None 10/15/16. Early interventions for ASD: Active ingredients and deployment in the community. Disclosures. Connie Kasari. PhD

Transcription

1 Early interventions for ASD: Active ingredients and deployment in the community Connie Kasari. PhD Autism Intervention Research Network for Behavioral Health SPD Conference, Seattle November 5, 2016 Disclosures None 3 issues Introduction Summary 1 a b c 3 1

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

3 Today s intervention landscape LAUSD Students with ASD 2 nd largest Hispanic school district; 14,000 students with ASD White Other District as a whole is.. 75% Hispanic; White 80% free & reduced lunch; Black Other 9% White Black Hispanic Disparities are real.. Public schools should be place without disparities in services 3

4 3 Issues to consider 1 There is a HUGE research to practice GAP 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) 4

5 Proliferation of programs 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 What is the evidence-base for early interventions? We can improve cognitive outcomes (DQ) in young children with comprehensive, many hour per week interventions 100 DTT- preschoolers 30 hrs/wk vs. < ESDM-toddlers 25 hrs/wk vs. fewer hrs DQ points pts 90 n=28 n= pts 5 pts 50 1 pt Baseline 2 years Baseline 1 year 2 years Smith, Groen & Wynn, AJMR, 2000 Dawson et al, Pediatrics,

6 Confidence in findings? Reproducibility of findings Problem in science Original studies small samples Often do not replicate Science, 2015 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 Follow up Studies Rare.. Follow up of ESDM, Estes et al, 2015 n= 39 NS 6

7 Similar outcomes in brief parent mediated interventions? 100 Focused Playtime Intervention 100 SCERTS DQ points pts 14 pts pts 2 pts Intervention phase Baseline 1 year Baseline Intervention phase 9 months Kasari, Siller et al, Infant Behavior & Development, 2014 Wetherby et al, Pediatrics, 2014 What do we make of these findings.. Outcome measures Active ingredients Primary outcome has been IQ But many factors can influence IQ Cannot rule out dose of intervention Year of study matters the counterfactual 7

8 While IQ is likely important; it is not a core deficit of ASD What are the active ingredients of early interventions? Dose Agent of change (BCBA therapist, parent, other?) Teaching approach Content ---what is focused on Others.. What are the active ingredients of early interventions? Dose Agent of change (BCBA therapist, parent, other?) Teaching approach Content ---what is focused on Others.. 8

9 What are the active ingredients of early interventions? Dose Agent of change (BCBA therapist, parent, other?) Teaching approach Content ---what is focused on Others.. Content focusing on core impairments Social Communication Restricted, repetitive behaviors To large extent, independent of IQ Early Core Deficits Social Communication Engagement Play Communicative gestures & language 9

10 Characteristics of ASD Rigid, no joy in play Object focused Typical 17 month old Social engagement, joint attention, shared affect Engagement Repetitive behavior 3 year old with ASD Why focus on early core deficits? 10

11 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) Evidence suggests that approach matters for improvements in joint attention, play, engagement Spontaneous, child initiations Differences in approach to teaching play ABA-traditional DTT teaching symbolic play NDBI JASPER 11

12 Joint Attention, Symbolic Play, Engagement, & Regulation JASPER Research Addressing Core Deficits NDBI Naturalistic Developmental Behavioral Intervention (Workgroup, 2014) Targeted Modular Short-term JASPER Core Concepts Joint Attention Play Engagement 12

13 JASPER Core Strategies Environmental Arrangement Imitation & Modeling Routines (play) Programming for JA Language Techniques Toy choices in close proximity Clear play space (rug is defined play area) Caregiver facing child 13

14 Engagement Play Joint attention Language JASPER is a layered intervention JASPER demonstrates effects above and beyond background treatment Highly replicable findings (therapists, teachers, parents) é Joint engagement é Play skills é Joint Attention Evidence 14

