Advocating for Supports to Improve Service Transitions

Study Overview
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Brief Summary
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This is a randomized intervention study to develop and test the national curriculum of a parent intervention training targeting parent's ability for advocate for services to improve the transition to adulthood for their youth with autism spectrum disorder (ASD). UPDATE regarding COVID-19: Due to social distancing restrictions, the in-person intervention series that began in Winter 2020 was paused in Spring 2020 for Cohort 1 intervention groups (TN and IL). The series resumed in Summer 2020 via synchronous web-conferencing. In response to continued pandemic regulations, ASSIST was permanently moved to synchronous web-conferencing in Fall 2020, and this method was the mode of delivery for all remaining sessions and series at all sites (TN, IL, WI). The remaining baseline data was also moved to remote collection through online interview and questionnaires in Spring 2020. The data collection for all follow ups and check ins (6, 12, 18, 24, and 30 month) were completed through web conference and/or phone calls in addition to online surveys. The final data collection for experimental and control groups from all sites will be complete by Summer 2023.

Detailed Description
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The proposed research plan is designed to develop and test the effectiveness of a national curriculum of the ASSIST (Advocating for SupportS to Improve Service Transition) program, a 12-week parent training program targeting parents' ability to advocate for services to improve the transition to adulthood for youth with autism (note that an optional 13th session on secondary transition planning can be offered if ASSIST is being delivered to families of youth who are in high school). Preliminary work demonstrated that youth whose parents participated in the Volunteer Advocacy Program- Transition or VAP-T (a pilot 12-week intervention program on which ASSIST is based) were more likely to be employed or in postsecondary education (PSE), and received more school-based and adult services, when compared to a wait-list control group. In the proposed research, the investigators conduct a randomized-controlled trial with 180 families to build on previous findings in four important ways: 1) by making modifications to the program content to make it applicable to service systems across the nation, and rigorously testing whether the ASSIST program is effective when delivered across three states (Tennessee, Illinois, Wisconsin); 2) by incorporating the perspective of offspring with autism into the intervention and data collection; 3) by examining mechanisms by which the ASSIST program influences youth outcomes; and 4) by exploring barriers to participation and factors that moderate treatment response. The investigators hypothesize that ASSIST participation will improve parents' advocacy ability, leading to higher rates of employment, PSE, social participation, and service access for youth with autism. The investigators will test this hypothesis by randomly assigning parents of transition-aged youth with autism (ages 16-26) to either a treatment or active, materials-only control group, and following families over 3 years. The investigators propose four Specific Aims: (1) To use a multi-site randomized-controlled trial to examine whether ASSIST participation increases parent advocacy ability (i.e. the intervention target); (2) To test whether participating in ASSIST leads to improved youth outcomes (employment, post-secondary education, social participation, service access) during the transition to adulthood; (3) To examine which aspects of parent advocacy ability mediate the relations between ASSIST participation and youth outcomes; and (4) To explore moderators of treatment response and barriers to participation in the intervention. By rigorously testing a new intervention to improve the transition to adulthood for youth with autism, the proposed research addresses an area of critical need as identified by the 2016-7 Interagency Autism Coordinating Committee Strategic Plan. The project will result in a new intervention to improve outcomes for youth with autism that can be disseminated through state and local agencies across the nation.

