Efficacy of a Comprehensive School-based Intervention for High-functioning Children With Autism Spectrum Disorder
Condition: Autism Spectrum Disorder
MeSH terms: Autistic Disorder; Autism Spectrum Disorder; Child Development Disorders, Pervasive
Study type: Interventional

Summary: 
      This study was a 4-year efficacy trial (cluster randomized trial) of a comprehensive
      school-based intervention (CSBI) for high-functioning elementary students with autism
      spectrum disorder (HFASD). The sample included children, in grades 1-5 with HFASD enrolled in
      public schools. School buildings were randomly assigned to either receive the CSBI or serve
      as the control comparison (business-as-usual [BAU]). School staff in the CSBI schools
      administered social skills groups (60-90 minutes per week), facial-emotion recognition
      computer instruction (60 minutes per week), therapeutic activities (40-60 minutes per week),
      a behavioral reinforcement system (across the school day), and parent training (60-90 minutes
      per month) during the school year. Children with HFASD in the BAU schools received their
      typical educational program. Implementation fidelity was assessed by research assistants
      throughout the school year in the CSBI schools using standardized fidelity monitoring sheets.
      The fidelity monitoring sheets were also completed by research assistants during observations
      in the BAU schools in order to identify the possible presence of any of the treatment
      elements in the control (BAU) schools. Outcome measures were completed for both groups at
      baseline (6 weeks into the school year prior to the initiation of the intervention) and at
      the end of the school year following completion of the intervention. Primary outcome measures
      included a test of emotion recognition and parent-teacher ratings of ASD symptoms and
      secondary measures included parent-teacher ratings of social/social-communication skills, a
      test of academic achievement skills, and a direct behavioral measure of social interaction
      skills (child testing and behavioral observations were completed by evaluators blinded to
      treatment condition; parent-teacher raters were not blinded to treatment condition). For the
      primary measures/analyses, it was hypothesized that students with HFASD who complete the CSBI
      will demonstrate significantly greater emotion-recognition skills and receive significantly
      lower parent-teacher ratings of ASD symptoms compared to controls. For the secondary
      measures/analyses, it was hypothesized that students with HFASD who complete the CSBI will
      receive significantly higher parent-teacher ratings of social/social-communication skills,
      demonstrate significantly higher academic skills, and exhibit significantly higher rates of
      social interactions with peers compared to controls.
    

Detailed description: 
      The efficacy of the comprehensive school-based intervention (CSBI) was evaluated in a cluster
      randomized trial (pretest-posttest control group design). A total of 96 students in grades
      1-5 with HFASD from 32 public elementary schools were initially targeted for enrollment over
      the 4-year study period. Once students were screened and determined to meet eligibility
      criteria, individual schools (clusters) were randomly assigned to either the treatment
      condition (CSBI) or control condition (business-as-usual [BAU]). A block randomization design
      with stratification by school economic level was used to insure approximate balance among the
      treatment groups. Recruitment was conducted during the 4-8 months prior to the upcoming
      school year. School staff from the treatment schools completed a manualized 5-day training
      during the summer preceding the treatment year and demonstrated fidelity with the protocol
      (competence). Pretesting was completed 6 weeks into the school year (prior to the initiation
      of the intervention) and posttesting at the end of the school year following completion of
      the intervention. Children with HFASD in the CSBI schools received the CSBI intervention
      implemented by school staff during the school year and children with HFASD in the BAU schools
      received their typical special education programming. Implementation accuracy (fidelity) was
      assessed by research assistants throughout the school year in the CSBI schools using
      standardized fidelity monitoring sheets. The fidelity monitoring sheets were also completed
      by research assistants during observations in the BAU schools in order to identify the
      possible presence of any of the treatment elements in the BAU schools.

      Treatment (CSBI) group protocol. The following is a description of the 5 treatment components
      (SSGs, IDN, MR, TAs, and PT) and fidelity protocol for the CSBI.

