4/2/2019

1

Building Capacity to Support Students with Autism Spectrum Disorder: A Modular Approach to Intervention

Rose iovannone, ph.d., bcba-

iovannone@usf..edu

The contents of this training were developed under grant R324A150032 from the US Department of Education

Rose Iovannone, Ph.D., BCBA-Diovannone@usf.edu

University of South Florida

Acknowledgements

• Pis

• Tristram Smith, University of Rochester

• Cynthia Anderson, May Institue

• MAAPS Coordinators and Coaches

• USF-Krystal McFee, Elizabeth Cassell

• UR-Samantha Hocheimer, Brenna Cavanaugh,

• May—Ryan Martin, Whitney Kleinert, Meghan Silva, Brittany Juban

• Qualitative Researcher

• Sharon Hodges, USF

In Memory of Tristram Smith1961-2018

Haggerty-Friedman Endowed

Professor of Developmental

Behavioral Pediatric (DBP)

Research, University of

Rochester Medical Center

Treasured collaborator, mentor,

and friend

“He could say in 30 words what

would take the rest of us a

lifetime. He may have been

unassuming, but when he spoke,

everyone would listen.” – Susan

Hyman, DBP Division Chief

Objectives

• Participants will:

• Identify the challenges of implementing evidence-based practices for students with ASD

• Describe the features of the MAAPS modular approach and discuss how the model addresses the challenges

• Describe the practice-based coaching process provided to teachers in implementing MAAPS interventions

• Discuss how implementation of MAAPS can improve the performance of students with ASD.

Preview

• Introduction to school-based intervention for students with ASD

• Introduction to MAAPS Model

• Research support

• Case Example

Who is here?

• Teachers

• Administrators

• Behavior Analysts

• School Psychologists

• Other educators

• Students

• University faculty/staff

• Family

4/2/2019

2

Intro to Autism spectrum disorders (ASD)

• Dramatically increased prevalence• 2000-2012 prevalence increase from 1/150 to 1/68 (CDC, 2012)

• 1998-2010, number of school aged children receiving ASD services increased from 54,064 to 370,011

• Children with ASD

• Core deficits

• Social/communication

• Restricted, repetitive behaviors

• Co-occurring

• Cognitive

• Challenging Behaviors

Challenges with Evidence-based practices in schools• Evidence-based interventions for children with ASD exist but are not

consistently implemented in school settings (Kasari & Smith, 2013).

• Barriers:

• External validity of current research base

• Environmental context

• School staff expertise and training

• Heterogeneity of ASD presentation

• Competition with fad-interventions, misinformation, etc.

Modular interventions

• Students with Autism Accessing General Education (MAAPS; Anderson, Smith, & Iovannone, 2018) provides individualized interventions grounded in behavior analysis.

• Comprehensive interventions vs. social validity

• Modular approach (Weisz et al., 2012) enables educators to choose evidence-based components that match the need of a given child.

Students with Autism access general education (MAAPS)• Research Development Grant

• Institute of Education Sciences (IES), National Center for Special Education Research (NCSER)

• Purpose

• Develop comprehensive intervention for students with ASD

• Effective

• Socially Valid

• Promise of effectiveness

MAAPS Development

• Year 1• Develop materials• Focus groups for feedback• Refine model

• Year 2• Feasibility test

• Year 3 • Evaluate effectiveness

What is MAAPS?

• Comprehensive modular approach to intervention

• Framework for school teams to:

• Assess student needs & select interventions

• Design and implement evidence-based interventions

• Active coaching to support educators

• Data-based decision-making

• Iterative process

4/2/2019

3

MAAPS Modules MAAPS Modules

• Modules Include:

• Outlines for Coaches

• Vignettes

• Sample intervention materials, data sheets

• Implementation guides for educators

OVERVIEW OF THE MAAPS PROCESS

MAAPS Process

Formation of Student-Focused Teams

Module Selection & Goal Setting

Module Development & Training

Module Implementation & Active Coaching

Data-Based Decision Making

MAAPS ProcessStep 1: Form a student-focused team• Core Team:

• MAAPS Coach

• Teacher/Educator (primary implementer)

• Caregivers

• Extended Team:• Specialists (SLP, OT, BCBA, School Psychologist, etc.)

