Interventions Benefitting Young Autistic Children

Abstract

The education and treatment of autistic children present numerous challenges. Researchers at Juniper Gardens Children’s Project (JGCP) have contributed several important interventions. The beginning of this article in the special issue focuses on interventions promoting communication and social interactions of young autistic children. This line of research greatly expanded knowledge on evidence-based school intervention strategies that include neurotypical peers. In small group settings, peers are taught to be responsive communication partners. Recent work includes interventions to maximize communication outcomes and peer interactions for minimally-verbal or non-verbal autistic children learning to use augmentative and alternative communication. The next section of the article summarizes a telehealth training program called The Online and Applied System of Intervention Skills (OASIS) that helps caregivers learn behavioral procedures to promote independence and reduce challenging behavior. In OASIS, parents learn behavioral strategies through a sequence of online tutorials and assessments, each of which is followed by telehealth coaching sessions. Parents practice strategies in the home with their child while receiving guidance from a trained coach. OASIS has been adopted by programs around the country, especially for families on waiting lists to receive home-based treatment or services.

The Problem

Autistic children demonstrate significant delays in communication and social reciprocity, and many present with challenging behaviors and limited cognitive ability (APA, 2013; Lerner et al., 2018). Recent Meta-analyses of the most intensive intervention approaches, such as applied behavior analysis, find that up to half of all autistic children can be characterized as low or less than optimal responders (Eldevik et al., 2010). Furthermore, approximately 30% of autistic preschoolers remain nonverbal at the time of kindergarten entry (Tager-Flusberg & Kasari, 2013). The subgroup of children with limited or no spoken language (also referred to as minimally-verbal or non-verbal) face additional challenges, and much more could be done to address their complex needs (Light & McNaughton, 2012; Lord et al., 2022). To address these problems, researchers at Juniper Gardens Children’s Project (JGCP; for a description and more information about JGCP, see the introductory article by Greenwood et al., this issue) have created and examined school- and home-based interventions to maximize language and social outcomes for young autistic children. The authors of this article recognized the clear need for research that would assist education service providers and parents in making informed decisions about evidence-based social communication and behavioral intervention strategies.

In one-on-one settings, early studies reported on the effectiveness of therapeutic arrangements that used principles of applied behavior analysis (ABA) to help autistic children learn (e.g., Koegel et al., 1987; McGee et al., 1985; Wolf et al., 1964). Improvements were noted in cogntive, play, and communication skills, as well as fewer challenging behaviors. However, limitations were noted with regard to the generalization of learned skills to natural environments (i.e., the classroom), intensity of treatment hours, and caregiver stress (Chandler et al., 1992; Lovaas, 1987). As children were entering the public schools, the support they needed to learn in natural, small and large group arrangements was unknown. One of the earliest classroom reports included effective small-group instruction procedures and individual peer tutoring (Kamps et al., 1990). These findings were replicated and extended in a series of studies at JGCP, demonstrating both academic and social benefits of involving peers (Kamps et al., 1994; Kamps et al., 1995; Kamps et al., 1991; Kamps et al., 1992). Classroom peers were soon recognized as potential change agents, with prior studies at JGCP by Greenwood and colleagues (1982, 1986) influencing knowledge of how to instruct educators to prompt and reinforce student interactions. This groundbreaking research was key to guiding programs focused on children’s early social competence with peers – a fundamental skill related to later language, social-emotional development, and academic achievement (National Autism Center, 2015; Spivak & Farran, 2016). Unfortunately, access to social environments with neurotypical peers remains restricted for autistic children, particularly those who have limited communication skills.

Another problem central to this article focuses on the need to enhance caregiver’s knowledge and skills in supporting their autistic child’s learning and behaviors at home. Recent research on behavioral interventions shows that the parents’ role in using evidence-based practices (EBPs) in daily routines is critical to addressing their child’s needs (Steinbrenner et al., 2020). Given that the demand for autism clinical services far outweighs the supply of licensed professionals (Maenner et al., 2021; Stephens et al., 2023), there is a clear need for alternatives to clinician-directed interventions, at least until services can be accessed (Sellinger & Elder, 2016; Steiner et al., 2012). For example, in 2023, there were over 5,000 Kansans on the waiting list to receive Medicaid-funded intervention support for intellectual or developmental disabilities, with an expected wait time of 12 years (Mipro, 2023). Effective parent training programs can improve a wide variety of child skills, such as social engagement and expressive communication, and reduce challenging behaviors (DiGennaro Reed & Henley, 2015; Heitzman-Powell et al., 2014; Meadan et al., 2014; Tsami et al., 2019; Wong et al., 2015). Given recent technological advances and expanding access to broadband via smartphones and tablets (e.g., Lee et al., 2021; Lindgren et al., 2020; Meadan et al., 2016; Neely et al., 2017; Unholz-Bowden et al., 2020), JGCP researchers developed an online telehealth program to improve access and feasibility for parents of autistic children.

