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Understanding Importance of UDLs for Autistic Students K-1.

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Understanding Importance of UDLs for Autistic Students K-1.

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"Reading Rockets" is a comprehensive website that focuses on promoting literacy development among children, particularly those with diverse learning needs. Within this platform, there is a specific emphasis on Universal Design for Learning (UDL), a framework that aims to address the individual needs of all students through flexible instructional methods, materials, and assessments. The UDL approach recognizes the diversity of learners and seeks to provide multiple means of engagement, representation, and expression.

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Education Opportunity Act of 2008, P.L. No. 110-315, 122nd Cong., §3079 (2008).

Hitchcock, C.G., Meyer, A., Rose, D., & Jackson, R. (2005). Equal access, participation, and progress in the general education curriculum. In D. Rose, A. Meyer, & C. Hitchcock (Eds). The universally designed classroom: Accessible curriculum and digital technologies (pp. 37-68). Cambridge, MA: Harvard Education Press.

National UDL Center. (2011). UDL examples and resources. Retrieved on May 28, 2011 from www.udlcenter.org/implementation/examples.

Rose, D. H., & Gravel, J. W. (2010). Universal design for learning. In P. Peterson, E. Baker, & B. McGraw, (Eds.), International encyclopedia of education (pp. 119-124). Oxford: Elsevier. Retrieved April 23, 1011 from www.udlcenter.org/sites/udlcenter.org/files/TechnologyandLearning.pdf [PDF].

Rose, D. H., & Meyer, A. (2002). Teaching every student in the digital age: Universal design for learning. Alexandria, VA: ASCD.

Rose, D. H., & Meyer, A. (2005). The future is in the margins: The role of technology and disability in educational reform. In D. H. Rose, A. Meyer, & C. Hitchcock (Eds.), A practical reader in universal design for learning (pp. 13-35). Cambridge, MA: Harvard Education Press.

Rose, D. H., & Meyer, A. (2006). A practical reader in universal design for learning. Cambridge, MA: Harvard Education Press.

Rose, D. H., Meyer, A., & Hitchcock, C. (Eds). (2005). The universally designed classroom: Accessible curriculum and digital technologies. Cambridge, MA: Harvard Education Press.

Rose, D. H., & Vue, G. (2010). 2020's Learning landscape: A retrospective on dyslexia. International Dyslexia Association, Perspectives on Language and Literacy, 36(1), 33-37. Retrieved on April 23, 2011 from http://www.udlcenter.org/resource_library/articles/2020.

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Universal Design for Learning: Meeting the Needs of All Students

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Universal Design for Learning (UDL) provides the opportunity for all students to access, participate in, and progress in the general-education curriculum by reducing barriers to instruction. Learn more about how UDL offers options for how information is presented, how students respond or demonstrate their knowledge and skills, and how students are engaged in learning.

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15 Accommodations for Students with Autism 

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15 Accommodations for Students with Autism 

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This resource provides 15 accommodations for students with Autism. These accommodations can be tailored and combined based on the unique strengths and needs of each student with autism to promote their academic, social, and emotional growth.

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15 Accommodations For Students With Autism

Autism is a neurological disorder that affects communication and social interaction. Students with autism often struggle in traditional classroom settings, but with the right accommodations, they can thrive academically and socially.

1. Sensory Breaks

Sensory overload can be overwhelming for students with autism. Providing sensory breaks throughout the day can help students regulate their sensory needs and improve their focus.

2. Visual Schedules

Visual schedules can help students with autism understand the structure of their day and reduce anxiety. A visual schedule can include pictures or symbols that represent different activities throughout the day.

3. Quiet Spaces

Quiet spaces can provide a safe and calming environment for students with autism to take a break from sensory overload or social interactions.

4. Noise-Cancelling Headphones

Noise-cancelling headphones can help students with autism block out distracting sounds and focus on their work.

5. Fidget Toys

Fidget toys can provide a sensory outlet for students with autism and improve their focus.

6. Preferential Seating

Placing students with autism in a quiet area of the classroom or away from distractions can help them focus on their work.

7. Positive Reinforcement

Positive reinforcement can motivate students with autism to complete tasks and improve their behavior. This can include verbal praise or rewards.

8. Clear Expectations

Clear expectations can reduce anxiety and confusion for students with autism. Teachers can provide clear instructions and expectations for assignments and classroom behavior.

9. Social Skills Training

Social skills training can help students with autism improve their communication and social interactions with peers.

10. Peer Mentors

Peer mentors can provide social support and guidance for students with autism in the classroom.

11. Breaks Between Activities

Breaks between activities can help students with autism transition between tasks and reduce anxiety.

12. Assistive Technology

Assistive technology, such as speech-to-text software or digital organizers, can help students with autism complete assignments and stay organized.

13. Modified Assignments

Modified assignments can help students with autism complete tasks at their own pace and level of understanding.

14. Individualized Education Plans (IEPs)

Individualized Education Plans (IEPs) can provide a customized education plan for students with autism that includes specific accommodations and goals.

15. Sensory-Friendly Classrooms

Sensory-friendly classrooms can create a safe and supportive environment for students with autism. This can include sensory-friendly lighting, seating, and materials.

In conclusion, providing accommodations for students with autism can help them succeed academically and socially. These 15 accommodations are just a few examples of the many ways that teachers can support students with autism in the classroom. By creating a supportive and inclusive environment, teachers can help students with autism reach their full potential.

What Is Autism Accommodation?

Accommodations for students with autism are modifications made to the learning environment or teaching methods to provide support and help them overcome challenges.

These accommodations can include changes in the classroom setup, instructional materials, communication, and behavior management strategies. The goal of accommodations is to create an inclusive learning environment that meets the unique needs of each student with autism.

Who Is Eligible To Receive Accommodations?

Any student with autism who is enrolled in a public or private school is eligible to receive accommodations under the Individuals with Disabilities Education Act (IDEA).

The law requires schools to provide free and appropriate public education (FAPE) to all students, including those with disabilities. To receive accommodations, students must first be evaluated by a qualified professional to determine their individual needs.

Once identified, the school must work with the student and their family to create an Individualized Education Program (IEP) that outlines specific accommodations and goals for academic and social success.

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15 Accommodations For Students With Autism

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Here are 15 accommodations that can help students with autism succeed in school.

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Strategies to help Social Skills to autistic students 

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Strategies to help Social Skills to autistic students 

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This resource "autism speaks" is a prominent organization dedicated to raising awareness, promoting research, and providing resources for individuals and families affected by autism spectrum disorder (ASD). Regarding social skills development, the website emphasizes several key points.

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School Community Tool Kit

Supporting social interaction is an important piece of the student's educational plan. Student's with autism often have the desire to interact with others, but do not have the skills to engage appropriately or may be overwhelmed by the process. Some students are painfully aware of their social deficits and will avoid interactions even though they desperately want to connect with others. Others will engage in attention seeking behavior to connect with others until they build the skills they need to interact. Social development represents a range of skills, including timing and attention, sensory integration and communication, that can be built and layered to improve social competence. Building competence will result in further interest and interaction.

Here are some strategies to support social skill development in your students with autism:

Reinforce what the student does well socially - use behavior-specific praise (and concrete reinforcement if needed) to shape pro-social behavior.

Model social interaction, turn taking and reciprocity.

Teach imitation, motor as well as verbal.

Teach context clues and referencing those around you (for example, 'if everyone else is standing, you should be too!').

Break social skills into small component parts, and teach these skills through supported interactions. Use visuals as appropriate.

Celebrate strengths and use these to your advantage. Many students with autism have a good sense of humor, a love of or affinity for music, strong rote memorization skills, or a heightened sense of color or visual perspective. Use these to motivate interest in social interactions or give a student a chance to shine and be viewed as competent and interesting.

Identify peers who model strong social skills and pair the student with them. Provide peers with strategies for eliciting communication or other targeted objectives, but be careful not to turn the peer into a teacher strive to keep peer interactions as natural as possible.

Create small lunch groups, perhaps with structured activities or topic boxes. (The group to pulls a topic out of a box and discusses things related to this topic, such as 'The most recent movie I saw was...' This can be helpful for students who tend to talk about the same things all the time since it provides supports and motivation and the benefit of a visual reminder of what the topic is.)

Focus on social learning during activities that are not otherwise challenging for the child (for example, conversational turn-taking may not occur if a child with poor fine motor skills is being asked to converse while cutting.)

Support peers and student with structured social situations. Define expectations of behavior in advance. (For example, first teach the necessary skill, such as how to play Uno, in isolation, and then introduce it in a social setting with peers.)

Teach empathy and reciprocity. To engage in a social interaction, a person needs to be able to take another's perspective and adjust the interaction accordingly. While their challenges may distort their expressions of empathy, people with autism often do have capacity for empathy. This can be taught by making a student aware - and providing appropriate vocabulary - through commentary and awareness of feelings, emotional states, recognition of others' facial expressions and non verbal cues.

Use social narratives and social cartooning as tools in describing and defining social rules and expectations.

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Autism and Social Skills Development | Autism Speaks

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Click here to read an excerpt on autism and social skills development from the Autism Speaks School Community Tool Kit.

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Ad-hoc and Scalar Implicatures in Children with Autism Spectrum Disorder

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Ad-hoc and Scalar Implicatures in Children with Autism Spectrum Disorder

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This current study expands upon prior investigations by examining two categories of implicature: scalar implicatures, which rely on lexical scales, and ad-hoc implicatures, which depend on contextual scales. The study involved 26 ASD children aged 4-10 years (mean age 7.1) and 26 typically developing (TD) children, matched for chronological age, and exhibiting similar performance levels in non-verbal IQ and vocabulary. The study concludes that children with ASD encounter challenges with both types of implicatures, highlighting potential implications for pragmatic theories and clinical interventions for individuals with ASD.

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Supporting the inclusion and retention of autistic students

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Supporting the inclusion and retention of autistic students

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This resource shows the study on the inclusion and retention of autistic students in public elementary schools, as discussed on the "Frontiers" website, examines the utilization of evidence-based practices by teachers and paraeducators, aiming to enhance support and promote successful outcomes for autistic students within inclusive educational environments.

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Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, United States

Department of Special Education, University of Kansas, Lawrence, KS, United States

Introduction: Educators in public schools are required to serve students in their least restrictive environment. While many evidence-based practices (EBPs), defined as practices and strategies shown by research to have meaningful effectson outcomes for autistic students are documented in the literature, less is known about EBP use among educators in public schools.

Methods: Eighty-six general and special education teachers and para educators completed a survey about familiarity, training, and EBP use for included autistic children.

Results: Across roles, educators reported familiarity (98.8%), use (97.7%), and training (83.7%) in reinforcement. They reported the least familiarity with behavioral momentum (29.1%), training in both video modeling and peer-mediated instruction and intervention (18.6%), and use of video modeling (14.0%). Follow-up interviews ( n = 80) highlighted mixed understanding of EBP definitions and use.

Discussion: Implications for inclusive education are discussed including autism-specific EBP training within pre-service teacher preparation programs.

One in 44 youth in the United States has autism spectrum disorder [ASD; ( 1)]. ASD is a pervasive developmental disorder characterized by deficits in social communication and the presence of restricted and/or repetitive behavior ( 2). As the primary setting in which autistic children receive services ( 3), schools are increasingly affected by this increased prevalence ( 4). Under the Individuals with Disabilities Education Act ( 5), schools are required to provide education in the least restrictive environment; thus, many autistic children are partially or fully included in general education settings ( 6). However, educators in these contexts have mixed familiarity, training, and varying degrees of support in their knowledge and use of evidence-based practices [EBPs; ( 7)], defined as practices and strategies shown by research to have meaningful effects on outcomes for autistic students ( 8). The types of EBPs most germane to inclusive settings and the extent to which general and special education teachers and paraeducators are trained to use EBPs is unknown ( 9, 10). Though EBP use is mandated in IDEA ( 11- 13), research has shown that EBPs have not been successfully adopted, implemented, or sustained in these settings to support the inclusion and retention of autistic students ( 14- 16). Understanding what interventions are used in these settings may provide a "road-map" for targeted efforts to improve the quality of training and supports for educators of autistic students ( 16, 17).

