Efficacy of a Comprehensive School-based Intervention for High-functioning Children With Autism Spectrum Disorder

The efficacy of the comprehensive school-based intervention (CSBI) was evaluated in a cluster randomized trial (pretest-posttest control group design). A total of 96 students in grades 1-5 with HFASD from 32 public elementary schools were initially targeted for enrollment over the 4-year study period. Once students were screened and determined to meet eligibility criteria, individual schools (clusters) were randomly assigned to either the treatment condition (CSBI) or control condition (business-as-usual [BAU]). A block randomization design with stratification by school economic level was used to insure approximate balance among the treatment groups. Recruitment was conducted during the 4-8 months prior to the upcoming school year. School staff from the treatment schools completed a manualized 5-day training during the summer preceding the treatment year and demonstrated fidelity with the protocol (competence). Pretesting was completed 6 weeks into the school year (prior to the initiation of the intervention) and posttesting at the end of the school year following completion of the intervention. Children with HFASD in the CSBI schools received the CSBI intervention implemented by school staff during the school year and children with HFASD in the BAU schools received their typical special education programming. Implementation accuracy (fidelity) was assessed by research assistants throughout the school year in the CSBI schools using standardized fidelity monitoring sheets. The fidelity monitoring sheets were also completed by research assistants during observations in the BAU schools in order to identify the possible presence of any of the treatment elements in the BAU schools.

Treatment (CSBI) group protocol. The following is a description of the 5 treatment components (SSGs, IDN, MR, TAs, and PT) and fidelity protocol for the CSBI.

Social skills groups (SSGs). SSGs were conducted 2-3x/wk. for a total of 60-90 min./wk. by a designated member of the school team. Groups contained 3-6 students with social impairments. Each manualized SSG began with a review of rules and was then conducted according to the framework of Skillstreaming (Goldstein et al., 1997). Skillstreaming is a structured program for teaching interpersonal skills to children with social deficits using teaching, modeling, role-playing, performance feedback, and transfer of learning (McGinnis & Goldstein, 1997). In the CSBI, 26 social skills were taught in a progression from basic to more complex. While the SSG protocol required active participation of every child each session, each child was required to be the primary role-player at least twice per 3 sessions. Each session ended with a short review and discussion of how to use the skill in future classroom activities. To ensure repeated practice and ongoing feedback, and promote generalization, 1) each participant had >2 social targets on her/his IDN (see IDN section), 2) classroom teachers displayed a list of the social skills taught to date and the component steps of each social skill, and 3) parents were continually informed of target skills. Fidelity of implementation. SSG facilitators recorded the date, attendees, minutes of group instruction, and skill for each session on a tracking sheet and research assistants monitored fidelity at least 1x/wk. using a standardized fidelity sheet.

Individual daily note (IDN). The IDN was administered across the school day and was used to practice and reinforce newly learned skills, and reduce problem behaviors/ASD symptoms. It directed the student, school team, and parents to focus on specific skills/behaviors and performance criteria, and promoted communication between school and home. Each IDN consisted of 3-5 operationally-defined targets; to increase generalization >2 were skills taught in the CSBI. Initially, IDN targets were identified by teachers and operationally defined, and base rate data were collected for 3-5 days to determine criteria for IDN goals. Each student's school day was then divided into intervals based on his/her reinforcement needs. At the end of each interval, the student could earn 1 point for each IDN target and must have earned >75% of her/his daily points to receive a home reward (reinforcer). During each interval, the student received immediate verbal feedback and a tally was recorded on his/her IDN. At the end of each interval, the teacher provided feedback on the student's performance during that interval based on the targets and performance criteria. At the end of the day, the teacher informed the student of her/his overall performance (% earned), sent a copy of the IDN home, and retained a copy of the IDN. Fidelity of implementation. A copy of each child's IDN was kept by the classroom teacher and collected every 2 weeks. Adherence was assessed during at least two 60-min. observations each week using a standardized fidelity sheet.

Mind Reading (MR) computer instruction. MR was conducted 3x/wk. for a total of 60 min./wk. by a designated member of the school team. MR is an interactive software program designed to teach recognition of emotions in facial and vocal formats (Baron-Cohen et al., 2004). It features 412 emotions organized into 24 emotion groups and by 6 emotion levels. The program presents instruction and tasks in the Emotions Library, Learning Center, and Games Zone and reinforcing activities in the Rewards Zone. It also employs a token system to reinforce participants with access to the Rewards Zone using points earned for accurate completion of questions in MR. The CSBI included 100 MR emotions divided into 10 groups (10 emotions per group). Each week students were taught 1 group of emotions (repeated during the 3 lessons). After each emotion group was taught, students repeated the 10 emotion groups 2 more times for a total of 3 exposures to the 10 groups. Each session was manualized to ensure children met time parameters accessing areas of MR. School staff members monitored students to ensure they accessed program areas according to the protocol. Fidelity of implementation. Data on time using the software for each participant were collected by an internal chronometer in the software and research assistants monitored implementation accuracy at least once per week using a standardized fidelity sheet.