The Solution

The transactional model of development is conceptualized as reciprocal and continuous influences between the child and the child’s environment (e.g., development accelerated by interactions and changes in social environments; Snyder-McLean & McLean, 1978). Thus, including peers (school-based) and parents (home-based) in early social and behavioral interventions, focusing on changing responsivity and back-and-forth interactions, is important to impact positive functional changes in communication and social skills and decrease behaviors that may interfere with learning. This article describes two types of intervention solutions that were developed at JGCP that are based on changing or enhancing (1) the child’s social environment at school with peers (i.e., peer-mediated interventions; PMIs) and (2) the child’s interactions with parents and others at home (i.e., The Online and Applied System of Intervention Skills, OASIS).

Peer-Mediated Interventions (PMIs)

In PMIs, peers without disabilities are taught, for example, to initiate, maintain proximity, and prompt target communication skills within structured, adult-guided activities (Bourque, 2020; Thiemann & Goldstein, 2001; 2004). The adult ensures successful social-communicative exchanges and child-peer interactions by prompting peers to use skills taught, instructing autistic children and peers to initiate and respond, and providing feedback for all children. Selection of specific target skills is generally done in collaboration with the school team and parent report of child social communication needs. Peers may learn to initiate or start exchanges by commenting, requesting objects or actions (e.g., spin it), gaining attention (e.g., call a name, tap on the shoulder), and using social niceties (e.g., high-five; see Table 1). To maintain proximity, strategies may include teaching peers how to stay (i.e., sit close, if your buddy moves you move) and play (i.e., take turns and share; Bourque, 2020). Peer network interventions focus on greater inclusion of older students with and without autism (Asmus et al., 2017; Kamps et al., 2014; Sreckovic et al., 2017). Peer networks involve scheduling regular, small group opportunities for students to interact across school settings.

Table 1.

Communication Skills, Definitions and Examples from a Peer Network Intervention^*

Communication Skill and Label for Teaching	Definition	Examples
Request and Share “Ask and share”	Children ask questions, ask for another to do an action, ask for turns, and give turns/toys.	Turn it over Roll it/spin it Do it again What is it? What color? Here you go
Comment about Self “Talk about it – my toys”	Children use comments to tell about their toys (e.g., to label; to describe the color, size, or shape), or tell about what they are doing (e.g., actions they are engaged in).	I have a (toy) Mine is fast This is blue I found a match
Comment about Others “Tell about it – friend’s toys”	Children use comments to tell about their friend’s toys (e.g., to label; to describe the color, size, or shape), or tell about what their friend is doing (e.g., actions engaged in).	You have a (toy) You have two Yours is red You have a match
Social Niceties “Talk nice”	Children encourage others, cheer for others, give compliments, and say words that are polite.	Cool! Nice job! Maybe next time That’s okay Yes please No thanks
Play Organizers “Ways to play”	Children talk about ways they can play related to deciding who goes first or second, negotiating the rules, being in charge of parts to pass out and having different roles.	I think we should _____. You be the parts passer. I’ll be the turn police.

^*Note: Communication skills from Kamps et al., 2015

Intervention research at JGCP aimed at benefiting young autistic children has been ongoing for the last 30 years. Specific to PMIs, school-based studies began with autistic elementary-school-age children, with strategies influenced by knowledge gained from prior JGCP studies on small-group instruction with autistic students (Kamps, Walker, et al., 1992), peer tutoring and cooperative learning group with autistic students (Dugan et al., 1995; Kamps et al., 1994; Kamps et al., 2002), social skills groups (Gonzalez-Lopez & Kamps, 1997; Kamps et al., 1992; Thiemann & Goldstein, 2004), and the benefits of implementing task analyses (Parker & Kamps, 2010). In the 1990s, the effectiveness of peer network interventions for autistic verbal school-age students was examined at JGCP using single-case designs (e.g., Garrison-Harrell et al., 1997; Kamps et al., 2002; Kamps et al., 1997). These studies represented a shift in focus from approaches targeting the duration or time engaged with peers, to developing strategies to improve functional communication with multiple partners and in varied social settings.

