Early Intervention Providers' Perspectives About Working with Families of Toddlers with Suspected ASD: A Qualitative Study.

Part C early intervention (EI) providers are at the front line of service provision for children under 3 years old with developmental delays or disabilities. As such, they can play a key role in both the early detection of autism spectrum disorder (ASD) and the provision of ASD-specialized treatment. Focus groups were conducted with 25 EI providers from three agencies in a Northwestern U.S. county to understand their role in the identification of ASD and communication about ASD concerns to families. Results revealed the tension that providers experience between maintaining a positive and supportive relationship with families and raising the issue of possible ASD. Cultural influences affecting ASD care and suggestions for desired resources were also discussed.

Embedding school cultures and climates that promote evidence-based practice implementation for youth with autism: A qualitative study.

LAY ABSTRACT: Schools play a major role in providing services to youth with autism; however, not all schools use evidence-based practices, defined as interventions that are proven to improve youth well-being through rigorous research. School culture and climate are strong predictors of whether or not a school uses evidence-based practices; however, little is known about how principals can create school cultures and climates that support the use of these practices. This study interviewed 32 teachers in elementary schools that implemented three closely related evidence-based practices for youth with autism to better understand how principals create school cultures and climates that support effective services. Analysis of the teachers' responses identified seven strategies principals can use to create school cultures and climates that support the implementation of effective practices for youth with autism. The strategies include the following: (a) support teachers to obtain professional development focused on autism, (b) align performance expectations and evaluations with the needs of students with autism and evidence-based practice delivery, (c) allocate resources to ensure adequate staff, materials, and training are available to implement evidence-based practices, (d) be open and flexible to allow teachers to use the building and resources as needed to meet students' needs, (e) provide direct assistance, feedback, and coaching to troubleshoot challenges or involve outside experts to do so, (f) openly value the work of special education teachers and provide recognition to those who develop expertise in evidence-based practices, and (g) look for opportunities to integrate special and general education teachers and students to foster a truly inclusive climate.

Parent Perceptions About Communicating With Providers Regarding Early Autism Concerns.

BACKGROUND: Long delays between parents' initial concerns about their children's development and a subsequent autism spectrum disorder (ASD) diagnosis are common. Although discussions between parents and providers about early ASD concerns can be difficult, they are critical for initiating early, specialized services. The principles of shared decision-making can facilitate these discussions. This qualitative study was designed to gain insights from parents of young children with ASD about their experiences communicating with primary care providers with the goal of identifying strategies for improving conversations and decision-making regarding the early detection of ASD. METHODS: Three 2-hour focus groups were conducted with 23 parents of children with ASD <8 years old. Qualitative analysis employed an iterative and systematic approach to identify key themes related to parents' experiences. RESULTS: Eight themes related to communication about early ASD concerns emerged: characteristics of the child that caused parental concerns, the response of others when the parent brought up concerns, how concerns were brought up to the parent by others, parental responses when others mentioned concerns, information seeking, barriers to and facilitators of acting on concerns, and recommendations to providers. Parent responses suggest the need for increased use of shared decision-making strategies and areas for process improvements. CONCLUSIONS: Primary care providers can play a key role in helping parents with ASD concerns make decisions about how to move forward and pursue appropriate referrals. Strategies include responding promptly to parental concerns, helping them weigh options, and monitoring the family's progress as they navigate the service delivery system.

Individual and organizational characteristics predicting intervention use for children with autism in schools.

LAY ABSTRACT: Several interventions or treatment programs have been shown through research to improve social outcomes for children with autism, but they often are not used in schools. This study examined individual (school personnel) and organizational (school level) factors associated with the use of a research-informed social engagement intervention, Remaking Recess, for children with autism in elementary schools. A total of 28 school personnel from 12 schools in 5 districts in the northeastern United States participated. Schools were randomly assigned to (1) training in Remaking Recess only or (2) training in Remaking Recess with implementation support (tailored strategies to remove barriers to increase use of Remaking Recess). School personnel rated their attitudes about research-informed interventions, organizational readiness (school's readiness to use a research-informed intervention), and fidelity or the degree to which an intervention is used as it was originally designed. Observers rated school personnel's fidelity at baseline (pre-intervention training) and exit (post-intervention training). The results suggest that self-rated fidelity was lower when staff perceived the use of Remaking Recess was required; however, observer-rated fidelity was lower when staff rated Remaking Recess as appealing. In addition, self-rated fidelity was higher when there was a sufficient number of staff, positive individual growth, and organizational adaptability. The results also indicated higher observer-rated fidelity when staff perceived positive influence over their coworkers. The results suggest that both individual (attitudes) and organizational (influence, staffing, growth, adaptability) characteristics may affect implementation success in schools. A collaborative decision-making approach for evidence-based practice use is recommended.

