Play brick therapy to aid the social skills of children and young people with autism spectrum disorder: the I-SOCIALISE cluster RCT

Background

Social skills interventions are commonly recommended to help children and young people with autism spectrum disorder develop social skills, but some struggle to engage in these interventions. LEGO® (LEGO System A/S, Billund, Denmark) based therapy, a group social skills intervention, aims to be more interesting and engaging.

Objective

To evaluate the clinical effectiveness of LEGO® based therapy on the social and emotional skills of children and young people with autism spectrum disorder in school settings compared with usual support. Secondary objectives included evaluations of cost-effectiveness, acceptability and treatment fidelity.

Design

A cluster randomised controlled trial randomly allocating participating schools to either LEGO® based therapy and usual support or usual support only.

Setting

Mainstream schools in the north of England.

Participants

Children and young people (aged 7-15 years) with autism spectrum disorder, their parent/guardian, an associated teacher/teaching assistant and a facilitator teacher/teaching assistant (intervention schools only).

Intervention

Schools randomised to the intervention arm delivered 12 weekly sessions of LEGO® based therapy, which promotes collaborative play and encourages social problem-solving in groups of three children and young people with a facilitator (trained teacher or teaching assistant). Participants received usual support from school and community services. Participants in the control arm received usual support only. Research assistants and statisticians were blind to treatment allocation.

Main outcome measure

The social skills subscale of the Social Skills Improvement System (SSIS), completed by the children and young people's unblinded teacher pre randomisation and 20 weeks post randomisation. The SSIS social skills subscale measures social skills including social communication, co-operation, empathy, assertion, responsibility and self-control. Participants completed a number of other pre- and post-randomisation measures of emotional health, quality of life, loneliness, problem behaviours, academic competence, service resource utilisation and adverse events.

Results

A total of 250 children and young people from 98 schools were randomised: 127 to the intervention arm and 123 to the control arm. Intention-to-treat analysis of the main outcome measure showed a modest positive difference of 3.74 points (95% confidence interval -0.16 to 7.63 points, standardised effect size 0.18; p = 0.06) in favour of the intervention arm. Statistical significance increased in per-protocol analysis, with a modest positive difference (standardised effect size 0.21; p = 0.036). Cost-effectiveness of the intervention was found in reduced service use costs and a small increase in quality-adjusted life-years. Intervention fidelity and acceptability were positive. No intervention-related adverse events or effects were reported.

Conclusions

The primary and pre-planned sensitivity analysis of the primary outcome consistently showed a positive clinical difference, with modest standardised effect sizes of between 0.15 and 0.21. There were positive health economics and qualitative findings, corroborated by the difference between arms for the majority of secondary outcomes, which were not statistically significant but favoured the intervention arm. Post hoc additional analysis was exploratory and was not used in drawing this conclusion. Given the small positive change, LEGO® based therapy for children and young people with autism spectrum disorder in schools should be considered.

Limitations

The primary outcome measure was completed by an unblinded teacher (rather than by the facilitator).

Future work

The study team recommends future research into LEGO® based therapy, particularly in school environments.

Trial registration

This trial is registered as ISRCTN64852382.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme (NIHR award ref: 15/49/32) and is published in full in Public Health Research; Vol. 11, No. 12. See the NIHR Funding and Awards website for further award information.

Peer-Mediated Interventions for Students with Intellectual and Developmental Disabilities: A Systematic Review of Reviews of Social and Behavioral Outcomes

Peer-mediated interventions (PMIs) have been firmly established as evidence-based approaches for facilitating peer relationships among students with and without disabilities. We conducted a review of reviews evaluating PMI studies to support social skills and positive behavioral outcomes for children, adolescents, and young adults with intellectual and developmental disabilities (IDD). A total of 4,254 individuals with IDD were participants across 43 reviews of the literature, reflecting 357 unique studies. This review includes coding related to participant demographic information, intervention characteristics, implementation fidelity, social validity, and social outcomes addressed by PMIs across reviews. Our findings suggest that PMIs yield positive social and behavioral outcomes for individuals with IDD, mostly in the areas of peer engagement and initiating social interactions. Specific skills, motor behaviors, and challenging as well as prosocial behaviors were less likely to be examined across studies. Implications for research and practice to support the implementation of PMIs will be discussed.

Effectiveness of interventions for children and adolescents with autism spectrum disorder in high-income vs. lower middle-income countries: An overview of systematic reviews and research papers from LMIC

Background

There is a multitude of systematic reviews of interventions for children and adolescents with autism spectrum disorder (ASD). However, most reviews seem to be based on research conducted in High-Income Countries (HIC). Thus, summary findings may not directly apply to Lower Middle-Income Countries (LMIC). Therefore, we conducted a Meta-Review analyzing systematic reviews on the effectiveness of interventions for target outcomes in children and adolescents with ASD to find out whether there are differences in effectiveness between HIC and LMIC and which interventions can be considered evidence-based in LMIC.