It is not clear which EBPs, if any, general and special education teachers and paraeducators are familiar with, commonly trained to use, or use to support inclusion of autistic students. Research improving the delivery of autism services in public schools has focused on training teachers of autistic children in self-contained settings ( 13, 18- 20). Bond et al. ( 21) reviewed educational interventions for autistic children and found that a promising 59% of the studies were implemented by or involved teachers and paraeducators. While this is an encouraging finding, few of these studies were conducted in general education settings. Despite the growing number of autistic children in general education settings ( 22, 23), far less attention has been afforded to improving the instructional practices of general education teachers and paraeducators ( 24). It is critical not only to better understand teachers' practices but also explore the role of paraeducators in supporting teachers and included autistic children ( 25).

Inclusion alone may be necessary but not sufficient for improving outcomes for autistic children. Inclusion is the "fundamental concept that [autistic] children can and should be educated in the same setting as their [neurotypical] peers" [( 26), p. 337]. The ways in which inclusion is facilitated in schools vary. Time in general education settings may be based on autism severity, where more impacted autistic children spend less time, and less impacted autistic children spend more time in general education ( 27). As expected, there is tremendous variability in the success of included autistic children ( 28, 29). Teachers and paraeducators may struggle to meet the range of intensive academic and developmental needs of autistic children in general education settings or rely on general teaching strategies that have little relevance to autistic children ( 30, 31). The complex and heterogeneous presentation of ASD symptoms may require specialized autism training that often is limited and unavailable in standard teacher preparation programs ( 32- 37).

A growing number of EBPs can be used to include and retain autistic children in general education settings purposefully ( 38- 40). In 2015, the National Professional Development Center on Autism Spectrum Disorder (NPDC) applied a rigorous set of criteria to classify 27 interventions as EBPs ( 38). In 2020, the NPDC updated their review finding 28 EBPs with some overlap of the previous EBPs (e.g., scripting and visual supports) and initial evidence qualifying as EBP for two new practices [Sensory Integration Therapy, and music-mediated intervention ( 40)]. While important, these lists do not ensure that teachers and paraeducators consistently receive training to deliver EBPs for autistic children in schools ( 41, 42). In fact, there is a large disconnect between best practice guidelines and actual practice ( 14, 43, 44).

For EBPs to be used, educators must be familiar with and trained in them. However, the extent to which general and special education teachers and paraeducators are familiar with and trained to use EBPs and the types of EBPs most germane to inclusive settings remains minimally explored ( 9, 10, 24, 45). Studies that have examined EBP use among educators have traditionally focused on teachers and not paraeducators. McNeill ( 7) found that educators' knowledge and use of EBPs for autistic students were closely related. Given that these same EBPs often are not successfully adopted, implemented, or sustained in public schools ( 15, 46), familiarity and knowledge should be explored to examine this chasm. Barry et al. ( 24) found that the majority of teachers received little initial teacher education training in autism and almost no continuous professional development before educating an autistic child. The lack of specific knowledge about the use of EBPs may impede implementation efforts to increase use, which could be addressed by more nuanced research.

The purpose of this study was to identify which EBPs general and special education teachers and paraeducators have heard of, been trained in, and use to include and retain autistic children in general education settings more meaningfully. Specifically, this study had the following research questions: (1) Which EBPs have teachers and paraeducators heard of? (2) Which EBPs for autistic children have general and special education teachers and paraeducators been trained to use to support inclusion? (3) Which EBPs do teachers and paraeducators use to support included autistic children? (4) What are the most frequently used EBPs to support the inclusion and retention of autistic children in general education classrooms and how do they differ by role? (5) How do teachers and paraeducators understand EBPs? An exploratory, mixed-methods design was used to obtain educator-reported EBP familiarity, training, and use. These data will allow us to understand usual care practices in schools to support the inclusion of autistic children in general education settings.

Methods

Participants and setting

A free web-based tool, https://thegeneralizer.org, was used to obtain a representative sample of schools based on selected school and district characteristics ( 47). The web-based tool allowed us to capture a broad range of perspectives on the use of EBPs in general education settings to achieve data saturation. The target sample was intended to infer to Washington State schools from Kindergarten-5th grade (K-5), with representative balance based on school characteristics (size, % free and reduced lunch, gender, race, urbanicity/rurality) and district characteristics (number of schools, % English Language Learners, % language at home, English only, and urbanicity/rurality). In total, 56 schools in 28 districts were invited to participate in the study. Approximately 126 interest forms from school educators were received. Educators were screened per established criteria: (1) identified as a general education teacher, special education teacher, or paraeducator; (2) supported an autistic student who participates in a general education setting at least 15 min per day; and (3) worked in a Washington state public elementary school. One-hundred and four interested educators who met criteria were sent the study survey via a Qualtrics-generated hyperlink. Eighty-six educators from 50 schools from 24 districts in WA state completed surveys. The generalizability index is a score between 0 and 1, with 1 indicating that the sample is exactly the same as the population on the characteristics described above, and a 0 indicating that the sample and population share no common features ( 48). The final recruited sample achieved a generalizability index score of 0.92 for Washington State (considered very high), and 0.78 for the US population of schools (considered high) in regard to the characteristics described above.

Demographics

Table 1 presents descriptive information on enrolled participants. A total of 86 educators participated across three roles: general educators ( n = 27), special educators ( n = 31), and paraeducators ( n = 28) who supported at least one autistic student in an inclusive general education classroom; 80 of these participants completed follow-up interviews. Most educators were between ages 35-44 ( n = 30, %=34.9) and had an average of 6.4 years in their current position ( SD = 4.8). Sex distribution was 91.9% female ( n = 79), 8.1% male ( n = 7). One paraeducator identified as Latinx (1.2% of entire sample). Educators self-identified as Asian (3.5%, n = 3), white (86.2%, n = 74), or multiracial (9.3%, n = 8). No participants identified exclusively as Black, Native American, or Hawaiian/Pacific Islander. There were no significant differences among roles based on sex, age, ethnicity, or race.

Procedures

The University of Washington's Institutional Review Boards (IRB) approved the study. When applicable, school district IRB approval was sought. Eight school district IRB applications were submitted and five school district IRB approvals were obtained. We contacted school district officials to obtain a list of elementary schools that have enrolled autistic children who are partially or fully included in a general education classroom and then emailed the school principal. Approximately 358 school principals were emailed. Subsequently, we distributed all recruitment materials (e.g., flyers, consent materials) to general and special education teachers and paraeducators. Before participation, the research team provided a full description to all participants of study procedures and activities included in study participation. Upon consent, participants were asked to complete a modified Autism Treatment Survey (ATS; 13) via an online survey. After completion, all participants were invited to an audio-recorded semi-structured interview (30-45 min) at a convenient time for the participant ( via Zoom). Of the 86 participants, 80 agreed to do a follow-up interview. As an incentive for their participation, all participants were offered a $40 gift card, and their schools received a resource kit of materials to use with autistic children (e.g., Velcro, visual timer, visual supports, sensory toys, and fidgets, etc.).

Measures

Modified Autism Treatment Survey [ATS]

The ATS was designed to measure teachers' frequency of use and training experiences with a comprehensive list of EBPs for autistic children ( 14). Given the increased research evaluating the efficacy of practices since the origination of the ATS, we have updated the ATS as follows: (a) we included practices that have been identified as evidence-based for autistic students since its publication according to the NPDC ( 40); (b) we separated evidence-based multicomponent practices (e.g., peer-based intervention) from strategies (e.g., modeling); (c) we used updated practice definitions that align with the NPDC that have been validated via cognitive interviewing in more recent research ( 49); and (d) we break down components of the implementation strategy-training-to inform later implementation support development (i.e., who provided the training, what type of training). In addition, we added a question about participants' familiarity with each practice with a dichotomous question that asked whether they had heard of the practice ( 49, 50).

Addressing calls for more specific investigations into subtypes of EBPs, we took a novel approach to autism EBP exploration by attending to both multicomponent practices and strategies ( 51). To develop a set of multicomponent practices and strategies that are used to support meaningful inclusion and retention of autistic children in general education settings, we used explicit criteria for exclusion of practices from the NPDC review-practices could not: (1) be assessments (e.g., functional behavior assessment); (2) implemented only outside of schools (e.g., parent-implemented); or (3) require certification (e.g., Pivotal Response Training, Sensory Integration Therapy). We reviewed these criteria and the final set of evidence-based multi-component practices and strategies with an autism intervention expert. Twenty-one EBPs from the 28 listed in the NPDC were included. Multicomponent EBPs included: social narratives, direct instruction, antecedent-based interventions, social skills training, self-management, functional communication training, discrete trial training, peer-mediated instruction and intervention, and naturalistic intervention. Evidence-based strategies included: reinforcement, modeling, task analysis, visual supports, prompting procedures, augmentative and alternative communication, extinction, response interruption/redirection, time delay, technology-aided instruction and intervention, video modeling, and behavioral momentum intervention. Distinguishing multicomponent practice and strategy was necessary to better understand the possible limited use of multicomponent practices rather than excluding these if participants report frequent use of strategies only ( 7, 43).

Semi-structured interview

To complement the modified ATS and more thoroughly explore EBP use to support and retain autistic children in general education settings, we developed a systematic and comprehensive interview guide with questions that explored what the terms "evidence-based practice" and "evidence-based strategy" meant to participants and how they used the identified EBPs from their survey responses. Questions were carefully constructed to elicit clear information without assigning valence to EBP use. We asked each participant about two to four EBPs from their survey. To achieve saturation across practices, strategies, training, and frequency of use, we selected each participant's EBPs based on the following decision-guide: one practice that they had been trained in but did not use, one practice and one strategy that they used frequently regardless of training, and one practice or strategy that was rarely used regardless of training.

Four research team members conducted interviews. Interviews were conducted via Zoom, and audio and visual media were recorded following the participant's consent. Interviewers recorded field notes to be referenced for documentation, recorded emerging themes, and uploaded audio media to Rev.com for transcription. Interviewers reviewed transcripts for accuracy and to confirm validity to audio recording, provide clarity around inaudible segments, and remove identifiable transcript text (e.g., name of school, district, city, etc.).

Data analysis

Crosstabulations with chi-square tests were used to compare educator roles on demographic and descriptive information. ANOVAs were computed to compare roles on the mean total number of different multicomponent practices and strategies the participants were familiar with, trained to use, or used. Due to the lack of homogeneity of variance, Ganes-Howell post-hoc tests were used to test between group differences for the number of multicomponent practices/strategies in which participants were familiar. Tukey's Honestly Significant Difference tests were used for multicomponent practices/strategies trained in and used. We descriptively analyzed the modified ATS by computing percentages of those who were familiar with the practice/strategy; who were trained to use the practice/strategy, and those who used the practice/strategy in the last 2 years.

For qualitative data, the principal investigator and three research team members independently coded an initial set of transcripts to identify codes and met as a group to discuss recurring codes. We developed a codebook with operational definitions and examples of when to use and not use the code; an integrated approach to coding as certain codes were conceptualized during the interview guide development (i.e., deductive approach) and other codes were developed through a close reading of the initial set of transcripts [i.e., inductive approach; ( 52)]. The coding scheme was refined throughout the data analytic process ( 52). Following the development of a stable codebook, three team members coded ten randomly selected transcripts to train and achieve inter-rater reliability above 90%. After achieving initial reliability of 95.1%, coders interpedently coded the remaining transcripts, overlapping on 20% of randomly selected transcripts to maintain interrater reliability; drift reliability was 95.5%. To capture data complexity, avoid errors, reduce groupthink, and circumvent some researcher biases, a consensus process was used in which all reviewers independently coded reliability transcripts and met to compare their coding to arrive at consensus judgments through open dialogue ( 53- 55). We used the approach of inductive thematic saturation to determine when there are no new emerging codes or themes, meaning data saturation has been reached ( 56).

