ERIC ED606372: Early Achievements for Education Settings: An Embedded Teacher-Implemented Social Communication Intervention for Preschoolers with Autism Spectrum Disorder

2020·0.55 MB·English

by  ERIC

PERSPECTIVES SIG 1
Research Article
Early Achievements for Education
Settings: An Embedded Teacher-
Implemented Social Communication
Intervention for Preschoolers
With Autism Spectrum Disorder
Anne-Michelle Engelstad,a Calliope Holingue,a,b,c and Rebecca J. Landaa,d
Purpose:EarlyAchievementsforEducationSettings(EA- wereconductedonteachers’fidelityofEA-ESimplementation
ES)isateacher-implementednaturalisticdevelopmental andchildren’sperformanceonaproximalmeasureofsocial
behavioralinterventionforpreschoolerswithautismspectrum andcommunicationbehaviorandonadistalstandardized
disorder (ASD) targeting core social communication measureofverbalandnonverbalfunctioning.
impairments. The purpose of this pilot randomized Results:TeacherstrainedtoimplementEA-ESattained
controlled clinical trial (RCT) was to examine promise of ahighlevelofimplementationfidelity,withsignificantly
efficacy of this iteratively developed intervention when greatergainscomparedtountrainedteachers.Children
implemented in authentic education settings. We examined receivingEA-ESshowedsignificantlygreatergainfrom
(1a) whether a high level of implementation fidelity was baselinetopostinterventioninfrequencyofproduced
attained by EA-ES trained teachers and (1b) whether their initiationofjointattentionandnonverbalcognitivefunctioning
fidelity attainment differed from that of untrained teachers; comparedtochildreninbusiness-as-usualclassrooms.A
and (2) whether the EA-ES intervention showed promise trendtowardsignificanceforGroup×Timeeffectswas
of improving child social, communication, and cognitive detectedforfrequencyofspontaneousverbalizations
outcomes as determined by within- and between-group produced,favoringtheEA-ESgroup.
comparisonsofchildreninEA-ESclassroomsandchildrenin Conclusions:EA-ESshowspromiseoffeasibilityforteacher
classroomsrandomizedtothebusinessasusualcondition. implementationingroupcontextsandforimprovingsocial
Method:Participantsincludedsixpreschoolteachers communicationandcognitiveskillsinpreschoolerswith
and43eligiblepreschoolerswithASD.Classroomswere ASD.Implicationsofresultsforfutureresearchandspeech-
randomizedtoEA-ESorbusinessasusual.Analysesof languagepathologist–teachercollaborationtoincrease
interventioneffectsusingbaselineandpostinterventiondata languageinterventiondosagearediscussed.
T
hemajorityofpreschoolerswithautismspectrum
disorder(ASD)receivetheirearlyinterventionser-
aCenterforAutismandRelatedDisorders,KennedyKriegerInstitute, vicesinpublicschools(Humeetal.,2005).Given
Baltimore,MD thattheincreasedprevalenceofASDintheUnitedStates
bDepartmentofMentalHealth,JohnsHopkinsUniversitySchoolof
(Baio et al.,2018) has mostly been noted within 2- and
PublicHealth,Baltimore,MD
3-year-olds(Hertz-Picciotto&Delwiche,2009)andthat
cDepartmentofNeuropsychology,KennedyKriegerInstitute,
expertsareabletoreliablydiagnoseASDbeforethethird
Baltimore,MD
dPsychiatryandBehavioralSciences,JohnsHopkinsUniversity birthday(Ozonoffetal.,2015),agrowingnumberofchildren
SchoolofMedicine,Baltimore,MD
CorrespondencetoRebeccaJ.Landa:[email protected]
Disclosures
Editor:LauraGreen Financial:Anne-MichelleEngelstadhasnorelevantfinancialintereststodisclose.
ReceivedOctober16,2019 CalliopeHolinguehasnorelevantfinancialintereststodisclose.RebeccaJ.Landa
RevisionreceivedFebruary6,2020 hasnorelevantfinancialintereststodisclose.
Nonfinancial:Anne-MichelleEngelstadhasnorelevantnonfinancialinterests
AcceptedFebruary12,2020
todisclose.CalliopeHolinguehasnorelevantnonfinancialintereststodisclose.
https://doi.org/10.1044/2020_PERSP-19-00155
RebeccaLandaisthedeveloperoftheEarlyAchievementsforEducationSettings
PublisherNote:ThisarticleispartoftheForum:InterventionFindings interventionandtrainingmaterials,butreceivesnoroyalties.Theresearchwas
AddressingUniqueCommunicationNeedsofYoungChildrenWith conductedintheabsenceofanycommercialorfinancialrelationshipsthatcould
AutismSpectrumDisorders. beconstruedasapotentialconflictofinterest.
PerspectivesoftheASHASpecialInterestGroups (cid:129) 1–20 (cid:129) Copyright©2020AmericanSpeech-Language-HearingAssociation 1
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SIG1LanguageLearningandEducation
withASDareenteringpublicpreschoolclassrooms.These mayhavethegreatestimplicationsforlanguagelearning.
childrenpresentwithsocialandcommunicationimpair- IJAisagoal-orientedbehaviorreflectingspontaneous
mentsthatdifferqualitativelyfromotherneurodevelop- seekingtosecureanotherperson’sattentioninorderto
mentaldisorders(AmericanPsychiatricAssociation,2013). shareexperienceaboutanobject,person,oreventofinter-
Yet,asyoungchildrenwithASDbeginschool,theyentera esttothechild.Achild’sIJAshowssocialmotivationand
milieuunpreparedtooptimizetheirsocialandcommunica- abilitytocoordinateandsynchronizeone’sownattention
tionoutcomes(Marshetal.,2017).Onereasonforthislikely withothers.Intypicaldevelopment,IJA,intheformof
pertainstoaresearch-to-practicegapthathasresultedin triadicgaze(e.g.,gazetothereferent,partner,andbackto
apaucityofevidence-basedinterventionsthat(a)target thereferent),beginstoemergeatage6months(Bhat
ASD-relatedsocialandcommunicationdeficitsand(b)can etal.,2011).Ataround8–10monthsofageintypical
be successfully and feasibly implemented by classroom development,thisgiveswaytopointing,showing,and
teachers. socialgivingasformsofIJA.Whenachildinitiatesjoint
attention,atopicisestablished.Adults’communication
aboutthattopic(thereferentofthechild’sIJA;Baldwin,
Communication Impairment in Young
1995)spotlightsreferent-relatedassociatedfeatures,rela-
Children With ASD
tions,andconcepts,enhancingthechild’sprocessingand
CommunicationdisorderinyoungchildrenwithASD encodingofinformationaboutthereferent(Kim&Mundy,
affectslanguageandsocialaspectsoffunctioning.Thelan- 2012;Mundyetal.,2016).Forexample,achildmight
guagecomponentofthecommunicationdisorderischaracter- hearaloudplaneandpointitouttohismother,initiating
izedbylateacquisitionoflanguagemilestonesandreduced jointattentiontotheplane.Hismother,respondingtohis
diversityofwords,wordcombinations,andgestures,along IJA,mightsay,“Youseetheplane!Itisflyingsofast.”