• Paraprofessionals/assistants

• Administrators

4/2/2019

4

Step 2: Assessment—MAAPS guiding questions

• Semi-structured Interview• 0-3 scale

• 0 = less urgency; 3 = high urgency

• Purpose-identify specific modules to address student concerns

• Two parts• Interview

• Action plan

• Questions with 2 or 3 responses indicate modules for consideration

MAAPS ProcessStep 2: module selection and goal setting

MAAPS ProcessStep 3: Development & Training• MAAPS Coach and the teacher review and customize

• A Module Implementation Guide (MIG) created

• Coach and teacher practice the intervention and plan for implementation.

4/2/2019

5

Step 4: Implementation

• Teacher implements MIG

• Collect data on outcomes

• Teacher Reflection Form

• Active Coaching - Feedback

MAAPS ProcessStep 4: Module Implementation & active coaching

4/2/2019

6

Coaching and feedbackMAAPS ProcessStep 5: team meetings & Data-Based Decision-making

• Core & Extended teams reconvene each month to:

• Review student progress

• Troubleshoot challenges with the intervention

• Set new goals and select new modules

MAAPS RESEARCH SUPPORT

Research

• Three studies

• Year 1 – Focus Group

• Year 2 – Feasibility Study

• Year 3 – Pilot (underpowered randomized controlled trial)

Model development & RefinementReview & Feedback• Research Question: What expansions and refinements are needed

to MAAPS for the development of a manualized modular intervention for students with ASD?

• Six national experts and six providers reviewed materials and provided feedback (mean Likert-type scale ratings, range 0-3)

• Evidence-based = 2.40

• Relevant to educators = 2.67

• Likely to increase opportunities for inclusion = 2.56

Model development & RefinementFocus Groups• Focus groups conducted across three sites:

• 14 focus groups (teachers, parents/caregivers, administrators)

• 20 administrators

• 33 teachers

• 18 parents

• 3 administrator interviews (in one site)

• Focus group questions stimulated discourse about implementation of evidence-based practice for students with ASD in schools.

4/2/2019

7

Focus group findings

• Balancing immediate resource needs with long-term needs for capacity building to support students with ASD• Lack of resources (training, staff, funding)

• Lack of educator skills to implement EBPs

• Need for modular approach to adjust to contextually diverse environments

Iova

nn

on

e et

al.,

(in

re

visi

on

)

Year 2 feasibility study participants & Setting• 15 students across sites

• 2 female

• 13 male

• Mean Age = 9.45

• Race-11 White; 2 Black; 1 More than one; 1 Other

• Ethnicity-Not Hispanic = 12; Hispanic = 3

• 18 teachers across sites• 15 female

• 2 male

• 1 not reported

• Mean Age = 39

• Race-16 White; 1 Black; 1 More than one (American Indian and Pacific Islander)

• Ethnicity-14 Not Hispanic; 4 Unknown

Year 2 ResultsStudent Outcomes• Goal Attainment Scaling (GAS)/Teacher-Nominated Target Problems (TNTB):

• 11/14 students rated “much improved” or “very much improved” on at least one of three behaviors

• 8/14 rated as “much” or “very much improved” on all 3 target behaviors

Year 2 ResultsTeacher Outcomes• Usage Rating Profile (URP); 6 point Likert Scale

• Acceptability M = 5.22

• Usability M = 5.61

• Feasibility M = 5.47

• Coaching Quality M = 3.84 (4 point Likert Scale)

• Teacher implementation fidelity

• Across 51 observations, adherence mean = 93%; quality mean = 99%

Lessons Learned from feasibility study

• Despite initial feasibility and acceptability, changes were necessary:

• Coach’s Outlines for modules were simplified

• Changes to modules: additions, combinations, omissions, etc.

• Reduction of team meetings

Year 3 pilot study

• Underpowered randomized controlled trial

• Compared MAAPS group with enhanced services as usual group (14 students in each group for 28 total)

• Primary dependent variable• Developmental Disabilities modification of the Children’s Global Assessment Scale (DD-CGAS)

• Data collected by masked evaluator (to condition)

• Three time measurements (baseline, mid, exit)

4/2/2019

8

Year 3 pilot study student outcomes Year 3 fidelity

CASE EXAMPLE 1

Forming the Student-Focused Team

Getting to Know the Student

Marley

• Age: 10 at time of intervention

• Family: Mother, father

• Strengths: inquisitive, kind to others

• School: self-contained autism classroom

• Grade: 5th

• Diagnosis: Autism Spectrum Disorder

Assessment—MAAPS Guiding Questions

Part 1: Interview• Team identified 3 areas:

