Personalized, Responsive Intervention Sequences for Minimally Verbal Children With Autism

This study will use a Sequential Multiple Assignment Randomized Trial (SMART) design to examine key scientific questions for assembling an optimal adaptive intervention for preschoolers with ASD .

Children will first be recruited through local school districts and early intervention service providers, approximately 35 children per year across all three sites (UCLA will have 15 per year, University of Oregon will have 10 per year, and University of Rochester will have 10 per year) for a total of 140 children.

Based on early intervention research conducted by this research team over the past 15 years, we are proposing a first stage treatment decision comparing the commonly applied ABA method of Discrete Trial Teaching or an NDBI approach of JASPER focused on social communication and play targets specifically. The dose of each intervention is delivered at a research dose of 2 hours per week (consistent with previous JASPER studies. All children are expected to receive federally subsidized early intervention services which we will track for dose and type (to be considered in analyses). The interventions are described below: Stage 1 DTT Intervention (2x60 minute sessions per week in community setting): Discrete Trial Training (DTT), an adult-led, highly structured, behavioral teaching approach, is considered to have the strongest evidence as a "standard of care" for young children with autism. DTT emphasizes didactic, adult-led instruction. This approach relies on teaching discriminations between stimuli, responses to stimuli, and providing systematic reinforcement for correct responses. The goals of DTT are to teach specific skills, to accelerate overall development and increase school readiness. In order to meet these goals the interventionist works to create an engaging environment to support the child's ability to attend to the instruction and demonstrate the skills correctly. Recently, DTT interventions have begun to teach skills to address early core social communication deficits such as joint attention in order to promote better language and communication outcomes. While many children will have been exposed to DTT prior to entering this trial as part of business as usual community treatment, community intervention quality and dosage can vary widely. It is important to insure that children (a) receive quality DTT, and (b) have exposure to elements related to language learning, specifically engagement in instruction, and joint attention and requesting gestures, in order to make the comparison with JASPER in stage 1. Thus, in addition to the expected ABA approach used in their early intervention preschool program (which in the sites we are located also includes DTT during the day), we will insure high quality DTT carried out by research staff in order to adequately make the comparison between models for children with ASD in this project.

Stage 1 JASPER Intervention (2x60 minute sessions per week in community setting): is a developmentally anchored behavioral intervention that assumes that communication develops from social interactions in which specific social engagement strategies, symbolic representations, and early communication forms are modeled and naturally reinforced by the adult's responses to the child. JASPER uses the child's current play level to choose appropriate toys and materials to create a context for learning. Developmental principles of following the child's attentional focus, balancing imitation and modeling to create and expand play routines, supporting children's regulation and engagement, as well as responding to and expanding children's communication/language targets are used. The goal of JASPER is to increase (a) joint engagement, (b) initiations of joint attention and requesting skills, (c) diversity in social play involving objects and persons, and (d) verbal and nonverbal communication by facilitating meaningful social interactions. The social interaction foundation of JASPER is critical. Modeling and expansions of communicative behaviors and play are used strategically within the interactions with an adult. For children at risk of minimally verbal status, meaningful social interaction is essential for establishing the platform on which language input and development will be built. Unlike DTT, JASPER is likely to be a novel intervention to which few children will have had previous exposure through business as usual treatment.

Stage 2: Responders (2x60 minute sessions per week): Responders in stage 1 stay the course in the same intervention at the same dose.