withthepresenceofstereotypicverbalbehavior(Landaetal., Thiscommunicationfromthechild’smotherabouttheref-
2013;Watsonetal.,2013;Weismeretal.,2010;Wetherby erent(theplane,inthiscase)highlightsfeaturesoftheplane
etal.,2007).Thelimitedrepertoireofconventionallexical (theyflyandarefast).Thechildencodesthisinformation
andgestureformsconstrainschildren’sabilitytocommu- intohissemanticnetwork.Frequentpracticewiththerich
nicate,inadifferentiatedway,aboutarangeofobjects, triadic(self–referent–otherperson)multimodal(visual,
events,people,andqualities.Evenwhenspokenwords auditory,tactile,linguistic,social,motor)eventsthatoccur
emerge,manychildrenwithASDhaveimpoverishedsym- surroundingachild’sIJAaffordsbrain–behaviorexperi-
bolicrepresentations(Wetherbyetal.,2007),resultingin encesthatlikelyentrainadistributedneuralnetwork
diminishedcomprehensionandproduction.This,incom- (Mundy&Newell,2007).Thus,jointattentionisconsid-
binationwiththeimpairmentingenerativityobservedin eredapivotalearlyinterventiontarget.Thisnotionissup-
childrenwithASD(Dichteretal.,2009),likelycurtails portedbyexperimentalwork.Kasarietal.(2006)found
learningtoflexiblycombinetheirexistingwordsinnovel thatpreschoolerswithASDrandomizedtoreceiveaninter-
ways(Kohler&Malott,2014).Theimpactofsuchdifficul- ventiontargetingjointattention(ratherthantotheinter-
tiescouldincludereducedcommunicativespecificityand ventiontargetingplayortothecontrolcondition)showed
effectiveness,aswellasreducedabilitytocontributenew greaterpre-topostinterventionjointattentiongains,butnot
informationtocommunicativeexchangesandtoelabo- expressiveorreceptivelanguagegains,comparedtothose
rateontopics.Thesocialcomponentofthecommunica- randomizedtoacontrolcondition.However,12months
tiondisorderinyoungchildrenwithASDischaracterized postintervention,childrenwhohadreceivedintervention
bydecreasedfrequencyofinitiationofcommunicativebids targetingjointattentionorplayshowedgreaterlanguage
(especiallytoinitiatejointattention)andreducedcommu- gainsthandidcontrols(Kasarietal.,2008).Furthermore,
nicativereciprocity(AmericanPsychiatricAssociation, childrenwiththelowestbaselinelanguagelevelsshowed
2013;Wetherbyetal.,2007).Diminishedfrequencyofcom- greaterexpressivelanguagegainsiftheyhadbeeninthe
municativeinitiations,especiallyforsocialpurposes,often jointattentionratherthantheplayinterventionorcontrol
resultsinchildrenwithASDfunctioningina“responder” conditions(Kasarietal.,2008).
roleincommunicativeinteractions;transactionalprocesses Intervention needs of young children with ASD
ofcommunicationaresubsequentlyimpeded(Wetherby areextensive.Thegeneralconsensusisthat15–25hrper
etal.,2007).Cascadingeffectsarelikely,wherebycommuni- weekofinterventionshouldbedelivered(Corsello,2005),
cativeexchangesoccurlessfrequently(Yoder&McDuffie, with greater intensity of intervention being associated
2006),arebriefer,andarecontentimpoverished.Theresult with better outcomes (Linstead et al., 2017). This ex-
isreducedlinguisticandsocialinputandreducedoppor- tends beyond what speech-language pathologists (SLPs)
tunitiestopracticeandengageindynamiclanguageand feasibly are able to provide, given their caseloads (Brandel
sociallearninginteractions(Massandetal.,2015).Thisis & Loeb, 2011; Katz et al., 2010). To approach such levels
concerningbecauseearlysocialandcommunicationfunc- of intensity, equipping teachers to implement evidence-
tionsareimportantpredictorsoflong-termoutcomes based intervention strategies is necessary. However, the
(Koveretal.,2016). intervention approach must be feasible for teachers to
Ofthesocialaspectsofcommunicationimpairment implement, given the other demands on their time and
inASD,impairmentininitiationofjointattention(IJA) resources.
2 PerspectivesoftheASHASpecialInterestGroups (cid:129) 1–20
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SIG1LanguageLearningandEducation
Targeting Core Deficits: About the Early cognitionwereobservedintheEA+ IScomparedtothe
Achievements Intervention EAgroup.Also,onlychildrenintheEA+IScondition
exhibitedsignificantgainsingeneralizedplayandexpres-
In order to address the need for feasible teacher-
sivelanguagefunctioning,aswellasfrequencyofIJA(Landa
implemented interventions for preschoolers with ASD,
etal.,2011).Inafollow-upstudy,LandaandKalb(2012)
Early Achievements (EA), a comprehensive clinical model,
foundthatASDseveritydecreasedinchildrenafterreceiving
was adapted for education settings. The original randomized
6monthsofEAintervention,regardlessoforiginalinterven-
comparative effectiveness trial of the EA interventionwas
tioncondition.However,afterthechildrenstoppedreceiving
conductedinaclinicalresearchsettingandexaminedsocial,
theintervention,ASDseverityworseneduntil,bythefinal
communication,andcognitiveoutcomesoftoddlers(M =
age follow-uptimepoint(T)3yearsafterEAorEA+ISpost-
28months)withASDandco-occurringcognitiveimpair-
interventionassessment,ASDseverityhadreturnedtothe
ment(2SDsbelowthemean)whowererandomizedtoone
elevatedpretreatmentlevels(Landa&Kalb,2012).Thistrend
oftwoconditions:EAorEAwithhighdosagelearningoppor-
occurreddespitethefactthat92.7%ofparentsreportedtheir
tunitiestargetinginterpersonalsynchrony(IS)skills(joint
childrenwerereceivingspecialeducationorappliedbehavior
attention,imitation,sharedaffect;EA+IS;Landaetal.,
analysisservicesinthe6monthsfollowingtheintervention
2011).InbothEAconditions,childrenreceivedacompre-
andthat66.7%ofparentsreportedtheirchildrenwerere-
hensiveinterventiontargetingsocial,communication,language,
ceivingtheseservicesthroughthefinalfollow-upT(Landa
play,andcognitivefunctionsusingnaturalisticdevelopmental
&Kalb,2012).Thesefindingssuggest that the services
behavioralintervention(NDBI;Schreibmanetal.,2015;
children received after EA or EA+IStreatmentmayhave
describedbelow)andstructuredteachingapproachesina
lackedthefocusonsocialcommunication,play,andinter-
nurseryschoolgroup-basedcontextfor10hraweekacross
personalsynchronythatwouldhavebeenneededtosustain
6months.Childreninbothgroupsreceiveddailyintervention
themitigatedASDsymptomatology.Indeed,veryfewin-
in wholegroup (five tosix children), dyads (twochildren),
terventionsshowntobeeffectiveintargetingASDcore
and,forpriming skillsand toestablish basic playskills, 1:1
deficitshavebeentranslatedforusebypreschoolteachers.
contexts.Interventionwasdeliveredbyanearlychildhood
specialeducatorwiththesupportoftwoteachingassistants.