Results

Modified Autism Treatment Survey [ATS; (14)]

Quantitative data were collected from 86 educators. Educator roles significantly differed by the mean number of different multicomponent practices and strategies in which they were familiar ( F = 12.1, p < 0.001), trained in ( F = 9.4, p < 0.001), or used ( F = 17.5, p < 0.001). Post-hoc testing revealed that general education teachers had significantly fewer multicomponent practices and strategies in which they were familiar, trained in, and used compared to the other two roles (see Figure 1). There were no significant differences between special education teachers and paraeducators on any variables.

Familiar multicomponent practices and strategies

Across educator roles, reinforcement (98.8%), modeling (97.7%), and task analysis (94.2%) were the most familiar multicomponent practices or strategies, and behavioral momentum intervention (29.1%), video modeling (44.2%), and naturalistic intervention (44.2%) were the least familiar multicomponent practices or strategies ( Table 2).

Familiar multicomponent practices and strategies by role

General educators were most familiar with reinforcement (96.3%), direct instruction (92.6%), modeling (92.6%), and visual supports (92.6%); and least familiar with behavioral momentum intervention (3.7%), discrete trial teaching (18.5%), and naturalistic intervention (22.2%). Special educators were most familiar with social narratives (100.0%), reinforcement (100.0%), modeling (100.0%), task analysis (100.0%) and visual supports (100.0%) and least familiar with technology-aided instruction and intervention (32.3%), behavioral momentum intervention (38.7%), naturalistic intervention (51.6%). Paraeducators were most familiar with reinforcement (100.0%), modeling (100.0%), task analysis (96.4%), social narratives (96.4%), and antecedent-based interventions (96.4%) and least familiar with video modeling (35.7%), behavioral momentum intervention (42.9%), technology-aided instruction and intervention (57.1%), discrete trial teaching (57.1%), and naturalistic intervention (57.1%).

Training in multicomponent practices and strategies

As shown in Table 3, educators were most frequently trained to use reinforcement (83.7%), modeling (79.1%), and visual supports (74.4%) and least frequently trained to use video modeling (18.6%), peer-mediated instruction and intervention (18.6%), and behavioral momentum intervention (19.8%).

Training in multicomponent practices and strategies by role

General educators were most frequently trained to use reinforcement (77.8%), modeling (70.4%), and visual supports (66.7%) and least frequently trained to use behavioral momentum intervention (0%), discrete trial teaching (3.7%), and video modeling (11.1%). Special educators were most frequently trained to use reinforcement (93.5%), modeling (90.3%), and visual supports (87.1%) and least frequently trained to use peer-mediated instruction and intervention (12.9%), technology-aided instruction and intervention (19.4%), and behavioral momentum intervention (29.0%). Paraeducators were most frequently trained to use reinforcement (78.6%), modeling (75.0%), and prompting procedures (75.0%), and least frequently trained to use video modeling (10.7%), behavioral momentum intervention (28.6%), peer-mediated instruction and intervention (32.1%), technology-aided instruction and intervention (32.1%), and naturalistic intervention (32.1%).

Use of multicomponent practices and strategies

As shown in Table 4, across educator roles and practice types (multicomponent or strategy), reinforcement (97.7%), modeling (94.2%), and visual supports (86.0%) were the most often used. Video modeling (14.0%), technology-aided instruction and intervention (17.4%), and behavioral momentum intervention (19.8%) were the least used. On a scale from 1 (rarely used) to 4 (very often used), the most frequently used (when only including those participants who used it to compute the mean score) were reinforcement ( M = 3.61, SD = 0.58), modeling ( M = 3.54, SD = 0.63), and prompting procedures ( M = 3.49, SD = 0.63), and the least frequently used were video modeling ( M = 2.25, SD = 0.75), peer-mediated instruction and intervention ( M = 2.50, SD = 0.91), and extinction ( M = 2.74, SD = 0.86).

Use of multicomponent practices and strategies by role

Among general educators, the most used multicomponent practices or strategies to facilitate inclusion of an autistic student were reinforcement (92.6%), modeling (88.9%), and visual supports (74.1%); behavioral momentum intervention (0%), discrete trial teaching (3.7%), and video modeling (3.7%) were the least used. On a scale from 1 (rarely used) to 4 (very often used), the most frequently used were modeling ( M = 3.63, SD = 0.50), reinforcement ( M = 3.60, SD = 0.65), and task analysis ( M = 3.60, SD = 0.51). The least frequently used were video modeling, with one participant reporting use, ( M = 2.00, SD = -); discrete trial teaching, with one participant reporting use ( M = 2.00, SD = -); and peer-mediated instruction and intervention ( M = 2.40, SD = 0.55).

Among special educators, the most used multicomponent practices or strategies to facilitate inclusion of an autistic student were reinforcement (100.0%), modeling (100.0%), and visual supports (100.0%) and the least used were peer-mediated instruction and intervention (16.1%), technology-aided instruction and intervention (16.1%), and visual modeling (22.6%). On a scale from 1 (rarely used) to 4 (very often used), of special educators who used a multicomponent practice or strategy, the most frequently used were reinforcement ( M = 3.77, SD = 0.43), modeling ( M = 3.71, SD = 0.46), visual supports ( M = 3.58, SD = 0.62), social skills training ( M = 3.58, SD = 0.70), and prompting procedure ( M = 3.58, SD = 0.58). The least frequently used were video modeling ( M = 2.29, SD = 0.76), peer-mediated instruction and intervention ( M = 2.60, SD = 1.14), and augmentative and alternative communication ( M = 2.65, SD = 1.17).

Among paraeducators, the most used multicomponent practices or strategies to facilitate inclusion of an autistic student were reinforcement (100.0%), modeling (92.9%), and antecedent-based interventions (82.1%) and the least used were video modeling (14.3%), technology-aided instruction and intervention (25.0%), and behavioral momentum intervention (28.6%). On a scale from 1 (rarely used) to 4 (very often used), the most frequently used multicomponent practices or strategies were prompting procedure ( M = 3.50, SD = 0.69), reinforcement ( M = 3.43, SD = 0.63), and modeling ( M = 3.27, SD = 0.83). The least frequently used were video modeling ( M = 2.25, SD = 0.96), peer-mediated instruction and intervention ( M = 2.50, SD = 1.00), and extinction ( M = 2.65, SD = 1.12).

Semi-structured interview

Qualitative data were collected from 80 educators ( n = 26 general education teachers, n = 30 special education teachers, and n = 24 paraeducators); six participants did not respond to the invitation or declined. Almost all educators believed that the term "EBP" meant that there is evidence (e.g., from their own experiences, others' work, and research) backing-up the effectiveness of the practices or strategies. Most also believed that EBPs need to be proven successful through replication in different settings, undergo "multiple trial and error", and "peer review". Some educators also mentioned "to get the desired effects, there needs to be data collection" and continuous effort to fit what individual students need. There were few educators who could not define EBPs or could only describe how they might use an EBP more broadly.

When asked about specific EBPs that educators said they used in their surveys, many educators had to be reminded what the specific EBP meant. Several participants asked the interviewer to provide the definition of that named EBP. Most educators could describe the components of the specific practice or strategy that was asked (e.g., steps that they use in the classroom with the student) but could not name the EBP. More educators asked for the definition (coded 50 times) compared to educators who knew what the term was and its definition (coded 19 times). There also were a few instances where the educators provided the wrong definition for a specific EBP they described. For example, one participant defined reinforcement when asked about antecedent-based intervention, "When I hear [Antecedent-Based Intervention], I'm thinking in my head, okay, so this is like a behavior chart where I'm reinforcing behaviors that I want and not reinforcing the behaviors that I don't, and then re-teaching new behaviors...".

Almost all educators described how they used or applied specific EBPs with autistic students. The majority said they used additional school-based programs such as Second Steps or Edmark to complement their EBP use. Many participants also mentioned combining multiple EBPs together (e.g., prompting and visual supports, direct instruction and social skills training) to help their autistic students. There were a few educators who described the use of specific EBPs incorrectly-the most frequent misapplication was naturalistic intervention (e.g., 25% of the time naturalistic intervention was described did not match the definition in the literature).

Discussion

The heterogeneity of autism symptoms poses a tremendous challenge in providing targeted, individualized, and meaningful EBPs to autistic children in public schools-no single EBP addresses the needs of all autistic children ( 8), which makes it almost impossible for educators to become familiar, receive training, and develop expertise to use a multitude of EBPs to support various autistic children in their care. Despite the catalog of promising, emerging, and established EBPs in the NPDC ( 40), it is still unclear which EBPs are used in elementary schools to support the inclusion and retention of autistic children in their least restrictive environment. This study is one of the first to prospectively understand the number and type of EBPs that elementary school general and special education teachers and paraeducators were familiar, trained in, and used to support autistic children in inclusive settings.

Overall, we found that educators were most familiar with and trained in reinforcement, modeling, task analysis, and visual supports but reinforcement, modeling, visual supports, and antecedent-based interventions were the most frequently used EBPs to support the inclusion and retention of autistic children in general education classrooms. We also found significant differences by educator role in that general education teachers had significantly less familiarity, training in EBPs, and use compared to special education teachers and paraeducators. Qualitative data explored nuanced differences in educators' understanding of EBPs and uncovered a mixed understanding of specific EBPs and their unique application to autistic students. The results of this study have important implications on how public schools consider and support EBP use among general and special education teachers and paraeducators for included autistic children.

Not surprisingly, all four EBPs (reinforcement, modeling, task analysis, and visual supports) that educators were most familiar with and trained in were evidence-based strategies. Only one EBP, antecedent-based intervention, was classified as a multicomponent practice. Although reinforcement, modeling, task analysis, and visual supports often are embedded steps in many of the queried multicomponent practices, these findings point to the challenges around EBP use of more "complex" interventions that comprise multiple strategies and components ( 51, 57). Multicomponent practices may be "harder" and more challenging for educators to implement, given their intervention complexity. One critical aspect of intervention complexity is that complex EBPs may require higher interventionist training and skill ( 57), a known barrier to implementing autism EBPs in school settings ( 28, 58). Interestingly, while these EBPs address ancillary behaviors related to the education of autistic children, they do not specifically address the core symptoms (e.g., social interaction and communication) underlying autism. Multicomponent practices with a strong evidence-base supporting social interaction and communication such as naturalistic intervention and peer-mediated instruction and intervention were infrequently used, despite evidence that educators can effectively implement these ( 59). Efforts to improve familiarity, training of targeted EBPs, and use to support specific outcomes such as social behaviors may be warranted to cultivate a more conducive environment for inclusion of autistic children.

The results also indicated that general education teachers had significantly less familiarity, training in EBPs, and use than their special education counterparts. These findings suggest that general education teachers may need more exposure to and training in autism-specific EBPs given the increased prevalence and high likelihood that autistic children will be included in their classrooms. There are several avenues in which this can occur. First, standard teacher preparation programs should consider requiring more specialized autism training (e.g., coursework, practicum, rotations, etc.) during educators' pre-service learning to build familiarity, practice, and gain mastery in EBP use ( 49, 60). Second, school districts and school buildings should prioritize in-service training or professional development opportunities to continuously learn new EBPs to support autistic children. Community-academic partnerships may be one avenue to support the training of providers to fidelity in autism EBPs ( 61, 62). Lastly, while most schools have adopted teams that comprise general and special educators and specialists (e.g., counselors, psychologists, speech therapists, etc.) to support autistic children, there may be some utility in protecting shared planning or meeting time to discuss supports for autistic children, monitor and track progress, or problem-solve around EBP implementation.

While it is promising that most educators understood what the term "EBP" meant, the qualitative data suggested there is some mismatch between how educators describe their use of specific EBPs compared to how those EBPs are defined in the literature. Although many educators were able to describe how they used specific EBPs in their classroom with autistic children, they could not name that EBP nor did they describe their use of it in a way that matched the research description. These findings highlight the discrepancy between the terminology used in autism research and educators' implementation-researchers may define practices in ways that educators may not understand or apply in practice. There is a need for future research to document educators' specific adaptations to EBPs from research trials that may improve EBP fit to the local contexts and resources of schools.