      Social skills groups (SSGs). SSGs were conducted 2-3x/wk. for a total of 60-90 min./wk. by a
      designated member of the school team. Groups contained 3-6 students with social impairments.
      Each manualized SSG began with a review of rules and was then conducted according to the
      framework of Skillstreaming (Goldstein et al., 1997). Skillstreaming is a structured program
      for teaching interpersonal skills to children with social deficits using teaching, modeling,
      role-playing, performance feedback, and transfer of learning (McGinnis & Goldstein, 1997). In
      the CSBI, 26 social skills were taught in a progression from basic to more complex. While the
      SSG protocol required active participation of every child each session, each child was
      required to be the primary role-player at least twice per 3 sessions. Each session ended with
      a short review and discussion of how to use the skill in future classroom activities. To
      ensure repeated practice and ongoing feedback, and promote generalization, 1) each
      participant had >2 social targets on her/his IDN (see IDN section), 2) classroom teachers
      displayed a list of the social skills taught to date and the component steps of each social
      skill, and 3) parents were continually informed of target skills. Fidelity of implementation.
      SSG facilitators recorded the date, attendees, minutes of group instruction, and skill for
      each session on a tracking sheet and research assistants monitored fidelity at least 1x/wk.
      using a standardized fidelity sheet.

      Individual daily note (IDN). The IDN was administered across the school day and was used to
      practice and reinforce newly learned skills, and reduce problem behaviors/ASD symptoms. It
      directed the student, school team, and parents to focus on specific skills/behaviors and
      performance criteria, and promoted communication between school and home. Each IDN consisted
      of 3-5 operationally-defined targets; to increase generalization >2 were skills taught in the
      CSBI. Initially, IDN targets were identified by teachers and operationally defined, and base
      rate data were collected for 3-5 days to determine criteria for IDN goals. Each student's
      school day was then divided into intervals based on his/her reinforcement needs. At the end
      of each interval, the student could earn 1 point for each IDN target and must have earned
      >75% of her/his daily points to receive a home reward (reinforcer). During each interval, the
      student received immediate verbal feedback and a tally was recorded on his/her IDN. At the
      end of each interval, the teacher provided feedback on the student's performance during that
      interval based on the targets and performance criteria. At the end of the day, the teacher
      informed the student of her/his overall performance (% earned), sent a copy of the IDN home,
      and retained a copy of the IDN. Fidelity of implementation. A copy of each child's IDN was
      kept by the classroom teacher and collected every 2 weeks. Adherence was assessed during at
      least two 60-min. observations each week using a standardized fidelity sheet.

      Mind Reading (MR) computer instruction. MR was conducted 3x/wk. for a total of 60 min./wk. by
      a designated member of the school team. MR is an interactive software program designed to
      teach recognition of emotions in facial and vocal formats (Baron-Cohen et al., 2004). It
      features 412 emotions organized into 24 emotion groups and by 6 emotion levels. The program
      presents instruction and tasks in the Emotions Library, Learning Center, and Games Zone and
      reinforcing activities in the Rewards Zone. It also employs a token system to reinforce
      participants with access to the Rewards Zone using points earned for accurate completion of
      questions in MR. The CSBI included 100 MR emotions divided into 10 groups (10 emotions per
      group). Each week students were taught 1 group of emotions (repeated during the 3 lessons).
      After each emotion group was taught, students repeated the 10 emotion groups 2 more times for
      a total of 3 exposures to the 10 groups. Each session was manualized to ensure children met
      time parameters accessing areas of MR. School staff members monitored students to ensure they
      accessed program areas according to the protocol. Fidelity of implementation. Data on time
      using the software for each participant were collected by an internal chronometer in the
      software and research assistants monitored implementation accuracy at least once per week
      using a standardized fidelity sheet.

      Therapeutic activities (TAs). TAs were conducted 2x/wk. for a total of 40-60 min./wk. by a
      designated member of the classroom team. TAs required >2 students and were conducted to
      practice and reinforce social skills and face-emotion recognition, and promote interest
      expansion. Each TA was written as a lesson plan that described the activity, its purpose,
      skill targeted, materials needed, deficit addressed, and procedures for conducting the
      activity. TAs were conducted with general and/or special education peers. At the outset,
      facilitators reviewed the activity rules and quickly discussed the activity. The facilitator
      also discussed with the target student how she/he can use the target and previously taught
      skills during the activity. During TAs, facilitators maintained proximity to the target
      students and provided frequent reinforcement when students exhibited target skills and
      corrective feedback when necessary. Each TA ended with a quick debriefing (1-3 min.)
      including how students used target skills during the TA and how they can use these skills
      during the school day/week. Fidelity of implementation. TA facilitators recorded the date,
      attendees, minutes of instruction, and skill targeted for each session on a tracking sheet.
      Research assistants monitored fidelity at least 3x/month using a standardized fidelity sheet.