Research-to-Practice Gap
EA+ISwasdesignedtotargetsocialandcommunica-
tiondeficitsofASDusingasociallyvalid,integrated,routine- Interventionappearstohavethemostsubstantialim-
embedded intervention approach (Landa et al., 2011). pactonlanguage,social,cognitive,andadaptivefunction-
Interventionists created a learning environment wherein inginyoungchildrenwithASDwhendeliveredinresearch
targeted communicative content was supported by strate- contextsandby research team members;effect sizesina
gically planned and placed visually salient pictures and meta-analysisof suchstudies ranged from 0.42 to 0.76
objects, as well as by the story in the book that was used (Reichow,2012).In contrast,a meta-analysis of interven-
in a book-sharing instructional activity each day. Commu- tionsroutinelyprovidedinthecommunitywithoutguid-
nicative interactions with peers and adults were scaffolded ancefromresearchers(hospital,clinic,home,andschool),
throughout the intervention activities. During shared book aswellas“treatmentasusual,”identifiedmuchlowereffect
reading and other group activities, thematically and story- sizes,rangingfrom0.17to0.37whenexaminingchangeover
relatedeventsequenceswerespotlightedastheinterventionist time,notbetweentreatmentandcontrolgroups(Nahmias
facilitatedchildren’sinitiationofandresponsetoothers’com- etal.,2019).Theresultsofthesemeta-analyses,paired
municationbids,expandedchildren’sutterances,scaffolded withtheverysmallnumberofstudiesidentifiedina2019
communicativeturn-taking,andmappedlanguageontochil- searchofWhatWorksClearinghouse(U.S.Departmentof
dren’stopicallyrelevantnonverbalbehavior.Thematically Education,n.d.)aseffectiveinauthenticeducationalsettings
andstory-relatedpropswereanintegralpartofstagingthis forchildrenwithASD,indicatearesearch-to-practicegap.
socialandcommunicativeenvironmentacrossinstructional Tobetterassesstheresearch-to-practicegaprelevant
activities(e.g.,snack,art,sensorymotor).Propsprovided forpreschoolerswithASD,onemustconsiderthestudies
concreteandmultipleexemplarsoftargetedvocabulary,as excludedfromNahmiasetal.’s(2019)meta-analysis:those
wellasreferentsforjointattentionbids.Theobjectschosen involvingcommunity providerstrained inintervention
aspropswerehighinaffordances(e.g.,afiretruckwitha implementation byresearchteam members.Such studies
ladderandslotforadriver)inordertomotivatecommuni- represent abodyof work in whichresearcher–community
cativeinitiations,facilitatecommunicativeturn-taking,and partnershipsareformedtodirectlyaddresstheresearch-to-
createopportunitiesforinterventioniststoexpandchildut- practicegapinearlyASDintervention.Weidentifiedseven
terances.Usingclearandconsistentpromptinghierarchies, suchstudiesconductedwithintheUnitedStates,employing
interventionistssupportedchildrentointeractwiththese NDBIstrategies,andassessingsocialand/orcommunica-
objectsinplayfulandsociallycontingentways,within- tionoutcomesandnotfocusedonasinglebehavior.
creasingplaycomplexityanddurationofjointengagement. Fiveofthesevenidentifiedstudiesfocusedonimprov-
In Landa et al.’s 2011 clinic-based comparative ingjointengagement,jointattention,and,infourofthese
effectivenessstudy,significantlygreatergainsinsocially fivestudies,play.Twoofthestudiesexaminedtheadvancing
engagedimitation(pairedwithdirectedgaze)andnonverbal social-communicationandplay(ASAP)interventionacross
Engelstadetal.:EarlyAchievementsforEducationSettings 3
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SIG1LanguageLearningandEducation
a school year. Three examined short-term (6–8 weeks) conditionsincludingteacherstrainedtoexpertiseinthe
implementationsoftheJointAttentionSymbolicPlayEmo- TEACCHautismprogramandanon–model-specifichigh-
tionRegulation(JASPER)intervention(Changetal.,2016; qualityEarlyChildhoodSpecialEducationclassroom
Lawton&Kasari,2012;Wong,2013).Theseinterventions (Boydetal.,2014).NosignificantGroup×Timeinterac-
weredeliveredin1:1and/orsmallgroupactivities.Themost tioneffectswasdetected.Boydetal.’s(2014)findingsindi-
consistenttreatmenteffectwasreduceddurationofchild catethatyoungchildrenwithASDdowellwhenenrolled
unengagementandgreaterdurationofchildengagement inhigh-qualityspecialeducationclassrooms.
(Boydetal.,2018;Changetal.,2016;Lawton&Kasari, Moreinterventionstargetingcorecommunication
2012;Wong,2013).ThesinglecasedesignASAPstudyin- deficitsofASDdesignedforteacherimplementationwith
dicatedthatgainsinsocialcommunicationandplayappeared preschoolerswithASDareneeded.Takingintoconsider-
moreclearlyoncea1:1context(deliveredbyaspeech- ationtheneedforfeasible,adoptable,andscalableinter-
languagepathologist)wasaddedtothepreviouslygroup- ventions,such interventions shouldbecompatiblewith
basedimplementationoftheintervention(Dykstraetal., teachers’pedagogyandpractices(Fishmanet al.,2018;
2012).WithinJASPERstudies,treatmenteffectswerede- Mandellet al., 2013);ableto beimplementedin group
tectedforjointattention,butonlyonmeasuresofclass- instructionalcontexts(Mandelletal.,2013);supplemental
roombehavior,notonresearcher-administeredmeasures to,ratherthanreplacing,schooldistrictcurricula(Mandell
(Changetal.,2016;Lawton&Kasari,2012;Wong,2013). etal.,2013);andcosteffectivewithtrainingdemandsmini-
Moremultiwordjointattention–relatedlanguageproduction mized, while still empowering teachers to achievehigh
(e.g.,“let’splay”)andsingle-wordregulatoryutterances(re- FOI. Here, wereport on a pilot randomized controlled
quests)werenotedintheJASPERthanthewaitlistgroup clinical trial(RCT) examining thepromiseof a teacher-
(Changetal.,2016).Significantgroupdifferencesinsimple implemented supplemental intervention for preschoolers
andfunctionalplaytypeswerenotedonanobservationaland with ASD, EA for Education Settings (EA-ES),derived
aresearch-administeredmeasure(Changetal.,2016).Though from the EA + IS intervention described above.