Methods

Electronic databases (PsycINFO, PubMed, Cochrane database of systematic reviews) were searched for reviews on interventions for ASD in children and adolescents from January 2011 through December 2021, which included studies not coming from HIC. Systematic reviews with qualitative and quantitative syntheses of findings were included. Two investigators independently assessed studies against predetermined inclusion/exclusion criteria and extracted relevant data including quality and evidence assessments. Evidence for different types of interventions in HIC vs. LMIC was planned to be compared, but none of the reviews assessed potential differences. Therefore, a narrative review of the studies from LMIC was conducted including an assessment of quality and evidence.

Results

Thirty-five reviews fulfilled the inclusion criteria. Eleven considered findings from HIC and LMIC. Sixty-nine percent included studies with various research designs; 63% provided a qualitative synthesis of findings; 77% percent assessed the quality of studies; 43% systematically assessed the level of evidence across studies. No review compared evidence from HIC and LMIC. A review of the studies from LMIC found some promising results, but the evidence was not sufficient due to a small number of studies, sometimes poor quality, and small sample sizes.

Conclusion

Systematic reviews on interventions for children and adolescents with ASD did not look for potential differences in the effectiveness of interventions in HIC and LMIC. Overall, there is very little evidence from LMIC. None of the interventions can be considered evidence-based in LMIC. Hence, additional research and mutually agreed methodological standards are needed to provide a more secure basis for evidence-based treatments in LMIC trying to establish evidence-based practices.

Supporting the inclusion and retention of autistic students: Exploring teachers' and paraeducators' use of evidence-based practices in public elementary schools

INTRODUCTION

Educators in public schools are required to serve students in their least restrictive environment. While many evidence-based practices (EBPs), defined as practices and strategies shown by research to have meaningful effectson outcomes for autistic students are documented in the literature, less is known about EBP use among educators in public schools.

METHODS

Eighty-six general and special education teachers and para educators completed a survey about familiarity, training, and EBP use for included autistic children.

RESULTS

Across roles, educators reported familiarity (98.8%), use (97.7%), and training (83.7%) in reinforcement. They reported the least familiarity with behavioral momentum (29.1%), training in both video modeling and peer-mediated instruction and intervention (18.6%), and use of video modeling (14.0%). Follow-up interviews (n = 80) highlighted mixed understanding of EBP definitions and use.

DISCUSSION

Implications for inclusive education are discussed including autism-specific EBP training within pre-service teacher preparation programs.

Evaluating evidence-based practice in light of the boundedness and proximity of outcomes: Capturing the scope of change

Evidence-based practice (EBP) reviews abound in early childhood autism intervention research. These reviews seek to describe and evaluate the evidence supporting the use of specific educational and clinical practices, but give little attention to evaluating intervention outcomes in terms of the extent to which they reflect change that extends beyond the exact targets and contexts of intervention. We urge consideration of these outcome characteristics, which we refer to as "proximity" and "boundedness," as key criteria in evaluating and describing the scope of change effected by EBPs, and provide an overview and illustration of these concepts as they relate to early childhood autism intervention research. We hope this guidance will assist future researchers in selecting and evaluating intervention outcomes, as well as in making important summative determinations of the evidence base for this population. LAY SUMMARY: Recent reviews have come to somewhat different conclusions regarding the evidence base for interventions geared toward autistic children, perhaps because such reviews vary in the degree to which they consider the types of outcome measures used in past studies testing the effects of treatments. Here, we provide guidance regarding characteristics of outcome measures that research suggests are particularly important to consider when evaluating the extent to which an intervention constitutes "evidence-based practice."

Emotional and behavioural problems of children with autism spectrum disorder attending mainstream schools

Emotional and behavioural problems occur more commonly in children with Autism Spectrum Disorder (ASD) compared to other children. Few studies have focused on these problems in children with ASD attending mainstream schools. We assessed via parent report the emotional and behavioural problems in 160 children aged 4-17 years with ASD attending mainstream schools and investigated differences between the primary and secondary aged children. Children with ASD had higher levels of problems across all domains of the Strengths and Difficulties Questionnaire (SDQ) compared to UK norms. Within the ASD sample, SDQ scores were associated with male sex, living in a household with more children, more severe autism symptoms and fewer adaptive skills, and higher levels of family socio-economic risk. No robust primary-secondary school differences were found. Implications for future research and the support of children with ASD in mainstream school settings are discussed.