Official Title
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Project ASSIST: Advocating for Supports to Improve Service Transitions

Conditions
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Autism Spectrum Disorder, Autism

Intervention / Treatment
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* Behavioral: ASSIST


Participation Criteria
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Eligibility Criteria
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Inclusion criteria include: parents willing to participate in the ASSIST 12-week intervention, who have an offspring with autism between the ages of 16 and 26 years. This age range was chosen to allow for the testing of whether the ASSIST is more effective if offered prior to versus after high school exit (a key moderator in Aim 4). The investigators set a lower bound of age 16, as that is when transition planning is mandated to have begun in the schools, and an upper bound of age 26 to capture families of youth who are still in the transition years as defined by the Institute of Medicine. If both parents in a family want to attend the training, the investigators will allow it but will designate one as the study's primary respondent. There is no minimum or maximum age limit for parent participants. parents are willing to be randomized to the treatment or control condition; parents are able to travel weekly to one of the project sites (Nashville, TN; Chicagoland;IL; Madison/Milwaukee, WI) to participate in the group ASSIST sessions (12 weekly sessions). The responding parent and the offspring with ASD must also be able to travel to a project site for a diagnostic evaluation to confirm the ASD diagnosis (using the gold- standard Autism Diagnostic Observation Schedule-2 or ADOS-2) and to establish IQ and adaptive behavior functioning; the participating parent and youth must live in one of the states where the intervention is being delivered, as the adult service system is different in every state; son/daughter has a previous diagnosis of ASD from an educational or health care provider, and meets lifetime cut-offs for ASD in a telephone screening of the Social Communication Questionnaire. This will decrease the risk that youth fail to meet diagnostic criteria for ASD during the diagnostic evaluation. Note that although the investigators will collect IQ and adaptive behavior information to assess functioning of the offspring with ASD, this information will not be used to determine eligibility; parents of offspring with all levels of functioning can participate in the ASSIST project; and the participating parent is proficient with the English language, as all ASSIST presentations and data collection materials are in English. Exclusion criteria include: parents unable to participate in the ASSIST 12-week intervention due to scheduling conflicts, or who are unable to travel weekly to one of the sites; parents NOT willing to be randomized to the treatment or control condition; parents and/or youth do NOT live in one of the states where the intervention is being delivered; The youth does not have a previous diagnosis of ASD from an educational or health care provider The youth does not meet lifetime cut-offs for ASD in a telephone screening of the Social Communication Questionnaire, answered by the parent. The participating parent is not proficient with the English language.
Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Interventional Model Description: After eligibility is determined and baseline data are collected, parents will be randomized, in two cohorts, to the treatment or materials-only control condition. Given the relatively small sample size in each cohort at each site (n = 30 at each of three sites), simple randomization is not recommended as it might result in unequal group sizes. The investigators will use 1:1 block randomization within each site to give equal number of subjects in each group. To ensure balance of important covariates, the investigators will block on key moderators: whether the youth has an Intellectual Disability (ID) and is in high school. Co-occurring ID and being in vs. out of high school impact service eligibility, and ID impacts the likelihood of post-secondary education (PSE) and community employment. By balancing moderators, the researchers maximize power to detect effect modification of the treatment effect.
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: ASSIST intervention group<br>This group will attend the 12 sessions of the ASSIST training program (one 2-hour session per week for 12 weeks). | Behavioral: ASSIST<br>* The ASSIST program is a 12-week advocacy training to educate parents of youth with autism about the adult service system (note that an optional 13th session on secondary transition planning can be offered if ASSIST is being delivered to families of youth who are in high school). It is a group training, comprised of didactic instruction, family-sharing activities, case studies, and group discussions. The ASSIST program for the proposed study will be directed at each site by an experienced Program Facilitator from the community with knowledge about group processes, person-centered planning, and adult service systems, who will be coached by a member of the study team. The ASSIST program will be delivered in full partnership with the local disability community. In most sessions, the Program Facilitator will be aided by community content experts who present the specifics of each topic.<br>|