infrequentlyobservedineithergroup,greatergainsinsym-
bolicplaywerenotedintheJASPERthanthewaitlistcontrol
EA-ES
group(Wong,2013).TeacherswhoreceivedASAPor
JASPERtrainingexhibitedhigherfidelityofimplementation GiventheevidenceoftheEAinterventiontoeffectsig-
(FOI)thancontrolteachers(Boydetal.,2018;Changetal., nificantsocialcommunicationandinterpersonalsynchrony
2016;Lawton&Kasari,2012).Intensivecoachingduring gains(Landaetal.,2011)withlong-termbenefitforcommu-
teachers’JASPERimplementationwasprovided(upto nicationandcognitiveoutcomes(Landa&Kalb2012),and
60coachingsessionsin8weeks;Changetal.,2016).The theresearch-to-practicegaprelatedtoteacher-implemented
abovefivestudieshighlightthemalleabilityofjointengage- ASDinterventionsforpreschool-agedchildren,EA+IS
ment,anearly-developingbehaviorintypicaldevelopment, wasadaptedforeducationsettings.Thepilotedversionof
andthatwithanintensiveinterventionfocus,jointattention EA-ES,examinedinthisstudy,wasdesignedtotargetthe
gainsarepossibleinteacher-implementedinterventionfor communicationandsocialcoredeficitsofASDbyembed-
preschoolerswithASDhavingmildtonocognitivedelaysin dingtheEA+ISstrategieswithinexistinginstructional
1:1(Lawton&Kasari,2012)andsmallgroupplay-based activities:storytime(hereafter,“booksharing”),art,and
sessions(Changetal.,2016;Wong,2013). mealtime(e.g.,snackorbreakfast).Duringa2-yeariterative
Theremainingtwostudiestargetedabroaderrange processofadaptingEA+ISforeducationsettings,deliberate
ofdevelopmentaloutcomes.Bothofthesestudiesexamined decisionsweremadeabouthowtosimplifyandmodifythein-
theLearningExperiencesandAlternateProgramforPre- tervention,includingdeterminingthemostimportantinstruc-
schoolersandtheirParents(LEAP;Boydetal.,2014;Strain tionaltargetstoretain,designingtheinstructionalapproach
&Bovey,2011)intervention,achild-contingent,peer-mediated andcontexts,andrefiningthePDprogrambasedonfeedback
interventionimplementedwithintypicalroutinesininclu- fromteachersandadministratorstosupportteachers’success-
siveclassroomspairedwithparentskilltraining.Results fulimplementationofEA-ES(Wilson&Landa,2019).Given
ofStrainandBovey’s(2011)studyindicatedthata2-year thenumberofchildrenenrolledinpreschoolclassroomsand
comprehensiveprofessionaldevelopment(PD)programwith amountofstaffingavailable,weeliminatedthe1:1inter-
job-embeddedcoaching(includingtrainingofanonsitesu- ventioncomponentsusedintheoriginalEAintervention,
pervisortosupportimplementationofLEAPstrategies)led aswellasskillprimingandplayinstructionalactivities.No
tobetterteacherFOI(90%forcomprehensivelytrained, instructionalactivitieswereaddedtoorreplacedteachers’
38%forself-trained)andchildoutcomes(reducedautism existinginstructionalactivities,whichoftenareprescribed
symptomseverity;improvedlanguage,cognitive,andso- byschools’protocolsand/orcurricula.
cialskills)thanaself-learningapproachinwhichteachers ThepurposeofthispilotRCTwastoexaminepromise
learntoimplementtheinterventionusingtheintervention ofefficacyofthisiterativelydevelopedinterventionwhen
manual.ChildreninthecomprehensivelytrainedLEAP implementedbyteachersinauthenticeducationsettings.
classroomsreceivedhigh-fidelityLEAPinterventionfor WetestedthehypothesisthatteachersreceivingtheEA-ES
17hraweekfor2years.Subsequently,LEAPwasexamined PDtrainingwouldattainasignificantlyhigherlevelofimple-
inacomparativequasi-experimentalstudy,withcomparison mentationfidelitycomparedtoteachersnottrainedinthe
4 PerspectivesoftheASHASpecialInterestGroups (cid:129) 1–20
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SIG1LanguageLearningandEducation
interventionmethod.Thesecondaryaimwastotestthehy- bachelor’sdegreesinspecialeducation.Three(oneEA-ES,
pothesisthatchildrenreceivingtheEA-ESinterventionwould twoBAU)had master’s degrees in education.Two (one
showgreaterimprovementinsocialcommunicationandcog- EA-ES, oneBAU)classroomswereinclusive,andthree(one
nitiveoutcomesasdeterminedbywithin-groupcomparison EA-ES,twoBAU)wereself-contained.
andbybetween-groupcomparisonswithchildreninclass-
roomsrandomizedtothebusiness-as-usual(BAU)condition.
Child Eligibility
Eligibilitycriteriaforchildrenincludedbeingbetween
Method
ages36and60monthsattimeofconsent,beingenrolled
Study Design and Sample inapreschoolclassroomofaparticipatingteacher,meet-
ing criteria for ASD per theAutism Diagnostic Observa-
ThispilotRCTwasapprovedbytheJohnsHopkins
tionSchedule-2(ADOS-2;Lordetal.,2012)andexpert
UniversitySchoolofMedicineInstitutionalReviewBoard
clinicaljudgment,andhavingadevelopmentalquotientof
andwasregisteredonhttps://clinicaltrials.gov.Allpartici-
atleast40basedontheearlylearningcompositeofthe
patingteachersandparentsofchildrenprovidedinformed
MullenScalesofEarlyLearning(MSEL;Mullen,1995).
consentusingInstitutionalReviewBoard–approvedcon-
Exclusioncriteriawereknowngeneticdisorder,uncorrected
sentforms.Participationlastedthecourseoftheschool
hearingorvisionimpairment,andhistoryofaheadinjury
year;allPDanddatacollectionreportedhereinwerecol-
thatresultedinlossofconsciousness.Fromthe11classes,
lectedwithinthatschoolyear.Enrollmentofteachersand
43eligiblechildrenwereconsentedtoparticipateinthe
childrenbeganinAugust.Baselineassessmentswerecon-
study.Attritionofthetwoclassrooms(EA-ES=1,BAU=1
ductedwithinthefirst2monthsoftheschoolyear.Follow-
see above) resulted in the loss of five child participants
ingbaselinedatacollection,classroomswererandomized.
(EA-ES = 3, BAU = 2). The flowchart of participation
Randomizingsixclassroomsattheclassroomlevelusinga
through each phase of the RCT, as recommended by the
computerizedrandomnumbergeneratorresultedinthree
Consolidated Standards of Reporting Trials, is depicted
classrooms(threeteachers,threeinstructionalassistants
in Figure 1.