Limitations and future directions

We note several limitations, including participant characterization, homogeneity, and reliance on self-rated assessments. The representativeness of our sample on certain school- and district-wide characteristics was very high for Washington State and high for the United States. This adds inferential power to these findings as generalizable. However, there may be other characteristics for which we do not have important data, such as the proportion of autistic students, rates of autism training and awareness, and availability of funding for special education services. Second, although participants were a representative sample of WA and the USA, included educators were predominately white (86.2%). While a large percentage of general education (81.9%) and special education teachers in the United State identify as white (82.1%), there are significant differences in diversity across regions, type of district and schools ( 63), which may limit generalization of the present findings to other US and international school contexts. Third, data were collected during the 2020-2021 school year when schools were closed due to COVID-19, and we were unable to conduct live observations to corroborate EBP use with fidelity. Although necessary, reliance on self-report to understand EBP use is prone to response bias. To better understand EBP use to support inclusion and retention of autistic students, future studies should explore characterization factors, include a more diverse sample, and corroborate self-report data with direct observation of EBP use.

Conclusions

In sum, the present paper highlights important overlap and divergence between how general and special educators and paraeducators are familiar, trained in, and use EBPs to support autistic students in inclusive education settings. Educators reported familiarity (98.8%), use (97.7%), and training (83.7%) in reinforcement and the least familiarity with behavioral momentum (29.1%), training in both video modeling and peer-mediated instruction and intervention (18.6%), and use of video modeling (14.0%). School personnel may benefit from more exposure, training, and collaboration related to what EBPs are, autism-specific EBPs, and selection of EBPs across education contexts. Due to increasing efforts to improve EBP use and inclusion of autistic students, public schools must consider how to better and more consistently train their educators to use EBPs to support their students with varying needs. These findings underscore the need for further research on how educators use EBPs as well as ways in which implementation supports may facilitate EBP use to support the inclusion and retention of autistic students.

Data availability statement

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Ethics statement

The studies involving human participants were reviewed and approved by the University of Washington IRB (IRB ID: STUDY00010045) as well as each participating school district's Institutional Review Boards have approved the study procedures. The patients/participants provided their written informed consent to participate in this study.

Author contributions

JL is the principal investigator of the study, generated the idea and designed the study, is the primary writer of the manuscript, and approved all changes. MDP is the study methodologist and drafted the data analysis sections. AH, MJ, and MH coded all qualitative data. AB and AO supported the writing of the manuscript. All authors were involved in developing, editing, reviewing, and providing feedback for this manuscript and have given approval of the final version to be published.

Funding

This study was previously reviewed and approved and is funded by the Institute of Education Sciences [grant #: R324A200033 (JL)] in the amount of $1,399,375 and Institute of Education Sciences [grant #: #R305B170021 (Bruns)] in the amount of $702,476. The funder had no role in the design of this project, in the writing of the manuscript, and in the decision to submit this manuscript for publication.

Acknowledgments

We thank Dr. Eric Bruns, who is PI of the training grant that supported MH's time on this project.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

References

5. IDEA. (2004). Individuals With Disabilities Education Act 20 U.S.C. § 1400. Washington, DC: US Department of Education (2004).
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Frontiers | Supporting the inclusion and retention of autistic students: Exploring teachers' and paraeducators' use of evidence-based practices in public elementary schools

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Introduction Educators in public schools are required to serve students in their least restrictive environment. While many evidence-bas...

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General education teachers can support students with ASD

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General education teachers can support students with ASD

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"Autism Speaks" provides guidance for general education teachers on effectively supporting students with Autism Spectrum Disorder (ASD). Most general education teachers lack sufficient autism-related instruction, where this resource allows teachers to learn how to support.

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How general education teachers can support students with ASD | Autism Speaks

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Click here for some great tips to share with your child’s teachers to help them create an inclusive classroom environment.

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The National Autism Association provides valuable information about the signs of autism spectrum disorder (ASD), which can help teachers and families recognize potential indicators of the condition. Through this association website, you are able to see early signs, symptoms, learn about diagnostic evaluation and more general information.

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Waterford is an organization dedicated to providing educational resources and support for children, parents, and educators. Offers a diverse range of activities tailored to children with autism, spanning various subjects and developmental areas. Waterford provides a wealth of activities, teaching strategies, and resources aimed at empowering educators and parents to effectively teach and support children with autism, fostering their overall development and success.

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Because approximately 1 in 59 students are diagnosed with autism, learning how to help students with this disorder in the classroom is so important.[1] Teaching young students with autism communication skills and learning strategies makes it all the more likely that they'll reach their academic potential later on. And the more you learn about autism spectrum disorder, the better you'll be able to prepare these students for lifelong success.

Autism spectrum disorder (ASD) is a developmental disability that causes hypersensitivity to sights, sounds, and other sensory information. Symptoms of autism generally fall into three categories:[2]

Communication issues

Social impairment

Repetitive behaviors (known among the autism community as "stimming")

Here are 15 fun activities to help children with autism feel welcome in your class while addressing their symptoms and individual learning styles. Whether you play them one-on-one or as group activities, these are excellent ways to keep students with autism engaged and ready to learn.

Social Skills Activities for Elementary Students with Autism

A common characteristic of students with autism is trouble communicating or connecting with their classmates. Use these social skills activities to teach kids with autism how to recognize social cues, practice empathy, and learn other important life skills.

1. Name Game [3]

This fun group communication activity teaches students with autism an essential skill: how to introduce themselves and learn someone else's name. To play this game, gather your students in a circle so they can all see each other. Start by pointing at yourself and saying your name ("I am Mr. or Ms. _____."). Then, ask the child on your right to share their name just like you did and then repeat your name while pointing at you. Have each child take turn saying their name, then pointing at another child in the class and repeating their name.

The Name Game is an especially fun social skills activity for children with autism to do at the beginning of the school year. That way, they'll be able to learn their classmates' names and get a head start on making new friends.

2. "How Would It Feel to Be ____?" [4]

Next time you read a book to your class, try asking your students how it would feel to be the main character in the story. If you're reading a picture book about Cinderella, for example, you could ask how they would feel if they had two evil stepsisters who were mean to them. Or if you're reading Peter Pan as a class, you could ask them what happy memories they would think about to fly with magic pixie dust.

This can help students with autism learn empathy as well as how to see situations in their lives from another perspective. It can also teach them how to recognize emotional cues by encouraging them to put themselves in the perspective of another person.

3. Sharing Time [5]

Sharing time is a classic elementary school staple, and it can also be a great social-emotional learning (SEL) activity for kids with autism. Every week, have one kid in your class bring something that they'd like to share with the class. This will not only show students with autism how to discuss their interests with others but also how to practice active listening. And if they're fascinated by something another student brings in (or vice versa), they may even make a friend.

4. Emotion Cards

These printable cards for students with autism can help them learn how to recognize different emotions in themselves and others. Cut out each one with scissors and shuffle them in a deck. Then, go through each card and see if your student can recognize the emotion without looking at the word.

If they get stuck, that's okay-just show them the word and give them context for the emotion shown. If the card is "embarrassed," for example, you could say, "When a person is embarrassed, they might feel like they have done something silly or wrong on accident."

5. Board Games with a Twist

Teaching children manners can be a helpful way to boost social skills and explain the importance of being polite. This simple, but effective activity puts an etiquette-related twist on a simple game of chess, checkers, or mancala by requiring players to wish their opponent "good luck" or "good game" before and after they have played.

6. What Would You Do?

For a take-home activity you can share with families, try this What Would You Do? game. Families can go through different scenarios together and decide how they would react with questions like "How would you help?" or "What would you say?"

This activity keeps social skills sharp and reinforces relationship-building skills.

Sensory Activities for Children with Autism

Because children with autism are often hyper aware of sensory input, it's helpful for educators to provide accommodations so their students can focus in class. These activities involving sensory stimulation can keep kids with autism grounded in the present and comfortable learning with the rest of their classmates.

7. Sorting with Snacks Activity [6]

This tactile activity for children with autism can be a fun way to engage students during math time. Give everyone in your class a food that is easy to sort, like chewy snacks or small crackers. Multicolored snacks are ideal, but you can also use food that comes in different shapes, textures, or sizes.

First, ask them to sort the food by color, shape, or another characteristic. Then, use the snacks to teach students basic math skills like counting, adding, or subtraction. Once they've grasped the concept you want to teach, reward your students by letting them eat the snack.

8. Vegetable Paint Stamps [7]

This art activity for children with autism engages touch and sight to keep students focused on their assignment. Before class begins, cut slices of vegetables like potatoes, cucumbers, or peppers. Hand out a few vegetable slices to each child along with a cup of paint. Instruct your students to dip the bottom of the vegetable slice into the paint and then press it against a piece of paper.

As your students use these homemade stamps, they will make vibrant botanical impressions on their paper. From there, your students can either leave them as they are or finger paint to transform them into whimsical artwork.

9. Scientific Slime Experiments

Slime is not only a popular craft for young children but also a great sensory activity for autism in class. There are plenty of simple slime recipes online-look up your favorite and have fun making it with your students. You can use this as a tactile art activity if you'd like or as a science activity for elementary students.

10. Fidget Toys

Fidget toys are a well-known sensory tool for helping children with autism and other sensory processing disorders stay calm and focused. Depending on your available resources, you can either stock your classroom with a few fidget toys or make some of your own.

We Are Teachers has compiled a list of eleven fidget toys you can make on a budget with your students. From classics like fidget spinners to repurposed pipe cleaners or popsicle sticks, you're sure to find something useful for your classroom.

11.Auditory Sensory Play

When the phrase "sensory play" comes up, visual or textual activities usually come to mind first. Autism Adventures, however, suggests including activities that involve sound-with a few examples to get you started:[15]

Musical chairs

White noise machine

Simon Says

Noise-cancelling headphones

Rhythm instruments like shakers, rain sticks, or drums

12. Sensory Bin

Sensory bins can be useful for two reasons. First, they encourage differentiated instruction or independent play-both of which can have academic benefits for students. And second, they're a straightforward and accessible sensory experience for students with autism.

The Kindergarten Smorgasbord has put together a few useful tips for making your own sensory bin. Use them as a guide to set up a sensory bin that will best accommodate your students' needs.

Calming Activities to Prevent Autism Meltdowns in Class

When students with autism are feeling overwhelmed, the intense response that they feel may cause them to lose control of their emotions. This is called an "autism meltdown" and is different from when students without autism act out in class. While the best strategy for autism meltdowns is to seek help from a school specialist, these calm down activities can help to de-escalate stressful situations.

13. Grounding Techniques

Grounding techniques are designed to help us focus on the present during stressful situations. Here are a few grounding activities for kids with autism to try if they seem agitated:[8]

Count to ten or recite the alphabet as slowly as you can

Listen to calming music and pay attention to the different instruments

List five different things that you can see around the room

Try stretching or simple yoga exercises and focus on how your body feels

Hold something tactile like a piece of clay or a stuffed animal

For older students with autism, you could also try mindfulness meditation. This can produce a similar effect and help students tune into the present rather than getting carried away by their emotions.

14. Student Retreat Zone [9]

When a student with autism is overwhelmed, giving them a place where they can relax and take a break from sensory stimulation can sometimes go a long way. Designate a corner of your class as the "Student Retreat Zone" and fill it with sensory toys, picture books, comfortable seats, and calming activities that students with autism could do on their own.

Let every student in your class know that if they feel anxious or stressed, they can always take a few minutes to decompress in the Student Retreat Zone. That way, you don't have to single your student with autism out but still let them know that it's an option. If your student with autism seems like they could use some time away from class, you could also ask them if they'd like to read or work on homework in the library for a while.

15. Calm Down Drawer [10]

Tactile toys can help children with autism calm down if they're agitated since their minds are so attuned to sensory information. If you have children with autism in your class, fill a drawer in your classroom with toys that could help neutralize overwhelming emotions. When your student seems stressed or has trouble focusing, give them a sensory toy or two to help them relax.

