice gap
Summary
3c
DeploymentSustainability
3 issues
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3
Today’s intervention landscape
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
Disparities are real…..
Public schools should be place without disparities in services
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3 Issues to consider……
There is a HUGE research to practice GAP
1
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)
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Joint Attention !Symbolic Play Engagement !
Regulation JASPER Early Start Denver !Model ESDM Pivotal Response Training !
PRT Floortime DIR Developmental Individual !difference Relationship-based RDI Relationship !
Development Intervention Early Achievements Proj!ImPACT PEERS Secret Agent Society Discrete Trial !
Training DTT Verbal Behavior Intervention VB SCERT !Social Communication Emotion Regulation Transaction
Supports Unstuck and On Target Focused Playtime Intervention Adapted Responsive Intervention Joint
Attention Symbolic Play Engagement Regulation JASP!Early Start Denver Model ESDM Pivotal Response !Training PRT Floortime Developmental Individual !difference Relationship-based DIR Relationship !
Development Intervention RDI Early Achi !Project ImPACT PEERS Secret Agent!
Society Discrete Trial Trainin !DTT Verbal Behavior
Proliferation of programs
What is the evidence-base for early interventions?
We can improve cognitive outcomes (DQ) in young children with comprehensive, many hour
per week interventionsDTT- preschoolers30 hrs/wk vs. <10
Good evidence of improving core deficits using JASPER
(NDBI interventions)Ingersoll, 2011, JADD RCT—improvement in JA initiations from training
imitationWetherby et al, 2014, Pediatrics---improvement of collapsed requesting, joint
attention category
Major questions going forward..
What are the downstream effects?
Can the intervention be deployed effectively?
IJA predicts to expressive language 1 and 5 years later
1. Which strategies or ‘active ingredients’ affect change in outcomes
a. 2 studies testing mechanism….both parent mediated models--- in toddlers ‘mirrored pacing’ affects joint engagement for JASPER (Gulsrud et al, 2015, JCPP) and in preschoolers parental synchrony affects ASD symptoms for PACT (Pickles et al, 2014, JCPP)
Bridging research to practiceConsider….
Active ingredients will be very important in deployment to rural, distance sites----Macedonia
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1. Which strategies or ‘active ingredients’ affect change in outcomes
a. 2 studies testing mechanism….both parent mediated models--- in toddlers ‘mirrored pacing’ affects joint engagement for JASPER (Gulsrud et al, 2015, JCPP) and in preschoolers parental synchrony affects ASD symptoms for PACT (Pickles et al, 2014, JCPP)
2. Strategies, modules to build a comprehensive program
a. Clinicians more likely to adopt a module than completely changing practices (Chorpita et al, 2005; Weisz et al, 2012)
Bridging research to practiceConsider….
A single treatment is not effective for all!
2
Methodologies are needed to personalize, tailor interventions
Address for whom the intervention works, and why…..
Sequence treatments…..
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Need: Diversify samples, in real world settings
Problem is that researchers tend to exclude subpopulations
Minimally verbal often excluded
NIH Workshop Who are the ‘minimally verbal’
• Clear most are not ‘nonverbal’
• Defined by number of functional words spoken
• Some can speak but rarely do or only in some contexts
• Treatment is often to do MORE of the same…..
• (or less, blaming child for lack of progress)
Sequence of treatments
Adaptations based on child response
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DEFINITION: A sequence of decision rules that specify whether, how, when (timing) and
based on which measures, to alter the dosage (duration, frequency or amount), type or
delivery of treatment(s) at decision stages in the course of care.
Adaptive Intervention designs systematize clinical practice
SMART design
Sequential Multiple Assignment Randomized Trial
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)