[IAs],and19children)beingassignedtotheEA-EStreat-
mentconditionandthreeclassrooms(threeteachers,four
IAs,and24children)beingassignedtotheBAUcondi- Description of EA-ES and BAU Conditions
tionbyastatisticiannotdirectlyinvolvedwiththestudy.
NoneoftheteachershadbeentrainedinEA-ES
Teacherswerenotinformedofconditionassignmentuntil
priortoparticipatinginthispilotRCT.Fourparticipating
completionofbaselinedatacollection.Allclassroomspro-
children,allintheBAUcondition,previouslyhadbeen
videdhalf-dayinstructiontostudents,withfiveofthesix
inclassroomsofteacherstrainedtoimplementEA-ESand
classroomsenrollingboththeira.m.andp.m.classesinthe
thuswereexcludedfromanalyses.
study(thesixthclassroomhadonlyana.m.class).This
resultedin11half-dayclasses.Enrollmentofchildrencon-
EA-ESInterventionCondition
tinueduntilNovember19,upto1monthaftertheteachers
Teachers in the EA-ES condition were trained to
in EA-EScondition receivedthefirst workshop.These
strategicallyengineerthelearningenvironmentandtouse
11children(n=2EA-ES,n=9BAU)werepermittedto
NDBIstrategiestotargetskillsthatsupportchildren’slan-
joinafterthefirstworkshopbecausetheywerenewlyenrolled
guageandsocialcommunicationdevelopment:jointatten-
intheirclassrooms.
tion,language,sociallycontingentimitation,peer-to-peer
Afterconditionassignment,twoclasseswerewith-
engagement,anduseofobjectsrelatedtotargetedlan-
drawnfromparticipation.Oneinvolvedateacher(EA-ES
guage.TeacherswerefirsttaughttodothisintheEAbook-
condition)whowithdrewheronlyenrolledhalf-dayclass
sharingactivityandthentaughttogeneralizeuseofthe
afterEA-EStraininghadbegunduetoclassroom person-
strategiestoothercontextsthroughouttheday.
nelchallenges.Theotherinvolvedateacher(BAUcondi-
tion)whowithdrewherp.m.classduetochildren’ssevere Strategicengineeringoftheenvironmentbeganwith
minimizingdistractionsinordertofocuschildren’satten-
challengingbehaviors,butcontinuedparticipationwithher
tiontostory-relatedprops,which,asinEA+IS,presented
a.m.class.
exemplarsoftargetedvocabulary,aswellasreferentsfor
jointattentionbids.Teachersweretaughttoimplementthe
Classroom Eligibility
followingNDBIstrategies:providingclearanddevelop-
Classroomswererecruitedfromasuburbanpublic mentallyappropriateantecedentcues,least-to-mostprompt-
mid-Atlanticschooldistrict.Therewerenoincentivesfor ing, natural and child-contingent reinforcement, event
studyparticipation.Eligibilitycriteriaforclassroompartic- casting,andexpanding.Forexample,teachersprovided
ipationincludedhavingatleasttwoeligiblechildrenwith opportunitiesforchildrentoinitiatejointattentiontoan
ASDandateachercertifiedtoteachinthestateinwhich item of importance in the story, usually aligned with vo-
thestudywasconducted.SeeTable1forteacherdemographic cabularyselectedbytheteacherasprimarylanguagetargets.
characteristics.Allfiveteachersthatcompletedthestudy Teachersprovidedclearantecedentsasillustratedinthe
haddegreesineducation.Two(oneEA-ES,oneBAU)had followingexample.“It’stimetoreadabook,but…hmm...
Engelstadetal.:EarlyAchievementsforEducationSettings 5
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SIG1LanguageLearningandEducation
Table1.Characteristicsofteachersandchildreninthepilotrandomizedcontrolledclinicaltrial.
EA-ES(n=2) BAU(n=3)
Teachervariables M(SD)orn(%) M(SD)orn(%)
Gender(Female) 2(100%) 3(100%)
Race(White,non-Hispanic/Latino) 2(100%) 3(100%)
Yearsofteaching 25.0(12.7) 4.0(3.5)
YearsofteachingchildrenwithASD 24.0(14.1) 3.3(3.1)
EA-ES(n=15) BAU(n=16)
Childvariables M(SD)orn(%) M(SD)orn(%)
Ageatpretest(months) 48.0(8.0) 46.0(6.7)
Gender
Female 6(40%) 3(18.8%)
Male 9(60%) 13(81.3%)
Race**
Asian 4(26.7%) 1(6.3%)
Black 1(6.7%) 7(43.8%)
Multiracial 2(13.4%) 3(18.8%)
White 8(53.3%) 5(31.3%)
Ethnicitya
Hispanic/Latino 0(0%) 1(6.3%)
Non-Hispanic/Latino 14(93%) 14(87.5%)
Maternaleducation*
Highschooldiplomaorless 0(0%) 6(43%)
Somecollegeorgreater 14(100%) 8(57%)
Paternaleducation
Highschooldiplomaorless 8(57%) 3(21%)
Somecollegeorgreater 6(43%) 11(79%)
Family SES(Hollingshead)*** 54.2(14.3) 37.8(15.5)
ADOScalibratedseverityscore* 5.9(1.6) 7.2(1.9)
MSELcompositescore 58.6(12.2) 53.0(4.3)
Numberofschooldaysmissed 9.9(8.6) 14.8(11.5)
Note. EA-ES=EarlyAchievementsforEducationSettings;BAU=businessasusual;SES=socioeconomicstatus;ADOS=AutismDiagnostic
ObservationSchedule;MSEL=MullenScalesofEarlyLearning.
aNotestimableduetolowvariabilityindata.
*p≤.10**p≤.05***p≤.01.
(teachervisuallysearchesthearea)doesanyoneseeour strategiesfosteredchildren’slearningacrossallfiveEA-ES
book?”Children werepromptedasnecessarytoinitiate targetedskilldomains(e.g.,peer-to-peerengagementand
jointattention by pointingtothebook orcommenting languageweretargetedaschildrenthrewthesnowballto
(e.g.,“thereitis!”)withaleast-to-mostpromptinghierarchy. peers, commenting, “my turn,” “throw to me,” or,
Teachersnaturallyreinforcedchildren’sIJAtothetargeted “Mathiasthrewthesnowball”).IntheEA-ESapproach,
object/picturebyprovidingaverbalaffirmationofthe thesamebookisusedfor2–3weekstopermitchildren’s
child’sbehaviorand/orallowingthemtointeractwiththe increasingfamiliarityandthescaffoldingofmorecomplex
referent. skills(McKeown&Beck,2014).TeachersintheEA-ES
Teachersselectedtheirownbooks,butweretrained conditioncontinuedtoimplementtheirschooldistrict’s
incriteriaforbookselectionatthefirstworkshop.Teachers designatedcurriculumandattendeddistrict-wideorschool-
were encouraged to select books with content that was requiredPDeventsthroughouttheschoolyear.