Improvement of Planning Skills in Children With Autism Spectrum Disorder After an Educational Intervention: A Study From a Mixed Methods Approach

The literature confirms that individuals with autism spectrum disorder (ASD) have planning deficits. However, few interventions have targeted these deficits. The aims of this study were to: (1) show that the mixed methods approach can be useful in studying planning skills of children with ASD during and after an educational intervention; (2) assess whether the planning skills of two groups of children with ASD improved during the intervention and if this progress was maintained 1 month after completing the intervention. The groups were formed depending on each child’s severity level (SL) of ASD according to DSM-5: SL1 (requiring support) and SL2 (requiring substantial support). Each group was composed of four children. In the framework of mixed methods, we used observational methodology, which is considered as mixed methods in itself because it integrates qualitative and quantitative elements. A nomothetic/follow-up/multidimensional observational design was used. Planning skills manifested by children during the intervention were codified, as well as the scaffolding behaviors provided by the educational specialist. These skills and behaviors were also coded in one session, which took place 1 month after the intervention. Coded data of each group were submitted to prospective and retrospective lag sequential analysis. This informed of the sequential structure of planning skills performed by children in interaction with the educational specialist at the beginning and at the end of the intervention, as well as 1 month later after the intervention. The comparison of the patterns obtained in these three temporal moments allowed us to know the improvement of the two groups in the use of planning skills. Results showed that both groups improved their autonomous use of planning skills. However, SL1 group used successfully and autonomously complex planning skills, while SL2 group were unable to achieve this gain. SL2 group progressed in autonomy, but only using basic planning skills. Both groups can further improve their use of planning skills; therefore, the intervention should be adjusted to their characteristics and temporarily extended. These findings contribute to the, as yet, little studied field of intervention and assessment of planning skills in children with ASD using a mixed methods approach.

Self-advocacy and self-determination of autistic students: a review of the literature

Purpose

The purpose of this paper is to examine current research on self-advocacy and self-determination of autistic students in order to provide an overview of the research and to critically evaluate researcher’s methods of inclusivity of autistic people. Additionally, this paper will critically analyse the discourse of the current research to assess the extent of deficit, stigma and pathology discourse.

Design/methodology/approach

Research will be selected from a list of criteria which is to seek research that is inclusive of autistic people. The research will be analysed using elements of critical discourse analysis, critical disability studies and critical autism studies. The critical autism studies approach used in this paper is emancipatory to promote autistic scholarship, autistic inclusivity and autistic led research methods.

Findings

The result of this paper is that by prioritising, and including autistic individuals in the studies about them provides valuable educational insights and often challenges assumptions, stigmas and stereotypes of autistic individuals.

Research limitations/implications

The findings of the paper may be limited by the selection of literature reviewed and generalizability, therefore, researchers are encouraged to explore further.

Practical implications

This paper holds potential implications that question the consistency of current discourse and research into self-advocacy for autistic individuals in addition to providing effective research, teaching and support strategies based on insight. This paper also highlights some research that challenges assumptions of autistic individuals.

Social implications

This paper challenges assumptions and stigmas associated with autistic individuals and demonstrates the importance of self-advocacy and self-determination. This research transforms the paradigm of autism and education practice that has the potential to improve autistic individuals’ education and ultimately, improve their lives.

Originality/value

This research is important and valuable as there is limited research in this area. The potential of this research is that it can shift the broad perceptions of autism and make improvements in education and autistic individuals lives.

Partners in School: An Innovative Parent-Teacher Consultation Model for Children with Autism Spectrum Disorder

Little research examines the best ways to improve communication between parents and teachers of children with Autism Spectrum Disorder (ASD) and its effect on child outcomes. The present study tests an innovative parent-teacher consultation model, entitled Partners in School. The goal of Partners in School is to improve parent-teacher communication aboutevidence-based practices (EBPs), and subsequently, outcomes for children with ASD. Participants were 26 teachers and 49 parents of children with ASD from a large urban public school district. Parents and teachers completed measures of their communication and child outcomes prior to and after receiving consultation through Partners in School. Results indicated that parents and teachers perceived improvements in child outcomes after participation inPartners in School. Changes in parent-teacher communication also were associated with changes in some child outcomes. Discussionhighlights the important role of communication inconsultations targeting family-school partnerships for children with ASD.

Staff Training in Autism: The One-Eyed Wo/Man…

Having well-trained staff is key to ensuring good quality autism services, especially since people affected with autism generally tend to have higher support needs than other populations in terms of daily living, as well as their mental and physical health. Poorly-trained staff can have detrimental effects on service provision and staff morale and can lead to staff burn-out, as well as increased service user anxiety and stress. This paper reports on a survey with health, social care, and education staff who work within the statutory autism services sector in the UK that explored their knowledge and training with regards to autism. Interview data obtained from staff and service users offer qualitative illustrations of survey findings. Overall, the findings expose an acute lack of autism-specific training that has detrimental impacts. At best, this training was based on brief and very basic awareness raising rather than on in-depth understanding of issues related to autism or skills for evidence-based practice. Service users were concerned with the effects that the lack of staff training had on the services they received. The paper concludes with a discussion of policy routes to achieving quality staff training based on international best practice. The focus is on improving the quality of life and mental health for services users and staff, as well as making potentially significant cost-savings for governments.