Here are a few ideas for sensory toys to put in your "calm down drawer:" [11]

Play dough

Fidget toys

Stress balls

Weighted blankets

Aromatherapy pillows

16. Coloring

According to a partner article by The National Institute for Trauma and Loss in Children published by We Are Teachers, coloring pages can be a great mind-body exercise for calming down and focusing on the here and now.[16]

Keep a few coloring pages on hand, and suggest them as a calm-down activity when your students are overwhelmed. For a few free coloring pages to get you started, check out this resource from Disney.

17. Calm-Down Cards

If your student with autism struggles with calming down after feeling strong emotions, calm-down cards can be a helpful resource. A mother whose child has autism has created a how-to on creating your own calm-down cards at And Next Comes L.

Each card has a helpful idea for calming down after a stressful moment. Plus, the author notes they can also be useful for children with anxiety-a great resource for your classroom to have.

18. Mindful Breathing

Mindfulness is a technique that encourages children to keep their mind in the present and deal with uncomfortable emotions. If your student is struggling to calm down, try watching this mindful breathing video to help them regain composure.

Effective Teaching Strategies for Children with Autism

In some cases, the learning characteristics of students with autism may differ from the rest of your class. But luckily, the right teaching strategies and methods can keep children with autism on track to finish the school year strong. Try these tips, educational accommodations, and resources for students with autism to help them learn concepts that might otherwise be difficult for them to grasp.

19. Bring Special Interests Into Lesson Plans [12]

Many children with autism have a fixation on certain topics or activities. Take advantage of what they're passionate about and use it while teaching students with autism to help them focus in class. If a child with autism loves outer space, for example, you could plan a math assignment about counting the planets in our Solar System.

20. Use Multisensory Learning

Many kids with autism are multisensory thinkers and don't focus as well when assignments only engage one of their senses. Renowned scientist and autism advocate Dr. Temple Grandin once said, "I used to think adults spoke a different language. I think in pictures. Words are like a second language to me." [13]

For this reason, lessons that engage several senses like sight, hearing, and touch can make students with autism more responsive in class. You could, for example, teach children with autism how to read with magnet letters or sing a patriotic song to learn about American history.

21. Try a SMART Goal Challenge

If a student with autism is having a hard time with school, sit down with them and pick a SMART goal to work on over the next month or semester. SMART goals are an effective way to help children with autism reach their potential, and they are: [14]

Suppose, for example, that your student with autism is having trouble learning how to recognize emotions. You could make a goal with them to practice flash cards with emotions on them every day for five minutes and for the student to recognize each card by the end of the month. As long as the SMART goal hits all of the criteria, it can help your student focus on ways to make progress.

22. Provide Clear Choices

According to educators at the special education program of St Joseph's University, children with autism may become overwhelmed when given too many options.[17] Keep this in mind while creating assignments for your students or asking them questions in class. That way, you're more likely to keep your student with autism focused and comfortable choosing an answer.

23. Create a Strong Classroom Routine

In an article with Scholastic, educator Kim Greene reminds teachers that students with autism work best with a strong daily structure.[18] She suggests posting your class schedule for every student to see and, if possible, providing visuals and extra transition time to students with autism.

24. Offer Accommodations for Students with Limited Motor Skills

Some students with autism may have more trouble with activities that require fine motor skills than others. In an article with the Indiana Resource Center for Autism, renowned scientist and advocate Dr. Temple Grandin suggests offering accommodations-like typing on a computer instead of writing-to mitigate these challenges.[19]

When it comes to specific accommodations, it may depend on the individual. It's always a good idea to reach out to a student's family to determine the best resources for their child.

Activities for Autism Awareness Month in April

April is Autism Awareness Month, a time when we celebrate neurodiversity and help students with autism feel welcome in private or public schools. Although parents may not want their child's autism diagnosis to be shared (and you never should without their permission), you can still teach your class about inclusion this month without mentioning a certain student.

Use these three games as autism awareness activities during April or whenever you want to teach a lesson on diversity.

25. "Just Like Me" Activity

For this activity, gather all of your students together on the floor so they can all see each other. Have each child take turns sharing something about themselves, like:

"I have a pet dog."

"I can play the piano."

"My birthday is in September."

"I love to play soccer."

"My favorite color is yellow."

If a statement also applies to other students (like, for example, they also play the piano), instruct them to raise their hands. This will help remind students that they share more similarities than differences with their peers and that they can always find something to talk about.

26. Picture Books About Diversity

By reading a story about inclusiveness to your class, you can help them remember to be kind to everyone and look out for people who are different.

Here are a few picture books about diversity that you can share with your students:

The Sneetches and Other Stories by Dr. Seuss

I'm New Here by Anne Sibley O'Brian

It's Okay to Be Different by Todd Parr

Everywhere Babies by Susan Meyers and Marla Frazee

The Girl Who Thought In Pictures: The Story of Dr. Temple Grandin by Julia Finley Mosca

The last book on this list, The Girl Who Thought in Pictures, is about a famous researcher who was diagnosed with autism and has since stood as an activist for people with her condition. It is perfect for helping kids understand autism a little better without calling out a specific student.

27. Apples and Actions Game [15]

This object lesson starts with showing your student an apple. Pass the apple around the class and, as you do, have each child insult it and drop it on their desk or the ground. After every child has dropped it and said a mean thing to it, cut the apple in half and show your students all the bruises inside.

Explain to them that our words have consequences and that everything we say can make an impact on someone else. Just like how insulting and dropping the apple can bruise it, being mean to a classmate can have big effects on them. That way, your students will always remember to be kind.

28. Autism Bulletin Board

The puzzle piece is a popular autism awareness symbol. For a simple yet meaningful way to teach your students about autism awareness, create this puzzle piece bulletin board from Mrs. D's Corner. Each piece fights against negative stereotypes by reminding your students that people with autism are intelligent, empathetic, important, and so much more.

29. Teach Students About Historical Figures with Autism

Although the disorder wasn't discovered until the twentieth-century, people with autism have made important contributions to history, and it's important to educate students about them-not just in April but throughout the year. Here are a few well-known figures who are diagnosed with or believed to have had autism to get you started:[20]

Greta Thunberg

Vincent van Gogh

Temple Grandin

Albert Einstein

Emily Dickinson

30. Hold a Professional Development Session on Autism

It's so important to teach faculty about autism awareness, too. If you're a school administrator, consider holding a professional development session on teaching students with autism or sharing a few resources.

For example, the Regional Educational Laboratory Program has put together a helpful resource for administrators on how educators can support students with autism during remote learning.
Sources:

1. Center for Disease Control and Prevention. Data & Statistics on Autism Spectrum Disorder. https://www.cdc.gov/ncbddd/autism/data.html.

2. The National Institute for Mental Health. A Parent's Guide to Autism Spectrum Disorder. https://www.autism-watch.org/general/nimh.pdf

3. Shapiro, L.E. 101 Ways to Teach Children Social Skills. The Bureau for At-Risk Youth, 2004.

4. Dougan, R. Social Emotional Learning Guidebook: Ideas for Incorporating SEL Activities into your Classroom. https://www.dvc.edu/faculty-staff/pdfs/SEL-Guidebook.pdf.

5. Shapiro, L.E. 101 Ways to Teach Children Social Skills. The Bureau for At-Risk Youth, 2004.

6. Autism Parenting Magazine. Sensory Play Ideas and Summer Activities for Kids with Autism. https://www.autismparentingmagazine.com/best-sensory-play-ideas/.

7. Autism Speaks. 10 Fun Summer DIY Sensory Games for Kids. https://www.autismspeaks.org/blog/10-fun-summer-diy-sensory-games-kids.

8. Noelke, K. Grounding Worksheet. https://www.winona.edu/resilience/Media/Grounding-Worksheet.pdf.

9. Tullemans, A. Self-Calming Strategies. Autism Spectrum Disorder News, July 2013, 23.

10. Center for Disease Control and Prevention. Data & Statistics on Autism Spectrum Disorder. Retrieved from cdc.gov: https://www.cdc.gov/ncbddd/autism/data.html.

11. Larkey, S. Strategies for teaching students with Autism Spectrum Disorder and other students with special needs. Learning Links: Helping Kids Learn, 3, pp. 1-5.

12. Blanc, M. Finding the Words... When They Are Pictures! Helping Your Child Become Verbal! Part 1. Autism/Asperger's Digest, May-June 2006, pp. 41-44.

13. Larkey, S. Strategies for teaching students with Autism Spectrum Disorder and other students with special needs. Learning Links: Helping Kids Learn, 3, pp. 1-5.

14. Penn State Extension. More Diversity Activities for Children and Adults. R https://extension.psu.edu/more-diversity-activities-for-youth-and-adults.

15. Autism Adventures. Sensory Play in the Classroom . www.autismadventures.com/sensory-play-in-the-classroom/

16. The National Institute for Trauma and Loss in Children. 5 Calming Mind-Body Exercises to Try With Your Students. We Are Teachers. April 2018. https://www.weareteachers.com/mind-body-skills/.

17. Saint Joseph's University. Techniques for Teaching Students with Autism Spectrum Disorder. https://online.sju.edu/graduate/masters-special-education/resources/articles/techniques-for-teaching-students-with-autism-spectrum-disorder.

18. Greene, K. Teaching Students with Autism Spectrum Disorder. https://www.scholastic.com/teachers/articles/teaching-content/teaching-students-autism-spectrum-disorder/.

19. Grandin, T. Teaching Tips for Children and Adults with Autism. Indiana Resource Center for Autism. https://www.iidc.indiana.edu/irca/articles/teaching-tips-for-children-and-adults-with-autism.html.

20. Autism Community Network. Famous-With Autism. https://www.autismcommunity.org.au/famous-with-autism.html.

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30 Activities, Teaching Strategies, and Resources for Teaching Children with Autism - Waterford.org

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Use these activities to help children with autism feel welcome in your class while addressing their symptoms and individual learning styles.

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Cortica is a comprehensive healthcare organization that offers a range of services for individuals with autism spectrum disorder (ASD) and other developmental differences. The website likely provides information about autism specialists and their role within the organization. Cortica's autism specialists are likely dedicated professionals committed to providing comprehensive and personalized care to individuals with autism and their families. They likely strive to empower individuals with autism to reach their full potential and lead fulfilling lives.

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Autism Treatments & Therapy Options | Cortica Care Model

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Learn about the Cortica Care Model: six autism treatment areas and integrative autism therapies that address a child’s developing brain.

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Effectiveness of a multi-level implementation strategy for ASD interventions

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Effectiveness of a multi-level implementation strategy for ASD interventions

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Implementation Science is resource that focuses on studying methods to promote the integration of evidence-based practices and interventions into real-world settings. This research shows the effectiveness of multi-level implementation strategies for ASD interventions contributes to our understanding of how to bridge the gap between research and practice, ultimately improving outcomes for individuals with ASD and their families.

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Implementation Science 13, Article number: 66 (2018) Cite this article

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Abstract

Background

The Centers for Disease Control (2018) estimates that 1 in 59 children has autism spectrum disorder, and the annual cost of ASD in the U.S. is estimated to be $236 billion. Evidence-based interventions have been developed and demonstrate effectiveness in improving child outcomes. However, research on generalizable methods to scale up these practices in the multiple service systems caring for these children has been limited and is critical to meet this growing public health need. This project includes two, coordinated studies testing the effectiveness of the T ranslating E vidence-based Interventions (EBI) for A SD: M ulti-Level Implementation S trategy (TEAMS) model. TEAMS focuses on improving implementation leadership, organizational climate, and provider attitudes and motivation in order to improve two key implementation outcomes-provider training completion and intervention fidelity and subsequent child outcomes. The TEAMS Leadership Institute applies implementation leadership strategies and TEAMS Individualized Provider Strategies for training applies motivational interviewing strategies to facilitate provider and organizational behavior change.