Content Areas of MAAPS:

4/2/2019

9

Assessment—MAAPS Guiding Questions

Part 1: Interview• Team identified 3 areas:

Part 2: Action Plan• Team prioritized implementation of selected modules

1. Engagement 2. Visual Cues3. Conversation

Restricted or Repetitive Behaviors, Interests, or Activities

Rituals Does the student engage in a series of behaviors in a set way, almost as if compelled to do so?

PROBES:

How does the student show rigidity or ritualistic behavior? Does it happen at other times?

Do you ever notice the student doing things in a specific way or number of times? How easily can you distract the student if he/she is in the middle of a ritual?

Low High

0 1 2 3

Engagement If the student has an intense interest, could that interest be incorporated into teaching?

PROBES:

Is the student’s interest something that he/she could work for? Could pictures or other materials related to the interest be used in teaching materials?

Low High

0 1 2 3

Increasing

Variability

Does the student play or interact with objects or activities in a restricted way?

PROBES:

Does the student seem to enjoy repeating movements with objects, lining objects up, or completing activities in the same order each day?

Does the student vary his/her play or activities from day to day or does he/she seem to always go back to the same thing?

Does the student seem to seek out these objects or activities, even during instructional time?

Low High

0 1 2 3

“The next four questions focus on the student’s interests.”

Module Guiding Questions Priority

Module Guiding Question Priority

“The next three questions focus on motivation and work completion”

Visual Cues* Does the student function well and engage fully without prompts to attend to instruction and

complete work?

PROBES:

How well does the student stay on task? Is this consistent or does it depend upon the activity?

How often does an adult have to remind the student of the instructions?

Low High

0 1 2 3

Reinforcement* Does the student engage in school work attentively and in a timely manner?

PROBES:

How does the student respond when given academic work to complete? How long can the student work and still be on-task? How does the student do with difficult work? Does the student currently earn rewards or privileges for doing work, either

individually or as part of a classroom-wide system?

Low High

0 1 2 3

Environmental

Modifications

Have changes been made to the overall structure or arrangement of the classroom that have

increased student learning or engagement?

PROBES:

Does the student have preferential seating? Is the student’s work environment adapted at all to meet their needs? Does the student have individualized visual supports, such as an individual schedule,

rule cards, or picture cues?

Low High

0 1 2 3

Cognitive and Academic Difficulties Development and Training – Module Implementation Guide Date: 3/27/2018 Module: Increasing Engagement – RRB

Student ID: 3-004 Teacher ID: 3-201 Coach ID: KF

Baseline Start Date: 3/28/2018 Implementation Start : 4/11/2018

Criteria for Fading the Intervention: Increase engagement - consistent rating of 5 on IBRST (one week)

Operational Definition of Behavior(s):

Restrictive interests: Sponge Bob, Dinosaurs, Harry Potter, Mine Craft

Engagement in small group: attend to or read independently, respond to questions, ask for help

Contexts, Routines, & Frequency of Implementation :

Language Arts: 3 centers total – initial target is Mary’s group (15 min)

Data Collection Plan (data collector, methods, etc.):

IBRST: Mary will rate Marley’s percentage of engagement for LA center 1

Teaching/Prevention Strategies:

Behavior Skills Training:

o Instruction – social narrative reviewed prior to centers

o Modeling – Mary will demonstrate engagement skills

o Rehearsal – role play with Marley after model

o Feedback – verbal praise and prompting as needed

Prompting Strategies:

Gestural prompt: to help cue cards or engagement visual cue when Marley is off task

Reinforcement/Consequence Strategies:

Specific praise for engagement + access to Marley’s special box when criterion for engagement is met (i.e. complete work = earn box)

Strategy Description Examples FadingModeling Demonstrate how to implement

an activityThe coach demonstrates how to use a token board with the student during a 1:1 activity

Consider fading to “Prompting” approach

Prompting Use verbal or model prompts to provide a cue to the teacher as to what to do next. You can also use these strategies to give feedback

The intervention specifies that a student should have access to a small toy for 2 minutes after completing several requests. The coach points to the clock on the wall to indicate that time has elapsed.