Together, this body of research provided a foundation for federal funding of the first randomized control trial investigating the implementation of PMIs for a large group of autistic students (N = 95) and peers without disabilities from the beginning of Kindergarten through the end of first grade (Kamps, Thiemann-Bourque et al., 2015). The authors scaled up and expanded on the positive outcomes of their prior single-case design studies by developing direct instruction strategies to teach both peers and autistic students functional communication skills (e.g., comments, requests, and social niceties). One school staff person was taught the intervention. School staff attended a 3-hour training focused on (1) the rationale for PMI, (2) role-play for teaching skills in a small group format, (3) scripted lessons for teaching peers target communication skills, and (4) direct instruction strategies to guide child-peer interactions. The majority of staff were speech-language pathologists (SLPs), followed by paraprofessionals, resource room teachers, and counselors. A higher number of SLPs likely reflects the similar social and communication goals targeted in speech and language interventions. The children receiving PMI showed significant improvement in social initiations to peers in structured play and generalized skill use to natural settings like recess and centers (Kamps et al., 2014; Kamps, Thiemann-Bourque et al., 2015). The breadth of disciplines involved who implemented the PMI with high fidelity across multiple schools speaks to the feasibility of the strategies, and how a team approach can lead to important changes in children’s social competencies. In addition, scaling up the PMI for a large number of children was a critical community-based solution to broaden the dissemination of outcomes to reach more educators, service providers, families, and children.

In more recent studies at JGCP, peer interventions were created to address the needs of a low-incidence group of autistic children with limited or no spoken language who are learning to use augmentative and alternative communication (AAC). These peer interventions included combining peer training and direct AAC instruction; that is, peers were taught to use a picture exchange system (Thiemann-Bourque et al., 2016) or a speech-generating device (i.e., iPad with a voice output app; Thiemann-Bourque et al., 2018) to communicate. For AAC approaches, there are many reports of improved vocabulary learning, speech production, and augmented communication (Flippin et al., 2010; Ganz et al., 2012). However, there is a lack of research focusing on young children with moderate-to-severe autism and limited or no spoken communication, and few studies that include training peers. Thus, the intent of combining effective AAC instructional approaches within peer-mediated interventions was to create a clearly defined, comprehensive method to improve core deficits in social communication and increase reciprocal interactions in this population of children (Bourque, 2020; Bourque & Goldstein, 2020; Thiemann-Bourque et al., 2018; Thiemann-Bourque et al., 2017).

The intervention approach focuses on teaching peers to Stay-Play-Talk using a modified version of a buddy skills teaching program originally developed by Goldstein and colleagues (1997). Modifications include: Stay sub-steps: 1. Sit close, and 2. If your buddy moves, you move, and Play sub-steps: 1. Take turns, and 2. Share toys. The Talk modifications include teaching peers to use the same augmentative communication system, for example, to “pick and put” objects in a child’s hand after the child selects a picture to exchange, or for those using speech-generating devices (SGDs) to “look and listen,” then “push and talk” to initiate and respond with symbols that match the communicative context (e.g., to request, comment, gain attention). The iPad with a voice output app (e.g., TouchChat) is one example of a cost-efficient and effective SGD that has prominently grown in popularity in recent years. There are multiple pages of symbols representing age-appropriate vocabulary, with flexibility in programming the size of symbols, the number of symbols per page, and the visual depiction (i.e., real photos, libraries of pictures). This allows the communication system to be modified based on the individual pace of each child’s vocabulary, academic, and social growth. The premise is that social communication can be accelerated by providing multiple opportunities to observe, imitate, and interact with responsive peers. Peer responsiveness will, in turn, improve if peers understand and can socially reinforce their autistic play partners’ communication attempts.

In a recent NIH-funded randomized control trial, the first author scaled up a peer-mediated Stay-Play-Talk approach with preschoolers with moderate-to-severe autism (N = 45) and limited or no spoken communication (Thiemann-Bourque et al., 2018). The children were randomly assigned to an SGD intervention with trained peers (i.e., peers taught to use iPad) or a comparison condition with SGD and untrained peers. Results indicated significant increases in (a) rates of communication or how often autistic children directed intentional spontaneous communication to peers, (b) rates of peer communication to autistic children, (c) rates of communication in generalization settings, (d) maintenance of communication gains, and (e) reciprocity or balanced levels of initiations and responses for children in treatment. Although all children receiving treatment showed progress, they did so at variable rates and levels of change.