familiartothechildrenandrelevanttothechildren’slife
experiences.Teachersweretrainedtosupportchildengage- EA-ESTrainingandCoaching
ment,initiation,andmeaningconstructionthroughoutthe Afterbaselinedatacollectionforteachersandchil-
book-sharingactivitybyusinganactivities-basedapproach dren,participatingteachersrandomizedtotheEA-EScon-
informedbyprinciplesofembodiedandsituatedcognition. ditionattendedthefirstofseven6-hrworkshopsfacilitated
Whenaneventsequenceoccurredinthebook(e.g.,asnow- bythelastauthor,developerofEA-ES,andprincipalin-
ballfight),teacherssupportedmeaningconstructionrelated vestigatorofthestudy,aswellastwostafftrainedtofidel-
totheeventbystagingrelevantprops(e.g.,a“snowball”), ityintheimplementationofEA-ESattheKennedyKrieger
supportingchildren’sinitiationofrelevantlanguageor Institute’sCenterforAutismandRelatedDisorders(CARD)
gestures by using scaffolded cues described above, and inMaryland.Workshopsweredistributedacross5months
contingentlyreinforcinginitiationsbycreatingaturn-taking oftheschoolyear(OctoberthroughFebruary)tointroduce
opportunity(e.g.,throwingthesnowball).Theseinstructional interventioncomponentsduringbooksharing(Workshops1
6 PerspectivesoftheASHASpecialInterestGroups (cid:129) 1–20
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Figure1.Theflowchartofparticipationthrougheachphaseoftherandomizedcontrolledclinicaltrial,asrecommendedbytheConsolidated
StandardsofReportingTrials.ADOS-2=AutismDiagnosticObservationSchedule-2;EA-ES=EarlyAchievementsforEducationSettings;
BAU=business-as-usual.
and 2), generalize the intervention strategies to other communicationinchildrenwithASDandsustainingEA-ES
contexts(Workshop3),reviewandunderstandadditional implementation (Workshop 7). Experiential workshop
waystoconstructinstructionalactivitiesanduseinstructional activities included practicing use of EA-ES instructional
strategiestopromotechildengagementanddevelopment strategies to scaffold children’s development of EA-ES
(Workshop4),experienceadditionalopportunitiestoprac- targetedskills,activelyanalyzinginterventionimplementa-
ticethenuancesofimplementationofNDBIstrategies tionin videoexamples,selecting and modifying instruc-
(Workshop5),addressmanagementofchildbehavioral tionalmaterials,planningdifferentiatedlearningactivities,
dysregulationandproblemsolvebarrierstoimplementa- role-playinginterventionimplementation,andengagingin
tionofEA-ESstrategies(Workshop6),and,finally,tocon- problem-solving discussions (seeTable2for workshop
solidateknowledgeandskillsrelatedtointerventiontargeting descriptionsandsampleactivities).
Engelstadetal.:EarlyAchievementsforEducationSettings 7
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SIG1LanguageLearningandEducation
Table2.EA-ESprofessionaldevelopmentworkshopdescriptionsandsampleactivities.
Workshop Content Sampleactivities
1 IntroductiontoEA-ES;booksharing;theme;adaptingbooks (cid:129) Identifybooktheme
(cid:129) Bookselectioncriteria
(cid:129) Howtousebookstotargetinterventiongoals
2 Targetingsocialskills;teachingthroughembodiment (cid:129) Environmentalengineering
(cid:129) Practice
3 Review;addressingcommoncorestandardsandIEPgoals; (cid:129) Mapcommoncorebenchmarksinreading,listening,
EA-ESinotherinstructionalactivities andspeakingontoEA-EStargetsandactivities
(cid:129) DesigninginstructionalactivitiesaroundsampleIEPgoals
4 Howtotargetsocialskills;instructionplanning“thinktank” (cid:129) Rationalebehindinstructionaltargets(deeperdive)
(cid:129) Practicehowtoembedinstructionforsocialandlanguage
targetsintheselectedbook
(cid:129) Planningconcreteinstructionalmaterialsandactivities
5 Naturalisticdevelopmentalbehavioralinterventionstrategies (cid:129) Guidedvideoreview
(cid:129) Practice
(cid:129) Planning
6 Behaviormanagement;videoreview;teamcollaboration; (cid:129) Guidedvideoreview
effectiveandefficientplanning (cid:129) Problem-solvingstrategies
(cid:129) Planning
7 Boosterandconsolidationsession:communication;sustaining (cid:129) Designinginstructionalactivities:review
EA-ES;reviewofessentialconcepts (cid:129) Practiceexpandingandextendingchildutterances
(cid:129) Thinktank:sustainingEAintervention
Note. EA-ES=EarlyAchievementsforEducationSettings;IEP=IndividualizedEducationProgram.
At thefirstworkshopEA-ES teachers met their in- primaryvariableinthisstudy.Todoso,videorecordings
terventioncoach,aspeech-languagepathologistwhohad ofteachersinbothconditionsduringimplementationof
beentrainedtofidelityinimplementationofEA-ESbythe their book-sharing instruction were collected at baseline
developeroftheintervention(R.Landa)andwhosuper- (September),eachmonthoftheEA-EStrainingperiod
visedhisownAchievementsGroupattheCARDclinic.The (OctoberfollowingthefirsttwoworkshopsthroughApril
coachvisitedtheclassroomsofEA-ESteachersweeklyusing whenthefinalcoachingsessionoccurred),andatpostinter-
anevidence-basedcoachingapproach(Snyderetal.,2015). vention(May)aftertrainingandcoachingwerecompleted
Coachingbegantheweekafterthefirstworkshopandcontin- fortheEA-EScondition.Researchassistants,studyteam
ueduntilAprilofthesameschoolyear;teachersreceived a memberswhowerenottrainedinEA-ES,collectedthe
meanof18job-embeddedcoachingsessions(range:16–20). videorecordings.Thesetapes(n=76)werecodedforFOI
Thecoachfacilitatedteachers’self-reflectionbeforetheclass ofEA-ESinterventioncomponents.Codingwascompleted
began,providedjob-embeddedcoachingasteachersimple- byearlyinterventionspecialistsatCARDwhowerenot
mentedEA-ESinstructionalactivities,and,duringdebrief- involvedinthetrainingorcoachingofstudyparticipants.