Understanding the Organizational Implementation Context of Schools: A Qualitative Study of School District Administrators, Principals, and Teachers.

Key features of the school environment can have a significant impact on teachers' effective use of evidence-based practices (EBP), yet implementation-specific organizational constructs have rarely been studied in the education sector. This study examined three aspects of the organizational implementation context (implementation leadership, climate, and citizenship behavior), which have been conceptualized and validated in other service settings. Focus groups with central office administrators, principals, and teachers were conducted to understand the applicability and conceptual boundaries of these organizational constructs in schools. Focus group transcripts were coded, and the results indicated both similarities and differences in their conceptualizations of implementation leadership, climate, and citizenship behavior in school. The data indicated that: (1) implementation leadership was largely present in schools with the addition of Distributed Leadership; (2) two implementation climate constructs were most clearly present (i.e., Focus on EBP and Educational Support for EBP) and two additional constructs (i.e., Existing Support to Deliver EBP and Prioritization of EBP) emerged as part of this construct; and (3) implementation citizenship behavior (Helping Others and Keeping Informed) was consistently acknowledged across schools and two new components emerged (i.e., Information Sharing and Observation/Feedback). Recommendations to researchers and community stakeholders are discussed.

Discrepancies and Agreement in Perceptions of Implementation Leadership: Associations with Dosage of School-Based Evidence-Based Practices for Children with Autism.

Studies demonstrate that discrepancies among leader-follower perceptions of leadership are related to organizational processes that may impact evidence-based practice (EBP) implementation. However, it is unknown whether discrepancies in leadership perceptions also predict EBP use. This study examined the association of principal-staff alignment and discrepancy in perceptions of implementation leadership with the dosage of three Autism-focused school-based EBPs, Discrete Trial Training, Pivotal Response Training (PRT), and Visual Schedules. PRT dosage was higher when principals under-rated their implementation leadership and when it was agreed upon that implementation leadership was low. Findings have implications for leaders support of EBPs implemented in school-based settings.

Individual and organizational factors that affect implementation of evidence-based practices for children with autism in public schools: a cross-sectional observational study.

BACKGROUND: Children with autism receive most of their intervention services in public schools, but implementation of evidence-based practices (EBPs) for autism varies. Studies suggest that individual (attitudes) and organizational characteristics (implementation leadership and climate) may influence providers' use of EBPs, but research is relatively limited in this area. This study examined individual and organizational factors associated with implementation of three EBPs-discrete trial training, pivotal response training, and visual schedules-for children with autism in special education classrooms in public elementary schools. METHODS: Participants included 67 autism support teachers and 85 other classroom staff from 52 public elementary schools in the northeastern United States. Participants reported their attitudes toward EBPs (e.g., intuitive appeal, willingness if required, openness, and divergence), implementation leadership and climate of their school, and the frequency with which they deliver each of three EBPs. Linear regression was used to estimate the association of attitudes about EBPs with organizational characteristics and intensity of EBP use. Demographic covariates with a bivariate association with EBP use significant at p < .20 were entered into the adjusted models. RESULTS: There were significant findings for only one EBP, discrete trial training. Teachers who reported higher perceived divergence (perceived difference of usual practice with academically developed or research-based practices) between EBPs and current practices used less discrete trial training (f2 = .18), and teachers who reported higher appeal (willingness to adopt EBPs given their intuitive appeal) of EBPs used more discrete trial training (f2 = .22). No organizational factors were significantly associated with implementation with any of the three EBPs. CONCLUSIONS: Attitudes toward EBPs may affect teachers' decisions to use EBPs; however, implementation leadership and climate did not predict EBP use. Future implementation efforts ought to consider the type of EBP and its fit within the context in terms of the EBP's similarities to and differences from existing practices and programs in the setting. Implementation strategies that target individual attitudes about EBPs may be warranted in public schools.

Organizational culture and climate profiles: relationships with fidelity to three evidence-based practices for autism in elementary schools.