Methods

A cluster randomized implementation/effectiveness Hybrid, type 3, trial with a dismantling design will be used to understand the effectiveness of TEAMS and the mechanisms of change across settings and participants. Study #1 will test the TEAMS model with AIM HI ( An Individualized Mental Health Intervention for ASD) in publicly funded mental health services. Study #2 will test TEAMS with CPRT ( Classroom Pivotal Response Teaching) in education settings. Thirty-seven mental health programs and 37 school districts will be randomized, stratified by county and study, to one of four groups (Standard Provider Training Only, Standard Provider Training + Leader Training, Enhanced Provider Training, Enhanced Provider Training + Leader Training) to test the effectiveness of combining standard, EBI-specific training with the two TEAMS modules individually and together on multiple implementation outcomes. Implementation outcomes including provider training completion, fidelity (coded by observers blind to group assignment) and child behavior change will be examined for 295 mental health providers, 295 teachers, and 590 children.

Discussion

This implementation intervention has the potential to increase quality of care for ASD in publicly funded settings by improving effectiveness of intervention implementation. The process and modules will be generalizable to multiple service systems, providers, and interventions, providing broad impact in community services.

Trial registration

This study is registered with Clinicaltrials.gov ( NCT03380078). Registered 20 December 2017, retrospectively registered.

Peer Review reports

Background

Caring for children with ASD is a significant public health concern

The Centers for Disease Control (CDC) estimates that 1 in 59 children has ASD [ 1]. Long-term outcomes for this populations are poor [ 2, 3, 4, 5], and the annual cost in the USA estimated to be $268 billion currently and an estimated $461 billion by 2025 given the high expenditures on care and lost productivity for parents and individuals with ASD [ 6]. Despite costly investments in the development of efficacious behavioral interventions, these ASD evidence-based interventions (EBI) are not routinely used in community-based care [ 7, 8, 9, 10]. In response to this quality gap, there have been urgent calls for the development and testing of implementation interventions to facilitate successful uptake and sustained delivery of EBI across public service systems [ 11, 12]. We apply the EPIS Implementation Model [ 13] (see Fig. 1) to frame our current and previous studies because it was developed for a public child-services context and integrates a multi-level framework. We build on our studies of intervention fit and effectiveness in this project which examines an implementation intervention that acts on interrelated inner context variables of implementation leadership, climate and provider attitudes [ 14].

Applying the exploration, preparation, implementation, sustainment (EPIS) conceptual model of implementation to ASD EBI

Routine services for school-age children with ASD (outer context)

National data indicate that children with ASD are likely to access a variety of public service systems [ 15, 16]. The two service systems that accessed most often for school-age children with ASD are education and mental health [ 17]. The number of children with ASD served by schools has grown fivefold from 93,000 in 2000 to 455,000 in 2011 [ 18]. The education system (ED) is responsible for targeting a wide range of needs that interfere with a child's ability to benefit from general ED including improving learning skills such as attention and engagement, and core symptoms of ASD. Over 90% of students with ASD are served in public schools in regular or special ED settings [ 18]. Mental health (MH) services also play an important role in caring for school-age children with ASD for treatment of behavioral and co-occurring psychiatric problems [ 16]. Approximately 70% of children with ASD meet criteria for at least one additional psychiatric disorder [ 15, 19]. Furthermore, challenging behaviors (e.g., aggression, noncompliance, self-injury) are commonly associated with ASD and significantly impact child and family functioning [ 20].

Efficacy of behavioral interventions for ASD (intervention characteristics)

Behavioral interventions are considered well established for targeting outcomes in many areas (e.g., academic, communication, social, mental health/behavioral) based on independent reviews by the National Autism Center [ 21] and National Professional Development Center on ASD [ 22]. Comprehensive packages of intervention strategies (e.g., pivotal response teaching) have been found to improve social communication, play, and engagement [ 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32]. Furthermore, function-based positive behavior support strategies effectively reduce challenging behaviors [ 20, 21, 22, 33]. Despite the growing evidence for behavior interventions for a wide range of treatment targets in children with ASD, these interventions are not consistently or effectively used in routine services [ 8, 9, 10].

Responding to gaps between research and community practice: development of AIM HI and CPRT interventions (EBI/inner context fit)

Unfortunately, there are concerning gaps between EBI and routine care in ED and MH services. For example, a majority of educators report using an "eclectic" treatment approach [ 10], which is not supported by empirical data [ 10, 34]. Studies in MH services indicate that therapists use EBI strategies with low intensity and have very limited training in ASD [ 8, 9]. Even when teachers and MH providers are aware of EBI for ASD and are attempting to use them, they do not do so with high levels of fidelity [ 35, 36]. Additionally, parents of children with ASD report poorer satisfaction with community services than parents of children with other special needs, further indicating an ongoing need for improving services [ 37], particularly for racial/ethnic minority families [ 38, 39].

In response to these concerning gaps between EBIs and routine care, our research groups have used community-partnered approaches to adapt and implement behavioral EBI for delivery in routine care in multiple service systems [ 40, 41, 42, 43]. AIM HI ("An Individualized Mental Health Intervention for ASD" [ 44]) refers to a package of well-established, evidence-based behavioral strategies designed to reduce challenging behaviors in children served in MH service settings. CPRT ("Classroom Pivotal Response Teaching" [ 45]) refers to a naturalistic behavioral intervention adapted from pivotal response training (PRT) for use during classroom activities to target social, communication, behavior, and learning skills. Pilot studies and ongoing large-scale effectiveness trials (NIMH R01MH094317; IES R324A140005; R324B070027) conducted in the targeted community service settings show high levels of feasibility, acceptability, and support the overall effectiveness of the clinical interventions for improving child outcomes when providers complete training and deliver the interventions with fidelity [ 41, 46]. AIM HI and CPRT research share common methods for developing, adapting, and testing interventions in varied community service settings [ 43] and report similar outcomes, making them ideal for cross-service setting comparison of innovative implementation interventions.

Need for multi-level implementation interventions targeting inner context factors to improve implementation outcomes (training completion, fidelity, child outcomes)

Recent data from the AIM HI and CPRT large-scale effectiveness trials indicate that, even with systematically adapted interventions, strong community partnership, and best practices in training and consultation, there is variability in training completion and fidelity (e.g., 17-26% of providers participating in our research-based training do not complete training and 27-30% do not meet fidelity criteria) [ 36]. Because provider fidelity of EBIs is related to child outcomes [ 47, 48], testing methods of improving implementation outcomes is critical to ensuring positive child-level outcomes when EBIs are implemented in routine care [ 49, 50].

Leadership- and provider-level targets of implementation interventions (see Fig. 2)

Glisson and Williams [ 51] call for carefully designed, multi-level studies testing specific change mechanisms as they affect both leader- and provider-level factors. However, there is limited research examining cross-level mechanisms linking specific implementation interventions to targeted changes in provider behaviors [ 52]. Preliminary data from AIM HI and CPRT effectiveness studies align with other literature indicating two inner context variables, provider attitudes and engagement in training [ 11, 53] and implementation leadership/climate and support strategies [ 54] are associated with successful implementation.

TEAMS intervention, mechanisms, and outcomes

Implementation leadership

Recent research highlights the importance of leadership in successful implementation of innovative practices [ 55, 56, 57, 58]. Implementation leadership focuses on specific behaviors and actions that demonstrate the leader's commitment to, knowledge of, support for, and perseverance during EBI implementation. Implementation leadership can improve the climate for use of EBI [ 14]. Positive implementation climate and use of support strategies such as training availability and ongoing monitoring of performance has been linked to better sustainment of innovation, improved child outcomes, and decreased staff burnout and turn over [ 59]. When leaders provide clear guidance during implementation, facilitate support among co-workers and from administration for effective implementation, trainees report an increased sense of competence and satisfaction [ 60]. Additionally, a clear relationship between organizational culture and climate and child-level outcomes has been identified in MH and ED settings for behavior disorders and ASD [ 12, 61, 62].

Therefore, the TEAMS Leadership Institute (TLI) module is directed toward a low-cost method of improving implementation climate through specific implementation leadership training [ 63]. We are focusing specifically on implementation leadership as it is highly targeted (as opposed to more general leadership training) and provides specific EBI strategies that can be used in public service settings with limited resources. TLI draws from the Leadership and Organizational Change for Implementation (LOCI) [ 54] model which targets development of first-level leaders (e.g., immediate supervisors) with the goal of optimizing EBI implementation [ 64]. We expect TLI to specifically affect implementation climate, which is related to providers' perceptions of leadership support of the EBI implementation [ 65].

Provider attitudes

Provider attitudes toward EBI have been linked to practice behavior [ 66, 67] and have been shown to predict use of EBI [ 13, 68, 69]. Multiple studies have found that provider attitudes before EBI training, especially openness to the use of EBI and perceptions of EBI appeal, are linked to fidelity after training [ 13, 70, 71, 72]. Furthermore, attitudes toward a specific practice are linked to reported use of that practice [ 69]. Negative beliefs about a practice may be a barrier to adoption [ 73, 74]. Data indicate that this may be especially true of behavioral interventions for ASD; however, poor attitudes can be improved with education [ 75, 76]. These studies, combined with preliminary data from the AIM HI and CPRT effectiveness trials linking attitudes toward ASD EBI and fidelity, indicate that provider attitudes are a promising and important target of implementation interventions aimed to increase uptake.

Therefore, the TEAMS Individual Provider Strategy (TIPS) for training applies well-established motivational enhancement strategies to motivate and engage providers in EBI training. Motivational interviewing (MI) [ 77, 78, 79, 80, 81, 82, 83, 84, 85] is a provider interaction style developed to address ambivalence about behavior change. MI is effective in facilitating behavior change for a wide-range of patient populations, improving treatment participation, attendance, adherence, and patient outcomes in a variety of treatments [ 86], including behavioral interventions [ 87]. Although MI is well-established for improving adult and adolescent client attitudes and engagement, there is limited application to enhance provider EBI training [ 73]. TIPS uses Miller's conceptual model and clinical guidelines [ 88] for MI which emphasize AIM HI and CPRT trainers' using an empathic learner-centered training style while evoking and strengthening the providers' motivations for overcoming ambivalence about change (i.e., using AIM HI or CPRT). We will use the well-studied processes of MI in the TIPS module to improve provider attitudes and increase provider engagement in EBI training with the expectation that this will lead to improved EBI training completion, EBI fidelity, and child-level outcomes.

Current project

This project includes two coordinated studies testing the impact of the " Translating Evidence-based Interventions for ASD: A Multi-Level Implementation Strategy" (TEAMS). TEAMS focuses on improving implementation leadership, organizational climate (TLI), and provider attitudes and engagement (TIPS) in order to improve two key implementation outcomes-training completion and ASD EBI fidelity and subsequent child outcomes. These studies will use a randomized Hybrid implementation/effectiveness, type 3, trial. Study #1 will test the TEAMS model with An Individualized Mental Health Intervention for ASD (AIM HI) [ 44] in publicly-funded mental health services. Study #2 will test TEAMS with Classroom Pivotal Response Teaching (CPRT) [ 41] in school settings (Fig. 3).

A dismantling design will be used to understand the effectiveness of TEAMS and the mechanisms of change across settings and participants [ 89]. The specific aims and hypotheses are to:

1. 1.
Test the effectiveness of the TEAMS modules individually and in combination on implementation outcomes when paired with two ASD EBI. (a) Compared to standard ASD EBI training (control) and individual TEAMS modules (TLI or TIPS), the full TEAMS model (TLI + TIPS) will lead to more positive implementation outcomes for providers (training completion, fidelity) and children (improvements in targeted symptoms).

2. 2.
Test the impact of TEAMS modules on organization- and provider-level mechanisms of change. (a) TLI will increase use of implementation leadership strategies, and TIPS will lead to greater changes in provider attitudes and engagement in EBI training.

3. 3.
Identify moderators and mediators of implementation outcomes. (a) Identify provider and organization characteristics that moderate implementation outcomes and (b) identify provider- and leader-level mechanisms of change that mediate implementation outcomes.

Method

This Hybrid, type 3 implementation/effectiveness trial will use a cluster randomized factorial dismantling design to examine the independent and combined effectiveness of TLI and TIPS. MH programs (AIM HI study) and School districts (CPRT study) from San Diego, Sacramento, and LA Counties will be randomized to one of four conditions (STANDARD EBI-specific training only (control condition); TIPS (Motivational Module); TLI (LOCI Implementation Leadership Module) or TIPS+TLI (Combined Modules). Data collection will be coordinated between the two studies and pooled for analyses.