ingperiodsconductedwhilechildrenwereengagedwithIAs Teachershavingbothana.m.andap.m.classroomhad
orafterschool,deliveredsupportiveandconstructivefeed- twofidelitytapesateachmonthlyT(oneforeachclassto
backontheteacher’sEA-ESimplementation.Duringthe measureimplementationacrossgroupsofchildrenhaving
debriefingsession,thecoachengagedtheteacherinproblem differentlearningandbehavioralprofiles).Foroneteacher
solving,goal-setting,andactionplanning.Formoreinforma- (BAU)ofana.m.classonly,baselinemeasurementwas
tiononEA-ESandthePDmodelutilizedinthestudy,please postponedby1monthduetosevereaggressivebehaviorof
visittheEAwebsite(www.earlyachievements.org). childreninherclassthatrequiredalternateuseofherin-
structionaltime,andthus,herBAUinstructionaldelivery
BAUCondition didnotbeginuntilNovember.TwoFOIdatapointswere
TeachersintheBAUconditiondeliveredinstruction missing:T1foroneEA-ESteacher’sa.m.classonlyand
andimplementedtheirschooldistrict’sdesignatedcurricu- T5 foroneBAU teacher’s a.m.class only.Codingcom-
lumastheytypicallywouldandattendeddistrict-wideor menced afterall datahadbeencollectedsothat video-
school-requiredPDeventsthroughouttheschoolyear.No tapes couldberandomizedacross time and condition,
trainingwasprovidedtoteachersintheBAUconditionby ensuring coders were naïve to timing of data acquisition
researchteammembers. duringthebaselineandintra-andpostinterventionperiods,
aswellasgroupassignment.TheEA-ESFOIscalewascom-
posedof35itemsdistributedacrossfivecategoriesofinter-
Measures
ventioncomponents.Itemswerecodedwitheithera3-point
PrimaryTeacherOutcome:FOI Likert-typescaleindicatingfrequency orquality of the
A rigorous method was used to assess teachers’ EA-ESstrategy,oradichotomousyes/noindicatingwhether
implementationofEA-ESinterventioncomponents,the the strategy was present or not. Coders trained on an
8 PerspectivesoftheASHASpecialInterestGroups (cid:129) 1–20
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SIG1LanguageLearningandEducation
initial pool of video recordings, coming to consensus when of thespontaneous communicativeverbalizations were
there was disagreement between coders. Following training, echolalicevents.
every 10th video was spot-checked for percentage agree- Thechildbehaviorcodingteamconsistedofresearch
ment, and a consensus meeting was held if agreement fell assistantswhowereuntrainedintheEA-ESmodel.Re-
below 80%. Interrater reliability was assessed for over 34% searchassistantsdidnotcodethevideofromclassroomsin
of independently coded FOI videotapes (n = 26). Agreement, whichtheyalsotaped.Rather,videostheywereassigned
across two raters, was excellent (average intraclass cor- tocodewerefromclassroomswithwhichtheywereunfa-
relation coefficient = .98). miliar.Thisprocedureavoidedbiasandservedasaprecau-
tionincaseateacherrevealedtheirclassroom’scondition
bydiscussingcoachingortrainingactivitieswhenthetaper
PrimaryChildOutcomes:SocialCommunicationBehaviors wasintheroom.Coderstrainedonthecodingschemaby
Five-minutechildbehaviorsamples,recordedduring studyingthesebehavioraldefinitionsoutlinedinacoding
ateacher-ledbook-sharingactivity,werecollectedatbase- manualandbycodinganinitialpoolofbehaviorsamples
line,6monthlyintra-interventionTs(Novemberthrough under the guidance of expert coders. Coders participated
April),andpostintervention.Intra-interventionchildclass- inregularconsensusmeetingsaftertheinitialtrainingpe-
room-baseddatacollectiondidnotbeginuntilNovember riodtomaintaingroupalignment.Interraterreliabilitywas
because EA-ES teachers did not receive the first work- assessedfor35%ofindependentlycodedbehaviorsamples
shopsuntilmid-October,andweprioritizedutilizationof (n=81).Intraclasscorrelationcoefficients(1,k)werecalcu-
research staff classroom-based data collection time in latedforeachofthefourraters,withonebeingthegold-
OctobertogatherteacherFOIdata.Thus,thereareseven standardratertowhomallothercoderswerecompared,
monthlyintra-interventiondatapointsforteacherFOIand forallthreesocialcommunicationbehaviors(Bartkoetal.,
sixforchildsocialcommunicationbehaviors;childTsT1– 1966;Fisher1958).Theintraclasscorrelationcoefficients
T6approximatelyalignwithteacherTsT2–T7.Asstated overthedurationofthestudywereasfollows:IJA,0.94;
above,11childrenenrolledinschoolafterdeliveryofthe directedgestures,0.81;andspontaneousverbalizations,
firstworkshopinmid-October.Thesechildrenreceived 0.97.Thesevaluesalldenoteexcellentreliabilityaccording
theirbaselinemeasurementatthetimethattheirclassmates toCicchetti’sguidelines(1994).
werereceivingtheirfirstintra-interventionmeasurement;thus,
theselateenrollmentsdidnothavesixintra-intervention SecondaryChildOutcomes:StandardizedChildMeasures
Ts.Everyeffortwasmadetocollectbaselinedataassoon The MSEL is a developmental assessment normed
afterenrollmentaspossible,onceinformedconsent and for birth through 68 months. The MSEL has shown
eligibilityscreeningwerecomplete.Theaveragenumberof validity in independent samples of young children with
schooldayselapsedfromconsenttocollectionofbaseline ASD and developmental disorders (Bishop et al., 2011;
datawas6.27schooldays(range:1–13). Farmer et al., 2016). The MSEL Expressive Language,
The5-minvideoswerecodedforfrequencyofIJA, Receptive Language, Visual Reception, and Fine Motor
directedgestures,andspontaneousdirectedcommunicative subscales were administered to participating children at
verbalizations.Behaviordefinitionswereadaptedfromthe baseline and postintervention at their schools by trained
existingsocialcommunicationliteratureandnorm-referenced research staff who were naïve to group membership. The
measuressuchastheCommunicationandSymbolicBe- Gross Motor subscale was not administered because
haviorScales:DevelopmentalProfile(Wetherby&Prizant, norms do not extend beyond age 30 months, and this sub-
2002),EarlySocialCommunicationScales(Mundyetal., scale score is not incorporated in the early learning com-
2003),andADOS-2.IJAwasdefinedasachild’sproduc- posite. The early learning composite, having a mean of
tionofapointinggestureorapproximationthereoftodraw 100 (SD = 15), serves as a developmental quotient. Base-
anotherperson’s attentiontowarda visualstimulus or line early learning composite scores for each group pro-
event.Directedgestures met oneormoreof thefollowing vide a norm-referenced indicator of children’s overall
criteria:Thegesturewas paired with eyecontact,the developmental functioning when they entered the study.
childapproachedanotherpersonoraddressedapersonby Age-equivalent scores served as dependent variables in
namebeforegesturing,and/orthechildmadearelevant analyses for each of the administered MSEL subscales
gestureinresponsetoaquestionorcommentbyanother because many children scored at the lowest possible stan-
person.TheproductionofapointinggestureduringIJA dard score (20) at baseline, resulting in a floor effect that
wasnotduallycodedasadirectedgesture.However,a made it impossible to distinguish performance between
child’sproductionofapointinggestureassociatedwith children scoring at or below 20. Use of age-equivalent
choice-makingorrequestingwascodedasadirectedges- scores avoided consequences of such floor effects (Rogers
tureiftheabovecriteriaweremet.Spontaneousverbaliza- et al., 2012) and thus enabled detection of developmental
tionsmetthefollowingcriteria:werenotprecededbya progression during the school year. Verbal (average of
modelandwerenotproducedinresponsetoaclose-ended Expressive and Receptive Language age-equivalent scores)
question(e.g.,yes/no)orinresponsetoaquestioninwhich andnonverbal(averageofVisualReceptionandFineMotor
theanswerwasimpliedorprovided(e.g.,teacher:“Doyou age-equivalent scores) composite scores were computed
wanttheredorgreenapple?”child:“Green”).Thus,none (Rogers et al., 2012).