| Other: Control: Written materials only group<br>This informational control group will receive the ASSIST binder and all written materials developed for the program on the same schedule as the treatment group but will not attend the group sessions. After the treatment group is treated and follow up data is collected for comparison between treatment and control, the control group will have the option to take the ASSIST training program. | Behavioral: ASSIST<br>* The ASSIST program is a 12-week advocacy training to educate parents of youth with autism about the adult service system (note that an optional 13th session on secondary transition planning can be offered if ASSIST is being delivered to families of youth who are in high school). It is a group training, comprised of didactic instruction, family-sharing activities, case studies, and group discussions. The ASSIST program for the proposed study will be directed at each site by an experienced Program Facilitator from the community with knowledge about group processes, person-centered planning, and adult service systems, who will be coached by a member of the study team. The ASSIST program will be delivered in full partnership with the local disability community. In most sessions, the Program Facilitator will be aided by community content experts who present the specifics of each topic.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Treatment Target: Change in Parental Empowerment Scale | Examine whether ASSIST participation increases the intervention target of parental empowerment measured using the Family Empowerment Scale (FES). The 34-item questionnaire measures the extent to which parents feel empowered across three dimensions: family, the service system; and the larger community and political environment. Items are rated on a 5-point Likert Scale from 1= not at all true to 5 = very true. The total score can range from 34 to 170, with higher scores indicating greater empowerment. | Baseline to 3-month post-intervention | 
| Treatment Target: Change in Parental Knowledge about adult services questionnaire | Examine whether ASSIST participation increases the intervention target of parental knowledge about adult service systems. A questionnaire based on a measure developed for the Volunteer Advocacy Program Transition (VAP-T) will be used to evaluate parental knowledge about adult services. The questionnaire consists of 22 multiple-choice questions asking for factual information about adult disability services and the adult disability service system. The total score can range from 0 to 22. Higher scores indicate greater knowledge of the adult disability service system. | Baseline to 3-month post-intervention | 
| Treatment Target: Change in Advocacy Skills and Comfort Scale | Examine whether ASSIST participation increases the intervention target of parent advocacy skills measured by the Advocacy Skills and Comfort Scale (ASC). The 10-item measure assesses the degree to which parents feel comfortable and skilled in advocating for their offspring with ASD. Response options range from 1 = not at all to 5 = excellent. The total score can range from 10 to 50, with higher scores indicating more skills/comfort in advocating for their offspring. | Baseline to 3-month post-intervention | 
| Change in Advocacy Activities Scale | Examine whether ASSIST participation increases the intervention target of parent advocacy activities. The 16-item instrument measures how frequently parents spend time in advocacy activities for the son/daughter with ASD. The response options range from 1 = not at all to 4 = very often. The total score can range from 16 to 64, with higher scores indicating greater parent participation in advocacy activities. | Baseline to 12-month post-intervention | 
| Change in Access to Services Interview: Number of services the family applied for | Test whether parent participation in the ASSIST intervention leads to increase access to services for youth with ASD transitioning from high school to adulthood. Using questions developed for the National Longitudinal Transition Study-2 (NLTS-2), the investigators will collect data (via a semi-structured interview) on total number of services that the family applied for. | Baseline to 6-month, Baseline to 12-month post intervention | 
| Change in Access to Services Interview: Number of services the family is receiving | Test whether parent participation in the ASSIST intervention leads to increase access to services for youth with ASD transitioning from high school to adulthood. Using questions developed for the National Longitudinal Transition Study-2 (NLTS-2) the investigators will collect data (via a semi-structured interview) on total number of services that the family is receiving. | Baseline to 6-month, Baseline to 12-month post intervention | 
| Post-Secondary Youth Outcomes | Test whether parent participation in the ASSIST intervention leads to increase in post-secondary vocational and educational participation for youth with ASD. The Vocational Index will be used to gather information on employment and post-secondary educational programs that youth with ASD are attending / attended 6 months after the intervention. The Vocational Index will be administered via structured interview. | Baseline to 6-month, Baseline to 12-month post intervention | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Social Participation Youth Outcomes | Test whether parent participation in the ASSIST intervention leads to increase in social participation for youth with ASD. Questions developed to measure social participation will be used to measure the social participation achievements of the youth participants before and after ASSIST per parent-report. This measure consists of 10 items with a 5-point Likert scale ranging from 0 = Less than yearly or never to 4 = Several times a week. The total score can range from 0 to 40, with higher scores indicating greater social participation for the youth with ASD. | Baseline to 12-month post-intervention and Baseline to 30-month post-intervention | 
| Goal Attainment | Goal Attainment Scaling (GAS) will be used to measure the extent to which individualized goals identified in the person-centered planning session have been obtained. Goals are selected from a goal bank that includes 5 categories: Employment & Post-Secondary Education, Daily living, Social and Spirituality, Healthy Living, and Safety & Security. These goals are customized by parent and youth. The investigators will collect information on the youth's goals' progress status. | Baseline to 12-month post-intervention | 