Consider fading to “Observe and Provide Feedback” approach

Observe and provide feedback

Observe the teacher implementing the activity, but provide ongoing feedback and suggestions as you watch

The teacher initiates using an activity schedule with a student during lunch. The coach praises her for pairing her verbal with gestural prompts.

Consider fading to “Observe and note” approach

Observe and note Simply observe the activity without interacting with the student or teacher. Feedback is provided at the end of the activity

Several peers have been taught to facilitate interactions with Ella during recess. The coach stands off to the side of the swings, where they are playing, and watches the interaction.

Consider fading to “Scheduled virtual support” approach

Scheduled virtual support

No in-vivo observation, but there is scheduled communication between teacher and coach before the session (e.g., setup, anticipated problems) and after the session (e.g., questions, troubleshooting)

The teacher and coach agree to run a peer tutoring session during math. The teacher emails the coach the day before confirming the steps to be used. After the session, the teacher emails the coach and asks about what to do if the peer tutor is also struggling with the academic material.

● Fading frequency of virtual support

● Make use of email check-ins, with the possibility of booster sessions as needed

Module Implementation and Active Coaching

Target Behavior

Dat

e

En

ga

ge

me

nt

Wh

ite

ta

ble

8 1 - 1 0 0 %

6 1 - 8 0 % 4 1 - 6 0 % 2 1 - 4 0 %

0 - 2 0 %

5 4 3 2 1

5 4 3 2 1

5 4 3 2 1

5 4 3 2 1

5 4 3 2 1

5 4 3 2 1

5 4 3 2 1

5 4 3 2 1

5 4 3 2 1

5 4 3 2 1

5 4 3 2 1

5 4 3 2 1

5 4 3 2 1

5 4 3 2 1

5 4 3 2 1

5 4 3 2 1

5 4 3 2 1

5 4 3 2 1

5 4 3 2 1

En

ga

ge

me

nt

Re

cta

ng

le

tab

le

8 1 - 1 0 0 %

6 1 - 8 0 % 4 1 - 6 0 % 2 1 - 4 0 %

0 - 2 0 %

5 4 3 2 1

5 4 3 2 1

5 4 3 2 1

5 4 3 2 1

5 4 3 2 1

5 4 3 2 1

5 4 3 2 1

5 4 3 2 1

5 4 3 2 1

5 4 3 2 1

5 4 3 2 1

5 4 3 2 1

5 4 3 2 1

5 4 3 2 1

5 4 3 2 1

5 4 3 2 1

5 4 3 2 1

5 4 3 2 1

5 4 3 2 1

En

ga

ge

me

nt

Ro

un

d t

ab

le/

wo

rk s

tati

on

8 1 - 1 0 0 %

6 1 - 8 0 % 4 1 - 6 0 % 2 1 - 4 0 %

0 - 2 0 %

5 4 3 2 1

5 4 3 2 1

5 4 3 2 1

5 4 3 2 1

5 4 3 2 1

5 4 3 2 1

5 4 3 2 1

5 4 3 2 1

5 4 3 2 1

5 4 3 2 1

5 4 3 2 1

5 4 3 2 1

5 4 3 2 1

5 4 3 2 1

5 4 3 2 1

5 4 3 2 1

5 4 3 2 1

5 4 3 2 1

5 4 3 2 1

Student: Marley School: XXX Routine: LA Centers

Individualized Behavior Rating Scale Tool (IBRST)

KEY:

Target Behavior #1: Engagement

Definition: attend to or read independently, respond to questions, ask for help

5 = Fantastic day 81-100%

4 = Good day 61-80% Specific time: 10:10-10:55am

3 = So-so day 41-60%

2 = Difficult day 21-40%

1 = Challenging day 0-20%

4/2/2019

10

Intervention Fidelity Form

1

2

3

4

5

3/28 3/29 3/30 4/2 4/3 4/5 4/6 4/9 4/10 4/11 4/12 4/13 4/16 4/17 4/19 4/20 4/24 4/25 4/26

Beh

avio

r R

atin

g Sc

ale

Date

Marley's Engagement - Language Arts

Baseline

Center 1

Center 2

Center 3

Intervention 3 LA Centers

Results

• Fidelity

• Average of 97%

• MAAPS Coach Collected AET

• Baseline – 71%

• Intervention – 98%

• Teacher Collected IBRST Data

• Baseline: 3.6

• Intervention: 5

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1 2

Ave

rgae

Per

cen

t En

gage

d

Academic Engagement - LA Routine

Pre-Intervention Post-Intervention

MAAPS Implementation Reflection Form

Parent Feedback

Krystal M. Fontechia, MA, BCBAEmail: kmcfee@usf.edu

Contact Information

Thank you!