This led to the next series of research questions examined in a 2-year study to identify specific child variables that predict response to PMIs. There is evidence of differences in social attention (i.e., visual attention/scanning of social stimuli) for autistic children compared to typically developing children (Sperdin et al., 2018). It is also probable that among autistic individuals, variability in performance on receptive and expressive language measures may be important predictors of response to PMIs (Vivanti et al., 2014). To examine social attention and peer interest, we used a combination of ecologically valid (semi-structured assessments and naturalistic observations with peers) and lab-based (eye tracking) measures administered before the start of treatment for N = 24 autistic preschoolers with limited or no speech. Information from multiple contexts may identify skills that do not appear on standardized tests. Preliminary data shows that children with higher receptive language at the start of treatment had greater gains in peer-directed communication in structured play (i.e., child and peer at a table), and those with higher expressive language show greater gains in reciprocal communication with peers. We continue to analyze a number of child variables that may predict response to PMI, with the goal of tailoring approaches to meet the needs of children with varying profiles. Together, results of these NIH-funded studies are changing the course of intervention research for young autistic children with complex communication needs who typically have limited access to inclusive social and educational environments.

One main goal of the PMI research at JGCP has always been to develop interventions that can be feasibly implemented by special educators and early service providers. School staff participants completed questionnaires to determine their perceptions of time commitment, the program’s benefits for the children, and feasibility and acceptance of the approaches. These social validity assessments revealed high acceptance levels, with school staff indicating ease of learning and implementing strategies, improved social communication, and greater classroom interactions (Kamps et al., 2015; Thiemann-Bourque et al., 2004). Importantly, implementers reported improvements in social behaviors and interactions with trained and non-trained peers. School staff also conveyed challenges with the time commitment, specifically release time for peers in elementary school and more limited school resources/staffing post-Covid.

The Online and Applied System of Intervention Skills (OASIS) Parent Training.

In the home environment, parents are a key resource as they play an integral role in their children’s learning. OASIS is a telehealth parent training program developed at JGCP and the University of Kansas Medical Center (KUMC). Initially, to address the dearth of service providers with basic knowledge and skills in behavioral interventions, Drs. Heitzman-Powell and Buzhardt developed an online training program designed to teach service providers general behavioral principles and practices (Buzhardt & Heitzman-Powell, 2005). While this helped programs build their capacity to increase services, as autism diagnoses continued to increase throughout the early 2000s, demand for services continued to exceed capacity (Milro, 2023). Therefore, they sought to develop a training program specifically for parents that utilizes web-based tutorials to build knowledge, with real-time feedback combined with remote coaching to develop parents’ skills with their child.

Parents can be effectively taught to use behavioral interventions such as functional behavioral assessment, functional communication training, and naturalistic interventions (Heitzman-Powell et al., 2014, 2022; Laugeson et al., 2009; Tsami et al., 2019; Unholz-Bowden et al., 2020). Functional behavioral assessments are designed to identify why challenging behavior occurs, and functional communication training teaches autistic children effective ways to communicate to replace challenging behavior that often occurs because caregivers do not understand their child’s needs (Aleid, 2019; Durand & Moskowitz, 2015). Naturalistic behavioral interventions facilitate the generalization of skills by providing opportunities for children to practice skills within natural contexts (e.g., child’s home) throughout the day (Dufek & Schreibman, 2014).

Initially developed through funding from the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR), OASIS training follows the sequence illustrated in Figure 1. Before training, a certified OASIS coach reviews training expectations, provides the family with login information to access the online assessments and tutorials, and schedules a coaching session. Before each coaching session, the coach reviews the parent’s performance on the module assessment and specific items they answered incorrectly. The OASIS training curriculum aims to teach parents how to use behavioral strategies with their children to improve social communication and reduce challenging behavior. These strategies include effective use of reinforcement, prompts and prompt fading, token boards, pre-corrects (i.e., reminder or cue of what is expected during an upcoming activity, particularly when challenging behaviors are likely to occur), structuring the environment, and working with early intervention providers and educators (Heitzman-Powell et al., 2014).

Figure 1.

The Online and Applied System of Intervention Skills (OASIS) training sequence and mastery requirements.

All OASIS coaching sessions target the skill presented in that week’s online tutorial and follow this format and last approximately 2 hours and 15 minutes: (1) introduction and module overview (5 min); (2) data review for tutorial performance, problem behavior, and incidental teaching (10 min); (3) introduction of current skill (10 min); (4) standardized skill fluency assessment (15 min); (5) break (3-5 min) – coach scores assessment – move to next session/module if parents are at 80% or higher on skill fluency; (6) coaching: parent/child interaction (30 min); (7) observational assessment (5 min); (8) coaching: parent/child interaction (30 min); (9) break (5 min); (10) question/answer period (5 min); (11) discussion of next session (5 min); and (12) confirmation of next appointment (5 min). During development and testing, we found this structured format improved implementation fidelity and consistency between coaches (Heitzman-Powell et al., 2013).