BACKGROUND: Implementation researchers have typically studied organizational culture and climate by testing whether individual dimensions are linked to the implementation of evidence-based practices (EBPs) rather than examining how the overarching social context influences implementation. This approach may limit implementation theory and strategy development to the extent that individual dimensions of culture and climate interact, mutually reinforce or counteract one another, or exhibit non-linear relationships. This study tests whether empirically identifiable culture and climate profiles emerge in a sample of organizations and examines how these profiles relate to EBP fidelity and work attitudes that support EBP sustainment, focusing on three EBPs for youth with autism delivered in schools as an example. METHODS: The study included 65 elementary schools in the U.S. that implemented three EBPs-discrete trial training, pivotal response training, and visual schedules-for youth with autism. Organizational culture and climate and work attitudes were assessed using the Organizational Social Context measure at the beginning of the school year. Observations of EBP fidelity occurred mid school-year. We used bias-adjusted stepwise latent profile modeling to (1) identify subpopulations of schools that share similar culture and climate profiles, and (2) test for mean differences across profiles in observed EBP fidelity and teacher and staff work attitudes. RESULTS: Controlling for region, four profiles best characterized the organizational cultures and climates of schools. Teachers and staff in schools with a comprehensive profile (high proficiency culture, positive climate) exhibited higher fidelity to two of three EBPs (d's = .95 to 1.64) and reported superior work attitudes (d's = .71 to 1.93) than teachers and staff in all other schools. Teachers and staff in supportive schools (low rigidity culture, positive climate) had better work attitudes, but not better fidelity, than those in schools with indifferent (low culture/climate, elevated stress) and constrained (high rigidity and resistance, high stress) profiles. CONCLUSIONS: Organizational culture and climate profiles are a strong predictor of EBP fidelity and work attitudes that support EBP sustainment, highlighting the importance of an organization's overarching social context when developing implementation theory and strategies. Strategies that foster a comprehensive profile may improve EBP implementation.

The impact of implementation support on the use of a social engagement intervention for children with autism in public schools.

Several interventions have demonstrated efficacy in improving social outcomes for children with autism; however, few have been successfully implemented in schools. This study compared two implementation strategies to improve the use of a social engagement intervention for children with autism in public schools. In total, 31 children with autism in grades K-5 and 28 school personnel participated in a randomized controlled trial. Schools were randomized to (1) training in Remaking Recess, a social engagement intervention, or (2) training in Remaking Recess with implementation support. Linear regression with random effects was used to test the intervention effects on implementation fidelity and social outcomes (peer engagement, social network inclusion, and friendship nominations). In both groups, implementation fidelity improved after training but remained low. Children in the Remaking Recess with implementation support condition had significantly higher social network inclusion and received more friendship nominations than children in the Remaking Recess-only condition (p = 0.03). Children in both groups experienced reduced solitary engagement (p < 0.001) and increased joint engagement (p < 0.001). The results suggest that implementation supports may have an effect on outcomes above and beyond the intervention, and that further research is needed into the active intervention mechanisms.

The games they play: Observations of children with autism spectrum disorder on the school playground.

The playground may be an important context to examine the social functioning of children with autism spectrum disorder. Previous literature on playground peer engagement has used quantitative methods, but there is limited research using qualitative observations to understand the nuances of playground behavior. Using a mixed-methods approach, 55 elementary school-aged children with autism spectrum disorder who are primarily included in general education settings were observed on the school playground using the Playground Observation of Peer Engagement. Quantitative and qualitative data were examined using a mixed-methods approach. The results showed that children with autism spectrum disorder: engage in solitary and peripheral activities; demonstrate appropriate initiations and responses to peers; display self-stimulatory, motoric behaviors most frequently during solitary activities; and often have neutral affect on the playground. These findings suggest that intervention and supports for children with autism spectrum disorder may be important to deliver at recess to address peer engagement.

Understanding Friendship Sex Heterophily and Relational Characteristics to Optimize the Selection of Peer Models for Children with Autism Spectrum Disorder.

This study used social network analysis to evaluate whether sex heterophily, the degree to which peers are different in sex, between 126 children with autism (ages 5-12 years) and their peers affected social network connectivity. Results indicate that: (1) the quantity and sex of friends were more important in predicting social network connectivity than the relational characteristics of the friends (friendship nominations and social network salience/popularity); and (2) sex heterophily is an important factor in predicting social network connectivity. For males with autism, having friends of the same sex was associated with better social network connectivity; this was not true for females with autism. These findings have important implications for the selection of peer models for elementary-aged children with autism.