Acceptability and Feasibility of a Pilot SMART Design in a School Setting

Oral Presentation
Thursday, May 10, 2018: 11:20 AM
Willem Burger Zaal (de Doelen ICC Rotterdam)
A. Sturm1, A. J. Schlink2, S. Y. Shire3, W. I. Shih4, D. Almirall5 and C. Kasari4, (1)UCLA, Los Angeles, CA, (2)UCLA Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA, (3)University of Oregon, Eugene, OR, (4)University of California, Los Angeles, Los Angeles, CA, (5)University of Michigan, Ann Arbor, MI

School-aged children with ASD require interventions that are evidence-based and adaptable if there are indications of slow-response to treatment. Adaptive interventions (AI) are sequences of individually-tailored interventions over time that can address this need. Yet, more work is needed to determine the acceptability and feasibility of AIs employing empirically-supported interventions in schools.


The present study aimed to evaluate the acceptability and feasibility of an AI in a school setting by assessing (1) the acceptability of AI changes to school staff (i.e., teachers and aides) delivering the component interventions and (2) the fidelity of AI components delivered by school staff.


The 18-week AI was composed of initial randomization to Remaking Recess (RR; delivered by playground aide), or RR plus Classroom Supports (CS; delivered by teacher), both environmental modification interventions. After 8 weeks, the environmental modifications were then augmented with Parent-Assisted Home Intervention (Parent) or Peer- mediated School Intervention (Peer) delivered by research staff. Twenty-four children ages 5 to 10 (M=7.2, 74% male, 67% Hispanic/Latino, 87% free or reduced meals) from 18 classrooms and five schools participated. Outcome measures included researcher-rated CS (teacher; N=22) and RR (aide; N=18) fidelity, teacher-rated treatment expectations (N=17), aide-rated treatment acceptability (N=18), and structured aide (N=17) and teacher (N=17) diaries assessing implementation issues.


Nearly all teachers surveyed held positive opinions regarding the potential for adaptive change in (82%), or intensification of (100%), student’s treatment and 100% endorsed that they were likely to agree to potential changes in intervention. Surveyed after intervention, 83% of aides held positive opinions about changes made to their student’s treatment. When no change in treatment was indicated, aides who felt negatively about lack of change (0.7%) would have preferred to add the intervention that their student had not received (Peer/Parent).

Aides (RR) and teachers (CS) found the respective intervention strategies to be natural and relatively simple. While most aides felt confident (82%) and comfortable (94%) in their delivery of RR strategies, teachers felt less so with CS (confident: 60%; comfortable 66%). However, fidelity at the end of treatment varied widely (RR, aides: 0-100%, M=58%; CS, teachers: 22-67%, M=37%). Aides and teachers reported the most difficulty finding time to implement the respective strategies, most often during Phase 2 when 76% of aides and 53% of teachers endorsed this to be at least “somewhat true”. Several aides (29%) and teachers (33%) reported that strategy implementation required substantial work. This was reflected in qualitative feedback from some aides who reported that they would have liked more time to review the RR strategies, and that they struggled with juggling strategy implementation and their other responsibilities on the playground.


The present study found that AIs are acceptable to school staff, however adjustments are required to ensure feasibility of school staff implemented intervention components. In planning for a fully-powered AI, variability in degree of successful strategy implementation suggests that researchers must provide sufficient individualized support to quickly ensure a high level of school staff comfort with intervention strategies and their flexible and accurate use.