15 Parent mediated interventions.strategies layered in over time FIRST---Goal is selected for child that is developmentally on target PHASE 1 (3 weeks) Environmental arrangements (setting up the environment) (and knowing child play level) Allowing the child to initiate an activity (following the child s attentional focus) Establishing and playing within established routines PHASE 2 (3 weeks) Facilitating, maintaining engagement states Balance between imitating and modeling Expansions, showing enjoyment, eye-contact Joint attention: recognizing, responding, modeling PHASE 3 (3-5 weeks) Allowing child access to communication Initiating and expanding language Generalizing skills across other routines Practice.up to 2 weeks more Some additional modules can float. unengaged module ; behavior regulation Information Sharing Hands on Coaching Parent Mediated Interventions Seconds Child initiated joint engagement JASPER Parent Education Entry Exit Follow up (Kasari, Gulsrud, Paparella, Hellemann, Berry, JCCP, 2015) RCT Comparative Efficacy N=86 15

16 Parent Mediated Intervention-- Toddlers 86 children (2-3 year olds) Comparison 2 interventions 20 sessions over 10 weeks 6 month follow up JASPER group é Joint engagement é Play diversity é Play level Group comparison ê Parenting stress (Kasari, Gulsrud, Paparella, Hellemann, Berry, JCCP, 2015 Parent Mediated Intervention Child initiated joint engagement JASPER Group Education 200 Entry Exit Follow up (Kasari, Lawton, Shih, Barker et al, Pediatrics, 2014 RCT-Comparative Efficacy N=112 Parent Mediated Intervention-- Preschoolers 112 children (2-5 year olds) Comparison 2 interventions 24 sessions over 12 weeks 3 month follow up JASPER group é Joint engagement é Symbolic play é Initiating JA (Kasari, Lawton et al, Pediatrics, 2014) 16

17 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 Major questions going forward.. What are the downstream effects? IJA predicts to expressive language 1 and 5 years later Can the intervention be deployed effectively? Bridging research to practice Consider. 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) Active ingredients will be very important in deployment to rural, distance sites----macedonia 17

18 Bridging research to practice Consider. 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) 2 A single treatment is not effective for all! Methodologies are needed to personalize, tailor interventions Address for whom the intervention works, and why.. Sequence treatments.. 18

19 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 19

20 Adaptive Intervention designs systematize clinical practice 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. 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) Kasari, Kaiser, Landa, Neitfeld, Mathy, Murphy, Almirall, JAACAP,

21 10/15/16 Slide courtesy of Danny Almirall May 16, 2014 Minimally verbal and meaningful outcomes Socially communicative utterances JAE+EMT+AAC JAE+EMT Total Socially Communicative Utterances Week Novel words and comments Kasari, Kaiser, Goods, Neitfeld, Mathy, Landa, Murphy, Almirall, JAACAP,

22 Minimally verbal School aged: No words in beginning; needs access to communication Preverbal child: preschool aged Day 1 Day 2 Day 12 3 Deployment can be limited Sustainability poor Training models and implementation fidelity Sustainability might be improved by 1. Deployment focused models Intervention development and testing with participants within context (e.g., homes/schools) for which intervention is intended and by people intended to deliver the intervention (e.g., parents, teachers) 2. Hybrid implementation models Focus on implementation and outcomes 3. Community partnered participatory research models Shared goals and responsibilities 22

23 Deployment Models Stephanie Shire, PhD Ya-Chih Chang, PhD! NYTD Train the trainer models; deploying to paraeducators who are doing both assessment and intervention Shire, Chang, Shih, Bracaglia, Kodjoe, & Kasari, 2016, JCPP LAPD Fitting the intervention into existing structure with support Chang, Shire, Shih, Kasari, 2016, JADD JASPER findings similar to lab when conducted in school: Better joint engagement with others Percentage of time JASPER Wait Entry Exit Percentage of children using points, shows, gives Nonverbal gestures (high level joint attention) JASPER Wait Entry Exit 23

24 Change in Language % of children using language ENTRY EXIt 0 JASPER Wait list Sustainable Change Community partnered participatory research models (AIR-B Network) Community- Academic Partnership Modular Implementation Sustainability 24

25 We know some things Can change core impairments and improve meaningful outcomes Teaching others matters----parents, teachers, and peers Evidence of some generalization and longer term outcomes We have much to learn! Active ingredients dismantling studies Personalizing treatments adaptive designs delivering interventions just when needed Disseminating effective interventions into the community using hybrid implementation models 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 Colleagues-UCLA Amanda Gulsrud,PhD, Stephanie Shire, PhD, Shafali Jeste, MD Acknowledgements 25

26 airbnetwork.org kasarilab.org 26