4/2/2019

11

CASE EXAMPLE 2

MAAPS ProcessStep 1: Form a student-focused team

• Core Team:• Mrs. K- Teacher• Mrs. C- Instructional Assistant

• MAAPS Coach

• Extended Team:• SLP• OT

• Mom and Dad

Meet Devante

• Age: 6 years old

• Grade: Kindergarten

• Family: Mom, Dad and older sister

• Placement: Social/communication (K-2)

• IEP Eligibility: ASD, LI, and OT

• Interests: IPad, sensory items (i.e. closing doors, clocks, play doh)

• Strengths: Intelligent, good natured, compliant, sweet, helpful, patient, active, flexible

Step 2: Assessment—MAAPS Guiding Questions

• Initial meeting and assessment

• 10 modules identified for consideration:• Social Communication:

• 2 modules

• Restricted or repetitive behaviors:• 4 modules

• Cognitive Academic:• 5 modules

• Problem behavior:• 0 modules

•Reviewed all modules rated 3• Reviewed goals of modules with team• Ranked top 3 modules

•Top 3 modules:1. Learning Strategies2. Requesting3. Opportunities to Respond

Module Prioritization/Planning 1.

2.

3.

4/2/2019

12

Goal Setting• Select new module

• Flow charts• Information about student

• Core team goals

• Provide modules choices to teams• Instructional support• Communication modules:

• Requesting

• Basic Communication

• Team selected Instructional Support Module• Match core teams goal & best matched module for student

• Build and maintain rapport

Next Steps

Flow Charts

•Team Goal:• Increase accurate responding to questions without echolalic

responses

• Reading Routine:• Read 1:1 with students at table group• Ask students comprehension questions

Instructional Support Module

“What are they eating” (2 times)- D repeat

Pause- “ What are they eating” (2 times) - D no response

Pause- “What are they eating” (2 times) – D no response, looking away

Prompt “Look at the seals, look at the picture”- D repeatChange question “What is that?” (2 times)- D no response

Prompt “Look”- D no response“What is that?” (2 times)- D repeat

Give choice “fish or cat?”- D repeat last choice- incorrect“What are they eating?”- D no response

Change question, Point “What are they swimming in?”- D “water”

Example

4/2/2019

13

Step 3:Developing Instructional Support–MIG

• Walk through each step of reading routine

• Get a book, Read, Get attention, Ask questions about book

• Open Ended Questions

• What strategies using currently?

• What goes well?

• What is most difficult?

• Provide examples of evidence-based strategies

• Provide choices on potential strategies

• Feasibility of implementation

• Specific steps of implementation

Development and Training – Module Implementation Guide Development and Training – Module Implementation Guide

4/2/2019

14

Individualized Behavior Rating Scale Tool

Step 4:Implementation

• Review MIG with Team• Make modifications to MIG if needed• Answer questions• Role plays

• Active Coaching• Teacher preference• Modeling• Side-by-side verbal prompting• Post-observation debrief

Fidelity Results

• Fidelity• Average: 93 %

• Teacher Collected IBRST Data• Baseline: 2.2, Intervention: 3.4

• Direct Observation Data• Number of prompts to answer question:

• Baseline: 4.5, Intervention: 1.2

• Percent of Echolalic Responses:• Baseline: 83.6%, Intervention: 31.5%

• Academic Engagement• Baseline: 51%, Intervention: 83%

4/2/2019

15

Teacher Fidelity Teacher Collected IBRST Data

Direct Observation Data

Data Baseline Intervention

Number of Prompts Needed to Answer Question

4.5 1.2

Percentage of Echolalic Responses 83.6% 31.5%

Academic Engagement

Discussion/Limitations

• School team effectively increased accurate responses with instructional support module

• Team implemented the module with high fidelity

• Family reported increased communication at home

• Short term collaboration

• Only enough time to complete 1 module

• Only 2 extended team meetings

Questions? Thank you!