Engelstadetal.:EarlyAchievementsforEducationSettings 9
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SIG1LanguageLearningandEducation
Analysis nonverbalandverbalcompositesasoutcomes,wedidnot
adjustforMSELcompositebecauseofcompleteoverlap
Teacher FOI
inthesevariables.
Linearmixed-effectsmodelswereusedtoestimate AllanalyseswereperformedinRVersion3.6.1(2019–
theeffect of group, time, and Group × Time on teacher 07–05;RCoreTeam,2019).Linearmixed-effectsmodels
fidelityscores(acontinuousvariable).Arandomintercept wereperformedwiththelmerTestpackageinR(Kuznetsova
wasusedfor“teacher”toaccountforthenonindependent, etal.,2015).
repeatedfidelitymeasuresovertime.Timewasmodeledas
adummyvariablebecauseofnonlinearityinfidelityscores
Results
overtime.
Descriptive
Child Outcomes Demographiccharacteristicsofteachersandchildren
whoreceivedthefullstudyprotocolinthispilotRCTare
UnadjustedMeanDifferencesinVariablesOverTime,
reportedinTable1.Examinationofbaselinecharacteris-
WithinandBetweenGroups
ticsacrossconditionsonallvariablesinTable1revealed
Wesummarizedthemean,standarddeviation(SD),
significantdifferencesindemographicfactors(moreAsian
andmeandifferencesinchildoutcomemeasures(social
andWhitechildrencomparedtoBlackchildren,greater
communicationbehaviors,andMSELverbalandnonver-
proportionofmotherswithatleastsomecollegeexperience,
balcompositescores)frombaselinetopostintervention
andhigherfamilysocioeconomicstatusintheEA-ESgroup
withinandbetweenEA-ESandBAUgroups.Toobtainan
comparedtotheBAUgroup).Additionally,therewasa
unadjusted estimate of the magnitude of difference be-
trendtowardsignificanceforlowerADOS-2calibratedsever-
tween thesechildoutcomemeasuresovertimewithinand
betweenthetwogroups,Hedge’sgwascalculatedusing ityscorescomparedtotheBAUgroup(5.9vs.7.2,p<.10).
pooledweightedstandarddeviations.Hedge’sgisappropriate
forsamplesizeslessthan20(Rosenthal&Rubin1986). Teacher FOI
Linearmixed-effectsmodelswereusedtoobtainanestimate
Teachers’implementationoftheEA-ESintervention
fortheGroup×Timeinteraction(i.e.,whetherthemeandif-
componentsatbaseline,asmeasuredbytheresearcher-
ferencefrombaselinetopostinterventiondifferedsignifi-
codedFOImeasure,was25%and40%fortheBAUand
cantlyintheEA-ESvs.BAUgroup).
EA-ESgroups,respectively.Attheposttrainingmeasure-
ment(about1monthafterthelastcoachingsession),
LinearMixed-EffectsModeling:Adjusted teachers’FOIattainmentwas29%and90%fortheBAU
forBaselineVariables andEA-ESgroups,respectively,showingthattheEA-ES
Next,wecarriedoutlinearmixed-effectsmodelsto teachersattainedhighfidelityofEA-ESinterventionim-
estimatetheassociationbetweengroup,time,andGroup× plementation.AteachT(T1,T2,T3,T4,T5,T6,T7,post-
Timeinteractionsoneachchildoutcomemeasuresepa- training),theEA-ESgrouphadsignificantlyhigherFOI
rately,witharandominterceptforchild,toaccountfor scoresrelativetobaselinethandidtheBAUgroup(esti-
thenonindependentrepeatedmeasuresforeachchild.Child matesrangedfrom0.45to0.54,p<.0001;seeFigure2).
outcomemeasuresweremodeledcontinuously.Because
therewasanonlinearrelationbetweenchildoutcomemea-
Child Outcomes
sures and time,wemodeledtimeas adummyvariable.
EachT (intra-intervention T1 through postintervention) UnadjustedMeanDifferencesinVariablesOverTime,
was modeledrelativetobaseline. WithinGroup
AlthoughchildrenwererandomizedtotheEA-ES Valuesoftheprimaryandsecondarychildoutcome
andBAUgroups,whichintheoryhasthebenefitofpro- measuresatbaselineandpostinterventionintheEA-ES
ducingtwogroupswithnobaselinedifferences,thesample andBAUgrouparesummarizedinTable3.TheEA-ES
sizeofthisstudyissmallandchancedifferencesmayoc- groupshowedincreasesonallthreeprimaryandbothsec-
cur. Thus, to control for between-group differences at ondary child outcome measures from baseline to postin-
baseline, regression modeling was used to adjust for tervention(seeTable3).Theaverage,unadjustedmean
baselineMSELcomposite(M=100,SD=15),ADOS-2 differencesfrombaselinetopostinterventionreflectedgains
CalibratedSeverityScore(maximumpossiblescore= infrequencyofproductionforIJAof1.8,directedgestures
10,with10representingthegreatestASDsymptomsever- of0.5,andspontaneousverbalizationsof3.7,andforMSEL
ity;Gothametal.,2009),numberofabsencesduringthe nonverbalandverbalcompositesof8.0and4.0months,
schoolyear,familysocioeconomicstatus(Hollingshead,1975), respectively(seeTable3andFigure3).ttestsrevealedsta-
andchildrace(Asian,Black,multiracial,White;refer- tisticallysignificantdifferenceswithintheEA-ESgroup
ence:White)tominimizethepotentialforconfounding. frombaselinetopostinterventioninIJA,spontaneousver-
Absencesweredefinedasdaysofschoolmissedthatwere balizations,andMSELnonverbalcompositescore(ps<.05).
aboveandbeyondschoolholidays,professionaldays,and Hedge’s g effect sizes were calculated to estimate the
weather-relatedclosures.ForregressionmodelswithMSEL magnitude of change from baseline to postintervention
10 PerspectivesoftheASHASpecialInterestGroups (cid:129) 1–20
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