| Satisfaction with Life Scale | The Satisfaction with Life Scale (SLS) is a short 5-item measure of an individual's subjective quality of life. The questionnaire asks parents to think about their youth and rate their agreement with the 5 statements on a 7-point scale, from 1 (Strongly Disagree) to 7 (Strongly Agree). The SLS scale allows participants to integrate and weigh these domains in whatever way they choose. | Baseline to 12-month post-intervention and Baseline to 30-month post-intervention | 
| Change in Access to Services Interview: Unmet service needs | Test whether parent participation in the ASSIST intervention leads to decrease in unmet service needs for youth with ASD transitioning from high school to adulthood. Using questions developed for the National Longitudinal Transition Study-2 (NLTS-2), the investigators will collect data (via a semi-structured interview) on total number of unmet service needs that the family is experiencing / experienced. | Baseline to 6-month, Baseline to 12-month, Baseline to 24-month, and Baseline to 30-month post intervention | 
| Change in Access to Services Interview: Barriers to service receipt | Test whether parent participation in the ASSIST intervention leads to decrease in barriers to services for youth with ASD transitioning from high school to adulthood. Using questions developed for the National Longitudinal Transition Study-2 (NLTS-2), the investigators will collect data (via a semi-structured interview) on total number of barriers to services that the family is experiencing / experienced. | Baseline to 6-month, Baseline to 12-month, Baseline to 24-month, and Baseline to 30-month post intervention | 
| Other Characteristics of Employment/Post-Secondary Educational Position: Length of Time/Stability | The Vocational Index will be used to gather information on employment and post-secondary educational (PSE) programs that youth with ASD are attending/attended before and after the ASSIST intervention. The Vocational Index will be administered via structured interview. Length of Time/Stability: Test whether parent participation in ASSIST leads to increase in employment and PSE stability for youth. The investigators will collect total number of youth activities. | Baseline to 6-month, Baseline to 12-month, Baseline to 24-month, and Baseline to 30-month post intervention | 
| Other Characteristics of Employment/Post-Secondary Educational Position: Hours Spent in Activity | The Vocational Index will be used to gather information on employment and post-secondary educational (PSE) programs that youth with ASD are attending/attended before and after the ASSIST intervention. The Vocational Index will be administered via structured interview. Hours Spent: Test whether parent participation in ASSIST leads to increase in employment and PSE participation for youth. The investigators will collect total number of hours per week spent in these activities. | Baseline to 6-month, Baseline to 12-month, Baseline to 24-month, and Baseline to 30-month post intervention | 
| Other Characteristics of Employment/Post-Secondary Educational Position: Fit | The Vocational Index will be used to gather information on employment and post-secondary educational (PSE) programs that youth with ASD are attending/attended before and after the ASSIST intervention. The Vocational Index will be administered via structured interview. Fit: Test whether parent participation in ASSIST leads to increase in youth satisfaction and degree of fit for their interest and skills in employment and PSE participation for youth. The investigators will collect information on if the job/position/program is a good fit for youth. | Baseline to 6-month, Baseline to 12-month, Baseline to 24-month, and Baseline to 30-month post intervention | 
| Change in Parental Empowerment Scale | Examine whether ASSIST participation increases the intervention target of parental empowerment measured using the Family Empowerment Scale (FES). The 34-item questionnaire measures the extent to which parents feel empowered across three dimensions: family, the service system; and the larger community and political environment. Items are rated on a 5-point Likert Scale from 1= not at all true to 5 = very true. The total score can range from 34 to 170, with higher scores indicating greater empowerment. | Baseline to 12-month, Baseline to 18-month, Baseline to 30-month post intervention | 
| Change in Parental Knowledge about adult services questionnaire | Examine whether ASSIST participation increases the intervention target of parental knowledge about adult service systems. A questionnaire based on a measure developed for the Volunteer Advocacy Program Transition (VAP-T) will be used to evaluate parental knowledge about adult services. The questionnaire consists of 22 multiple-choice questions asking for factual information about adult disability services and the adult disability service system. The total score can range from 0 to 22. Higher scores indicate greater knowledge of the adult disability service system. | Baseline to 12-month, Baseline to 18-month post-intervention | 
| Change in Advocacy Skills and Comfort Scale | Examine whether ASSIST participation increases the intervention target of parent advocacy skills measured by the Advocacy Skills and Comfort Scale (ASC). The 10-item measure assesses the degree to which parents feel comfortable and skilled in advocating for their offspring with ASD. Response options range from 1 = not at all to 5 = excellent. The total score can range from 10 to 50, with higher scores indicating more skills/comfort in advocating for their offspring. | Baseline to 12-month, and Baseline to 18-month post-intervention |