Sample

The combined multi-level sample for both studies will include 74 programs/districts, 74 agency/district leaders (1 per agency/district), 590 providers (average of 8 per program/district), and 590 children (1 per provider). This sample size was determined so as to be sufficiently powered for aim 3 mediation analyses. (Refer to Table 1 for the breakdown of participants by study and type).

Table 1 Participants by type and study

AIM HI study eligibility

Programs are eligible for enrollment if they provide publicly funded outpatient or school-based psychotherapy services to children in the San Diego, Sacramento, or Los Angeles areas. Leaders are eligible if they provide administrative oversight to an enrolled program site. Therapist eligibility includes the following: employed as staff or a trainee in an enrolled program; anticipated to provide services for at least the next 7 months (i.e. practicum or internship not ending in next 7 months); has an eligible child on current caseload; and did not participate in the prior AIM HI effectiveness trial. Families are enrolled as a dyad with a participating therapist. Eligible families have a child aged 5 to 14 years who has a current ASD diagnosis on record.

CPRT study eligibility

School districts are eligible for enrollment if they provide publicly funded educational services to students in preschool through fifth grade in the San Diego, Sacramento, or Los Angeles areas. Leaders are eligible if they provide administrative oversight at an enrolled district. Teacher eligibility includes the following: employed in an enrolled district; anticipated employment for at least the full training academic year; has an eligible child in his or her classroom; and did not participate in the prior CPRT effectiveness trial. Families are enrolled as a dyad with a participating teacher. Eligible families have a child aged 2 to 10 who has a primary educational classification of ASD.

Procedures

Enrollment procedures

Programs and districts will be recruited in three waves, over 3 years. Once programs are enrolled, leaders from within the enrolled programs/districts will be recruited. Potentially eligible providers will then be recruited through presentations at standing staff meetings or team meetings. Providers will then identity potentially eligible family participants from their caseload or classrooms and will obtain permission for the research team to contact the caregiver to recruit for participation. All participants will be provided information about the study from research staff and provide consent obtained prior to data collection.

ASD EBI (AIM HI/CPRT) intervention and training procedures

AIM HI and CPRT are manualized programs with user-friendly materials for training, intervention planning, and fidelity monitoring provided in printed and web-based formats. AIM HI is a package of evidence-based parent-mediated and child-focused strategies, designed to reduce behavior problems in children with ASD ages 5 to 13 served in MH programs. AIM HI involves a series of 10 steps (8 required, 2 as indicated) and within-session elements aimed to teach parents of children with ASD to manage challenging behaviors and teach children positive alternative skills (e.g., self-regulation, social skills) using applied behavioral analytic EBI strategies. There are no set number of sessions as the steps can be repeated as needed; however, a minimum of 13 sessions are required. It takes approximately 6 months to accommodate inevitable missed sessions and the variability in the length of time it takes each family/therapist to complete the steps. CPRT is a naturalistic behavioral intervention designed to increase the "pivotal" child responses of motivation, initiation and breadth of attention. Specific components of CPRT include providing clear and appropriate instructions, sharing control with the child by providing choices and taking turns, interspersing easy and difficult tasks, requiring responding to multiple materials, providing contingent consequences, reinforcing attempts, and providing reinforcement that is directly related to behavior. CPRT has procedures for using components across groups of students and includes specific resources for teachers such as methods for targeting educational goals and curriculum areas using CPRT, data collection materials etc.

Provider training procedures

The training curricula follow the manual in both cases. Consistent with our previous studies, training and coaching will be conducted by MA or postdoctoral level researchers with extensive training and experience with AIM HI or CPRT. (Refer to Table 2 for a summary of the training components and process.) AIM HI and CPRT have established training plans developed based on the current knowledge of adult learning theory, health care provider behavior change [ 90, 91], and data from our pilot and effectiveness studies. Although there is variability in scheduling and details based on the needs of the specific provider group (i.e., therapists or teachers), training in both interventions includes active, systematic, direct, and explicit instructional methods (e.g., step-wise training of general principles then specific strategies; interactive, structured performance-based feedback on skill-building; practice with feedback; sustained training efforts) that have been associated with improved provider competence and patient outcomes [ 90, 91, 92, 93, 94, 95]. The inclusion of ongoing coaching/consultation in both models is especially important for improving and maintaining treatment integrity and provider confidence in their ability to use the intervention [ 96, 97].

Table 2 ASD EBI provider training components

Trainer training procedures

Both ASD EBI have established trainer training processes, which include ongoing fidelity monitoring for trainers by the PIs/intervention developers.

TEAMS implementation strategy procedures

TEAMS Leadership Institute (TLI) module

This module is based on the Strategic Implementation Leadership (which includes implementation support strategies) module of the Aarons' & Ehrhart LOCI intervention [ 54]. TLI provides leaders a menu of implementation leadership and climate building strategies and a method for choosing appropriate strategies based on a pre-training assessment. All TLI training and coaching will be audio recorded and a subset of sessions will be coded quarterly to ensure ongoing fidelity. TLI fidelity will be examined across sites during ongoing supervision, and concerns will be readily addressed.

TLI includes 5 key components of LOCI: 1. Assessment: The Implementation Leadership Scale (ILS) [ 98] and Implementation Climate Scale (ICS) [ 99] will be completed by first-level leaders participating in the intervention, his/her subordinates (i.e., providers), and executive leaders. Data are synthesized into a detailed feedback report and used to develop an implementation leadership plan specific to the leader that will build a positive implementation climate. 2. Initial training: TLI begins with a 3-h implementation leadership didactic and interactive session that includes training in implementation leadership and identifying leader behaviors and strategies that can be used to build a climate for EBI implementation. Facilitators and leaders will work together to review the assessment data and identify strengths and areas for development. Leaders will develop a plan for using specific implementation support strategies. 3. Coaching: Weekly, brief (15-30 min) coaching calls keep leaders on track with goals and plans. Coaching includes review of progress toward goals, updating plan based on emergent issues, and problem solving. 4. Follow-up session: At month 4, leaders attend a 2-h booster session to assess progress and guide modification of the implementation leadership plans. 5. Graduation: Graduation is deliberately included in TLI to mark completion of the program. TLI programs will have a group-based graduation for the leaders and provider trainees at EBI training completion to celebrate accomplishments, processes' changes, and plan for the future.

TIPS for training module

The TIPS module applies MI principles and strategies to address attitudinal barriers through elicitation of change talk and improve engagement in training [ 100]. AIM HI and CPRT trainers (in the TIPS conditions only) will incorporate MI during training and ongoing consultation/coaching with providers using established MI approaches to increase provider engagement and problem solving throughout the training process [ 101]: 1. Pre-training call: Prior to AIM HI or CPRT initial didactic workshops, providers will receive a pre-training call designed to provide information about training and the intervention, and promote change talk around training (What do you anticipate to go well during this training? Why is this training important to you?). 2. Proactive planning: During the initial workshop, trainers will elicit change talk about participating in the EBI training. (e.g., "What would you like to accomplish during this training?" "What do you see as the benefits of getting started in this intervention?"). Trainers will have discussions that elicit self-motivational statements about provider plans for using the intervention strategies, attending training, and adhering to the training plan (e.g., "What steps can you to take to include strategy X in this week's session?"). Trainees will emphasize autonomy and build confidence in the use strategies and problem solving any challenges. Planning worksheets will include affirmations of strengths and change efforts during each session. 3. On-going reflection: During each coaching/consultation session, providers will reflect on the importance of the training and their confidence in their use of the strategies at the beginning and end of each session. Trainer feedback will be tailored to link provider behavior to changes in child or parent behavior. Trainers will use reflective methods to facilitate provider independence with the strategies, relate training to broader professional development, and develop possible solutions and next steps for any challenges-sessions will end with collaborative development of next steps. 4. Motivational notes: Providers will receive a weekly motivational text or email (depending on preference) to encourage on-going participation. Messages will be based on identified attitudinal barriers for each participant. They might include motivational texts and/or reminders about attendance and practice and therapy outcomes.

TIPS fidelity will be assessed using the 12-item MI Coach Rating Scale (MI-CRS) [ 102] developed by Dr. Naar-King, the MI expert on the study. Trainers will provide audio recordings of their interactions with providers three times monthly following training and then quarterly thereafter. A similar sample of training sessions for trainers using only standard training (not trained in MI) will be coded to ensure they are not using MI strategies. TIPS fidelity will be examined across sites during ongoing supervision, and concerns will be readily addressed.

Procedures for randomization and data collection

Randomization

Programs and districts will be randomized by an independent researcher and stratified by county and study via computer-generated randomization to one of four conditions per study following official study enrollment

TLI

For the 2 groups randomized to TLI or TLI + PROV, the initial TLI workshop will be completed before provider enrollment. This will be done each spring/summer. Each fall, programs, and districts in all conditions will begin provider/child dyad enrollment, complete pre-assessments, and training.

Outcome measures

Because we are testing an implementation intervention and our ASD EBI have been shown to be effective in our large-scale effectiveness trials, our primary measures are related to provider implementation (training completion/fidelity). However, consistent with Hybrid, type 3 designs, we will collect child outcome data as secondary outcome measures (within session behavior; standardized measures). Outcomes will be collected for leaders and providers using the following timeframes: Baseline (BL-initial program/district enrollment), Pre (PRE-prior to EBI Training), Post training (POST-6 months after initiation EBI training), and Follow-Up (12 months post PRE). Parents will complete child measures at PRE and POST as children may not remain with the same provider or be receiving services at follow-up. Data will be collected by administering a brief battery of measures (including demographic measures for all participants) via on-line survey or phone interview. The outcome constructs include implementation outcomes (provider and child) as well as measurement of the specific mechanisms of change expected from the implementation intervention. Refer to Table 3 for specific outcome measures and timing.

Provider fidelity measures

Provider ASD EBI (AIM HI/CPRT) fidelity is the primary study outcome. Provider fidelity will be based on ratings by trained observers blind to study condition and time frame. Fidelity ratings are designed to capture provider use of the core EBI strategies included in the AIM HI and CPRT protocols. Fidelity will be rated with the target child at PRE, mid training, and POST. Fidelity will be coded based on video recordings of sessions/activities using our established procedures for video data collection. AIM HI Fidelity includes 16 Adherence items reflecting expected within-session therapist behaviors in three categories (Structuring Sessions for Skill-Building, Motivating Children, Active Teaching). These are rated separately for parents and children. There are also 4 Effectiveness Items (e.g., session is organized and structured). The inter-rater reliability of these items are high ( M = .77, range = 0.65 to 0.90 based on 299 double-coded sessions). Furthermore, all individual and composite scores for therapists trained in AIM HI are significantly higher than therapists delivering usual care (based on over 600 coded sessions), providing support for the discriminant validity of the measure. Sessions recordings will be submitted online prior to training and monthly during the 6-month training/consultation period. CPRT fidelity includes 15 adherence items reflecting expected within-session teacher behaviors in three categories (maximizing student motivation, facilitating student responding, providing appropriate consequences). There are also 4 effectiveness items (e.g., manages distractions in the teaching environment). All items are rated on a 1-5 Likert scale after observing the complete activity with 1 being teacher does not implement or implements correctly less than 30% of the time to 5, teacher implements correctly throughout the session (100%). The inter-rater reliability of these items are high ( M  = .73, range = 0.50-0.90 based on 240+ double-coded sessions).

Coder training

Coders will be trained to code fidelity for one of the EBI (AIM HI or CPRT), and child session behavior. All coders will be blind to treatment groups (STAN, TLI; TIPS; TLI + TIPS) and time frame. They will be trained to 80% reliability across 6 videos before coding for the study. If there is less than 80% agreement between the investigator and the coder, additional training will be provided until agreement is achieved. Twenty-five percent of all video samples will be scored by a second person for the purpose of monitoring reliability of coding.