      Parent training (PT). PT was conducted 1x/month for 60-90 min./session during the school year
      by at least 1 member of the school team. This served to increase home-school communication
      and integrate the CSBI across settings. It also fostered active parent participation in the
      establishment of home reinforcers for school performance on treatment targets and increased
      parental understanding of the CSBI. PT content and instructional procedures were manualized
      to ensure delivery of consistent content. Facilitators delivered content using detailed
      lesson plans and PowerPoint slides or showed a video recording of the session(s) (which
      covered the same lesson plans and PowerPoints). Each session was structured as follows: 1)
      Brief updates on CSBI and PT agenda; 2) Lesson content (delivered live or via video); 3)
      Discussion of content and integration of content into daily routine; and 4) Review of session
      content and implementation procedures. Fidelity of implementation. PT facilitators recorded
      the date, attendees, duration of session, and topic covered for each session on a tracking
      sheet. Research assistants monitored fidelity at least 1x per 2 PT sessions using a
      standardized fidelity sheet.

      Consultation support. Consultants provided support for classroom teams via weekly meetings.
      Consultants generally consisted of graduate students with advanced training in assessment and
      treatment of ASD/HFASD. Most were recruited from prior psychosocial treatment trials for
      children with HFASD conducted by our team and, as such they had extensive training and
      experience in administering the active components of the CSBI, and the fidelity, data
      collection, and data entry procedures. Fidelity of implementation. Consultants met with teams
      at least 1x/wk. and documented meetings on a log which included the school/team, date, time,
      topic(s), and outcome. The logs were reviewed monthly and child progress was reviewed at
      weekly consultant case review meetings with the study's clinical director.

      Comparison (BAU) group protocol. Research indicates that students with HFASD do not receive
      adequate, intensive, or comprehensive school interventions (White, Scahill et al., 2007).
      This suggested that students randomly assigned to the control (BAU) condition would not
      receive services that remotely approximated the intensity or scope of the CSBI. Given
      randomization at the school level, contamination was unlikely however we monitored the roles
      of school staff and excluded any staff member (e.g., related-service provider) who provided
      services across buildings. The services received by the control children (programming and
      services mandated on their IEPs) were also monitored to ensure they were sufficiently
      different from the CSBI group. Four procedures were used. 1) Each student's IEP was reviewed
      to identify and document the legally mandated services she/he received. 2) For those
      receiving counseling (group or individual) or speech-language services, the related-service
      provider completed a survey indicating specific treatment targets and the protocol for
      service provision (techniques used, number of trials, etc.). 3) Parents completed a monthly
      survey of any external therapeutic or social-communicative programming their child may have
      received. 4) Fidelity measures designed for the intervention group (with sequencing
      requirements removed) were completed for the control condition during two 60-minute classroom
      observations per week by research assistants.
    

Intervention name(s): Comprehensive School-Based Intervention
Intervention type(s): Behavioral
Intervention description(s): School staff administered the 5 components during the school year. Social Skills Groups were conducted 2-3x/wk. for a total of 60-90 min./wk.; each group contained 3-6 students with social impairments. The Individual Daily Note was administered across the school day to reinforce new skills and reduce problem symptoms. Students' performance on targets was linked to home rewards. Mind Reading computer instruction targeting emotion recognition skills was conducted 3x/wk. for a total of 60 min./wk. Therapeutic Activities were conducted 2x/wk. for a total of 40-60 min./wk.; these cooperative activities were designed to practice targeted skills. Parent Training was conducted 1x/month for 60-90 min./session in order to increase home-school communication and integrate the CSBI across settings.
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: The efficacy of the comprehensive school-based intervention (CSBI) was evaluated in a cluster randomized trial (pretest-posttest control group design). School buildings were randomly assigned to receive the CSBI or their typical educational programming. The CSBI was examined for its effect on the social performance/competence, ASD symptoms, and academic skills of children with HFASD compared to children with HFASD that did not receive the intervention. School staff delivered the multi-component intervention during the school year and research staff monitored intervention implementation (fidelity).
Masking: Single (Outcomes Assessor)
Primary purpose: Treatment
Keywords: Psychosocial treatment; School intervention; Autism Spectrum Disorder