Sustaining Quality Implementation of a Targeted Social Communication Interventions in Authentic Community Settings: Paraprofessional Implemented Jasper with Toddlers

Background:  Due to the gap between known efficacious interventions for young children with ASD and routine daily care, implementation science studies address questions about intervention acceptability, feasibility, and fidelity by community practitioners. While these studies are increasing in the literature, examination of the sustainability of such programs in ongoing real-world contexts is not often reported. The present project explores the sustainability of a targeted social communication intervention for toddlers with ASD when implemented and supervised by public early intervention providers.

Objectives:  First, to explore maintenance of Teaching Assistants’ (TAs’) intervention implementation delivered to a second cohort of toddlers in an authentic early intervention setting with on-site community support and no support from the research team. Second, to compare change in children’s initiations of joint attention (IJA) between the first supported year of the study and the second unsupported year of the study.

Methods:  As part of a randomized trial, 78 children with ASD age 2-3 years (Mage=31.71 months) received JASPER intervention in project Year 1 (Yr1). An additional 63 toddlers with ASD (Mage=32.15 months) received JASPER in a second randomized trial- Year 2 (Yr2). Twenty-two TAs delivered JASPER in both YR1 and YR2. All TAs and all but 7 children were members of an ethnic minority group.

Intervention. In YR1, TAs were provided with intensive supports from the university team including two weeks of in-vivo training plus weekly feedback and support to deliver the Joint Attention, Symbolic Play, Engagement, and Regulation intervention (JASPER: Kasari et al., 2008; 2014; 2015). Significant effects on joint engagement, joint attention gestures, play skills, and language were demonstrated for JASPER over usual treatment (Shire et al., in press). In YR2, TAs were provided with on-site community supervision and no external support from the research team. Each child received JASPER for 30 minutes a day for 10 weeks in both YR1 and YR2. This is the first examination of the sustainability of community supervised, and community implemented JASPER with toddlers in center-based care (YR2).

Measures. Ten-minute TA-child interactions at 10-week exit were coded for TAs’ JASPER implementation. Independent assessors also administered an assessment of children’s spontaneous joint attention skills including gaze, gesture, and language (Short Play and Communication Evaluation: Shire et al., in press). The total number of spontaneous initiations of joint attention (IJA) was obtained from video coding of this assessment.

Results:  In YR1, TAs’ average JASPER implementation was 80.90% (SD=16.31%) by treatment exit. At YR 2 exit, TA’s average implementation was 71.21% (SD=11.74%). Children’s gains in IJA skills over treatment were significant in both YR1 (f(1,88)=40.84, p<.001) and YR2 (f(1,88)=33.74, p<0.001). Gains in IJA were not significantly different between Yr1 and Yr2 (f(1,88)= 0.02, p=0.89).

Conclusions:  Through on-site community supervision, TAs maintained quality implementation of JASPER intervention with a new cohort of toddlers with ASD where toddlers in YR2 made comparable IJA gains to toddlers in YR1. This is one of the first studies to examine long-term implementation outcomes for an evidence-based social communication intervention with toddlers with ASD implemented by community paraprofessionals.