Data analysis

General data analytic plan for aims 1-3

All data analytic strategies will follow the recommendations of Brown et al. and the Prevention Science and Methodology Group for randomized field trials [ 103]. Preliminary data screening and cleaning will require examination of the data distributions for normality and missing data patterns at both the univariate and multivariate level. Preliminary data analysis will also be conducted to determine if there are significant differences between the two studies (CPRT and AIM HI) on target variables. If no significant differences are found, data from the two studies will be integrated to maximize the available data for specific analyses. In the case that outcome variables differ by study, variables representing study will be included as a covariate in all models. Some of the target outcome variables in the two studies were measured using different scales (e.g., AIM HI and CPRT Fidelity). To ensure comparability on these measures, variables will be converted to z-scores before statistical comparisons are made. Hierarchical linear modeling (HLM) will be used as the primary, but not only, statistical model due to the nested structure of the data and when the outcome measure is at the provider/outcome level: repeated measures [level-1] nested within providers/children [level-2] nested within program/district [level-3]). Possible clustering effects will initially be estimated by examining intraclass correlation coefficients to determine if accounting for clustering is necessary. All analyses will use an intent-to-treat approach for the TEAMS groups. Because the TEAMS condition variable will contain four groups, three dummy-coded variables will be created and used as predictor variables in target statistical models. To account for the different type of leader at the program/district level, a level-3 binary variable representing whether or not the agency/district leader is a director or a first-level leader will be used in all analyses. Covariates (e.g., baseline scores) may be included in the models to adjust for nonequivalence at baseline and to minimize bias. All analyses will use AR(1) to model a first-order autoregressive correlation structure for the repeated-measures data. Missing data common to longitudinal designs is readily incorporated in HLM if the data can be assumed to be missing at random. However, because there is no statistical test of data that is missing at random [ 104], all data analysis will also employ selection models [ 105] to model relationships of interest for the data missing not at random mechanism, as recommended by Little and Rubin [ 106]. Of interest in some of proffered hypotheses are the differences in target outcomes between the TEAMS groups over time. The TEAMS groups will be statistically compared when a significant cross-level (Time X TEAMS Group) interaction is evident using the statistical methods of Preacher, Curran, and Bauer [ 107].

Specific analyses for aim 1: test the effectiveness of the TEAMS modules individually and in combination on implementation outcomes when paired with two ASD EBI

To determine if there are significant main effects and interactions between the TEAMS groups on observed therapist fidelity (based on video recorded sessions coded at 3 time points over 6 months), statistical analyses will proceed using the 3-level nested data structure outlined in the General Analytic Plan section. To determine if there are significant differences between the TEAMS groups on observed child behaviors during sessions, statistical analyses will proceed using the 3-level nested data structure outlined in the General Analytic Plan section. To determine if there are differences between the TEAMS groups on child symptoms (EBCI or PDDBI) at 6 months, the 3-level nested data structured will be used.

Specific analyses for aim 2: test the impact of TEAMS modules on leader- and provider-level mechanisms of change

Measurement of leader-level outcomes is of primary interest. Implementation Leadership and Climate scores will be aggregated to the leader level. For this reason, HLM models (or single-level regression models if ICC values suggest clustering is negligible) will be used to test for TEAMS group differences on measures of implementation leadership and climate scores at 6 and 12 months. These analyses will control for baseline scores on these measures. To determine if there are significant differences between the TEAMS groups on therapist attitudes (EBPAS), analyses will proceed using the 3-level nested data structure outlined in the General Analytic Plan. These analyses will control for baseline EBPAS scores.

Specific analyses for aim 3: identify moderators and mediators of implementation outcomes

Variables representing participant characteristics (e.g., job tenure, gender, race/ethnicity) and organizational characteristics (e.g., size) will be evaluated as moderators of the relationship between the dummy-coded TEAMS group variables and outcome variables specified in aim 1. All analyses will proceed as specified in aim 1 above. Relevant interaction terms between the TEAMS group variables and a given moderator will be created and entered as predictor variables. Two sets of models will be used: one set for provider-level outcomes and a second for child-level outcomes. To examine the hypothesized mediated effects of TEAMS group status on fidelity and child outcomes, multilevel path analysis will be conducted. Measures of provider attitudes, implementation leadership and implementation climate will be tested as mediators in respective models. The specific mediated effects within these models will be tested using the bias-corrected bootstrap approach [ 108].

Power analyses

To estimate the sample size needed to detect statistically significant differences between TEAMS groups in the context of the 3-level nested data structure (e.g., aim 1, hypothesis 1), the power program RMASS2 [ 109] was used. The RMASS2 program is specifically designed to calculate the projected sample size needed for longitudinal data with attrition when a comparison is made between groups. To determine the minimum sample size necessary, several assumptions were made: (1) An alpha level of .05 and a power level of 0.80, (2) an effect size of d = .39 (based on the CPRT effectiveness trial ES for impact of training on teacher fidelity), (3) 30% overall attrition rate was specified, and (4) a stationary autoregressive structure (lag 1) was specified for the variance-covariance matrix of the repeated measures, using an autocorrelation value of 0.60. In addition, clustering at the programs/districts level was accounted for via the variance inflation factor (VIF = 1.28): 1 + ( c − 1) × ICC, where c is the average number of providers/children per programs/districts ( n  = 8) and the ICC at the programs/districts level (ICC = 0.04, based on AIM HI therapist fidelity outcome). Given these assumptions, 502 providers/children nested within 63 programs/districts are needed to detect statically significant differences between at least two of the TEAMS intervention groups.

Additional power analyses were conducted to determine the sample size needed to detect a hypothesized mediated effect or moderation of the antecedent to mediator relationship (see Aim 3), which is likely to be the most underpowered effect proposed. This set of power analyses was conducted to determine the minimum necessary sample size to find a statically significant mediated effect from variables presenting the TEAMS groups to a target mediator (e.g., provider attitudes) to a target outcome (e.g., provider fidelity outcome). Using the simulation approach for meditational models of Thoemmes, MacKinnon, and Reiser [ 110], small effects ( R ² values of 2%) were specified for both the mediator and outcome variables. Accounting for the VIF defined above, 591 providers/children nested within 74 programs/districts are needed to detect statistically significant mediated effect.

Discussion

AIM HI and CPRT data indicate that (1) implementation leadership/climate and (2) provider attitudes toward EBI are promising targets of implementation interventions. The roles of both factors have been indicated for broader patient populations [ 54] and also in our current projects. As such, we will apply two, established interventions (LOCI, MI) in the TEAMS model to target these specific mechanisms of change. This study will test the impact of combining standard, EBI-specific training with the two TEAMS modules individually and together on multiple implementation outcomes.

This study builds on a novel, bi-directional, approach to translational research. AIM HI and CPRT were developed in response to a recognized quality gap and stakeholder-identified needs. They were designed specifically for, and in collaboration with, the "end users" of the intervention with the goal of maximizing the "fit" between EBPs and the care settings in which they are delivered [ 111, 112]. This implementation-effectiveness Hybrid type 3 trial [ 113] builds on our previous Hybrid Type 1 trials where the primary focus was testing the clinical effectiveness of the ASD EBI.

Testing TEAMS paired with two ASD EBIs, developed for two different service settings offers substantially greater efficiency, generalizability, and reproducibility over testing TEAMS with either EBI alone.

Few studies have systematically examined the mechanisms of action of leader-level interventions and none in ASD [ 98, 114, 115]. Consistent with RDoC, TEAMS targets potential mechanisms of behavior change at leader and provider levels. The dismantling design will allow us to examine the independent and combined effectiveness of both TEAMS modules and the potential to impact scale-up of EBI across systems. This design is a highly innovative feature that will help us to learn more about common and specific elements of implementation strategies across settings. This is an important innovation as it is essential to understand the potential differential contributions of provider versus leader-level interventions (e.g., At what level and under what conditions are the two targets most impactful in moving implementation outcomes? Is it possible that a provider-level engagement intervention can impact outcomes even in the context of an organization with low implementation leadership or implementation supports?). In addition, examining the moderators will allow for individualization of the TEAMS intervention based on the specific needs of the program, district or provider, increasing efficiency of the intervention.

TEAMS is the first implementation intervention to apply leadership level implementation support and motivational interviewing techniques together to improve EBI training completion, fidelity, and child outcomes. This approach has the potential to improve provider fidelity to the EBI, thereby improving child outcomes.

Abbreviations

AIM HI:

An Individualized Mental Health Intervention for ASD

CPRT:

Classroom Pivotal Response Teaching

EBI:

Evidence-based intervention

LOCI:

Leadership and Organizational Change for Implementation

MH:

Mental health

MI:

Motivational interviewing

TEAMS:

Translating Evidence-based Interventions (EBI) for ASD: Multi-Level Implementation Strategy

TIPS:

TEAMS Individual Provider Strategy

TLI:

TEAMS Leadership Institute

References

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Acknowledgements

The developmental work that served as the foundation of these studies was funded by the National Institute of Mental Health grant R01MH094317 and the Institute for Education Sciences grants R324A140005 and R324B070027. Drs. Stahmer and Brookman-Frazee were Fellows with the Implementation Research Institute (IRI), at the George Warren Brown School of Social Work, Washington University in St. Louis, through an award from the National Institute of Mental Health (R25 MH080916-01A2) and the Department of Veterans Affairs, Health Services Research & Development Service, Quality Enhancement Research Initiative (QUERI).

Funding

The funding for this project is provided by the National Institute of Mental Health grants R01MH111950 and R01MH111981. The opinions expressed herein are the views of the authors and do not necessarily reflect the official policy or position of the NIMH or any other part of the US Department of Health and Human Services.

Availability of data and materials

The datasets used and/or analyzed during the current study will be available from the corresponding author on reasonable request.

Author information

Authors and Affiliations

1. Department of Psychiatry, University of California, San Diego, 9500 Gilman Drive, La Jolla, CA, 92093-0812, USA

Lauren Brookman-Frazee

2. Child and Adolescent Services Research Center, 3020 Children's Way MC 5033, San Diego, CA, 92123, USA

Lauren Brookman-Frazee & Aubyn C. Stahmer

3. Department of Psychiatry and Behavioral Sciences, University of California, Davis, UC Davis MIND Institute, 2825 50th Street, Sacramento, CA, 95817, USA

Aubyn C. Stahmer

Contributions

LBF (PI of study #1) and AS (PI of study #2) conceptualized the project and developed this manuscript. Both authors read and approved the final manuscript.

Corresponding author

Correspondence to Lauren Brookman-Frazee.

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Ethics approval and consent to participate

This study was approved by the University of California, San Diego, Human Research Protections Program (HRPP; Protocol # 161234) and is being relied upon by the University of California, Davis, and the University of California, Los Angeles. Informed consent will be obtained from all relevant participants.

Competing interests

The authors declare that they have no competing interests.

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Brookman-Frazee, L., Stahmer, A.C. Effectiveness of a multi-level implementation strategy for ASD interventions: study protocol for two linked cluster randomized trials. Implementation Sci 13, 66 (2018). https://doi.org/10.1186/s13012-018-0757-2
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# data[].attributes.attachment_link.title
Effectiveness of a multi-level implementation strategy for ASD interventions: study protocol for two linked cluster randomized trials - Implementation Science

# data[].attributes.attachment_link.description
Background The Centers for Disease Control (2018) estimates that 1 in 59 children has autism spectrum disorder, and the annual cost of ASD in the U.S. is estimated to be $236 billion. Evidence-based interventions have been developed and demonstrate effectiveness in improving child outcomes.

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Importance of Inclusion among students with ASD

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Importance of Inclusion among students with ASD

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This resource for Autism Research highlights the significance of peers in inclusive education for individuals with Autism Spectrum Disorder . It underscores the crucial role that peers play in facilitating social interaction, skill development, and overall inclusion for individuals with ASD within educational settings. The discusses how peer interactions provide opportunities for individuals with ASD to learn and practice social skills, communication, and adaptive behaviors in naturalistic environments. It also emphasize the importance of fostering positive peer relationships, promoting acceptance, and reducing stigma towards individuals with ASD.