School’s in

We all know that most kids with autism spend more time in schools than in any other environment, but how much do we actually know about developing effective school-based interventions? Not much, it turns out.

One thing we do know is that schools represent a huge opportunity for advancing and improving the impact of autism interventions — but not without some challenges. As my colleague Sarah Parsons and I noted in an editorial for a special issue on school-based intervention studies, published in May in Autism, it is time to implement proven interventions in real-world school settings¹.  This claim too often appears just in the parting comments of the discussion section — few have made good on it. But the tide may be turning.

The federal Autism Intervention Research Network for Behavioral Health, funded by the Health Resources and Services Administration and of which I am the principal investigator, has been aggressively taking on the challenges of conducting intervention research in schools.  One significant advantage of working in schools is access to children. School-based interventions are arguably the best way to reach the truly underserved, under-represented and under-resourced children with autism.

In our local Los Angeles Unified School District, 91 percent of children served are ethnic minorities and 80 percent qualify for Free and Reduced Lunch programs. And importantly, there are about 12,000 children with autism. The opportunity for a successfully transplanted intervention in such a setting is truly enormous, so there is hope formaking a meaningful difference.

Still, identifying quality treatments and finding success in implementation is easier said than done.

Conducting research in schools is not for the faint of heart. Indeed, developing a partnership with school-district personnel takes real work, a lot of time and the development of trust. Schools need to be convinced that the researchers are committedto the bigger picture, and are there for more than just the data.

There is also a science to this process that goes beyond good faith. We are testing both the implementation and the effectiveness of two interventions with our school partners — Remaking Recess, a social-engagement intervention on the playgrounds, and Schedules, Tools, and Activities for Transitions, which helps children transition between activities in the classroom.

Equal partners:

Our project uses Community Partnered Participatory Research, meaning we are on equal footing with our school partners in identifying challenges and working collaboratively to come up with feasible solutions². Based on their feedback, we are applying a randomized controlled design in multiple schools within three different urban, low-resourced school districts across the country.

The results of this three-year implementation process will yield data on the success of the intervention, as well as teacher, staff and student outcomes. We expect preliminaryresults around the end of the 2013-2014 school year.

After conducting several studies in school settings for the past 12 years, we have learned many lessons that will guide us along the way.

One obvious lesson is that tightly controlled, restricted-sample interventions that work well in the laboratory do not transfer easily to real-world settings. Schoolchildren with autism rarely match the participants carefully selected for studies. This is especially true of children who test as nonverbal or are non-English-speaking, who might be poor or have multiple disabilities.

So, painfully, we must admit that large numbers (perhaps the majority) of children with autism served in public schools are not represented in studies constituting the “evidence base.” Rather than trying to bring this demographic to us, we are trying to reach out to them. By design, then, school-based studies will be more inclusive of a broader range of children with autism.

Another reason our best lab-based interventions may not transfer to real-world settings is that we are not really certain about the active ingredients of the interventions — for example, how many hours are necessary per week, how much one-on-one support is needed, or what exactly should be the focus of intervention in teaching communication.  So much of what we do may be either unnecessary or missing the right stuff for the population. No doubt, knowing the necessary elements of an intervention can potentially change the scale of an intervention from unfeasible to realistic.

Some elements might be more easily adopted than others, however, and even simply being added to a teacher’s toolbox of skills can lead to a more informed, eclectic approach to interventions for children with autism.

This means that we are looking to provide teachers and school personnel with a variety of skills that can be incorporated within a diverse classroom setting, rather than trying to offer a nicely packaged intervention that looks good in theory but that turns out to be ineffective in practice.

‘Informed eclecticism’ is an approach that takes into account the rapidly changing components of life in school settings. Rather than providing narrow treatments for restricted settings, itcan offer an individualized, powerful approach to intervention in which the sum is far greater than the parts³.

Finally, we are seeking to shorten the time it takes to bring evidence-based interventions into real-world settings and to increase their effectiveness and sustainability. Testing interventions in schools from the beginning, rather than after the first, second or third lab-based trial may increase the likelihood that we will get it right.

Obviously, we still have much to learn about the experiences of children, teachers and staff in schools. But we believe that the best approach to improving interventions for these children is likely to come from real-world research in partnership with schools. Together we can throw the net wider to bring evidence-based interventions to the diverse population of children with autism.

Connie Kasari is professor of human development and psychology at the University of California, Los Angeles.

References:

1.  Parsons S. and C. Kasari Autism 17,251-253 (2013) PubMed

2.  Jones L. and K. Wells JAMA 297, 407-410 (2007) PubMed

3.  Kasari C. and T. Smith Autism 17, 254-267 (2013) PubMed