Each session has a scripted outline for the coach to follow, which serves as a guide for coaches and a fidelity check for coaching. Each session outline has space to designate if that particular coaching component occurred or did not occur, as well as a table to record the frequency of coaching statements made by the OASIS coach. This format allows independent observers to code the coach’s fidelity of implementation. Items on the form reflected the structure of the session, coach instruction, script following, and coaching statements on each targeted skill. Importantly, the coach also documents the fidelity of parents’ skill implementation. Parents must demonstrate at least 80% fidelity to proceed to the next module.

Advances in the Discipline and Professional Knowledge

PMI Research

JGCP researchers and colleagues have produced over 30 peer-reviewed publications and chapters documenting the effectiveness of peer tutoring and small group peer training approaches, peer network interventions, low-tech (e.g., written-text scripts) and high-tech (e.g., SGD with voice output apps) AAC instruction, and combining teaching approaches to impact early social communication skills. This body of research has been widely cited across professional disciplines. It has expanded knowledge outlining specific procedures to (a) recruit and teach neurotypical peers, (b) measure progress in both child and peer behaviors, (c) assess changes in the balance or reciprocity of communication, (d) train school staff to implement with fidelity in inclusive settings, and (e) teach children with limited or no spoken language to use AAC with peer partners in routine preschool activities and across settings.

Founding of the Kansas Center for Autism Research and Training at KU

The Kansas Center for Autism Research and Training (K-CART) was established in 2008 as one of 13 centers at KU’s Life Span Institute. The mission of K-CART is to (a) generate new scientific discoveries about autism, (b) use research-based practices to train professionals, practitioners, and families who serve autistic children and adults, and (c) collaborate with partners providing clinical services through the KUMC. Ten pilot discovery studies, funded to examine bio-behavioral assessments and interventions for autistic persons, supported new research initiatives and led to federally funded projects. Efforts to expand the use of EBPs include (a) state-funded training programs based on the OASIS Parent Training Program providing online coursework and interventions at a distance for autistic children (Heitzman-Powell et al., 2013), (b) monthly seminars and an annual conference with sessions by KU researchers and national experts, (c) community-based activities in partnership with the Johnson County Community College and KU Edwards Campus including an autism support group for young adults, and (d) development of the K-CART website designed to link families to services across the state and professionals to discoveries in the area of autism.

The Phase II Expansion for K-CART included funding for a national expert in the neuroscience and the neurocognitive aspects of autism. Dr. Matthew Mosconi was appointed Director of K-CART in 2017 and has been spearheading collaborative and interdisciplinary efforts to increase the national profile of KU since that time. Under his leadership, K-CART currently includes two major branches: (1) discovering insights into the primary neurobehavioral basis of autism and (2) developing interventions to prevent and treat the impact of autism on individuals and families (https://kcart.ku.edu/).

OASIS Research

Research, development, and dissemination of OASIS has demonstrated that parents with limited or no knowledge of behavioral interventions can learn these skills without in-person contact. Remote training is particularly important for parents in rural/remote areas who are often the least likely to have access to services. Additionally, training parents at home with their child rather than in a clinical setting improves the likelihood that they will be able to use learned skills at home. Studies of OASIS with families of autistic children have shown that parents demonstrate statistically- and clinically significant gains in both knowledge and observed skills in implementing behavioral strategies with their child. For example, a randomized control trial found that families receiving OASIS training had a significant increase in implementing behavioral strategies with their child(ren) in their home, while families who just received information about best practices did not show changes in knowledge or practices (Heitzman-Powell et al., 2014; 2022). Parents also reported high satisfaction with the training (mean rating of 4.7 out of 5) and found it important in caring for their autistic child (4.6 out of 5). Similar findings have been reported by independent research teams implementing OASIS training in their practices (Batton et al., 2022; Boydston et al., 2022). Because of the financial and privacy challenges associated with long-term monitoring of child and family outcomes after caregivers complete OASIS, we have limited reliable data on the long-term effects of OASIS. This is a need for future research. To summarize, increasing parents’ use of EBPs through parent training can maximize outcomes for autistic children by promoting the maintenance and generalization of skills to children’s natural environment. Training parents to support their children’s needs better also increases parental empowerment, advocacy, parenting efficacy, and decreased stress (Beaudoin et al., 2014; Ingersoll & Wainer, 2013).

Translation to Practice and Scale

Current PMI Research at JGCP

When interventions are efficacious yet show variability in outcomes, it is logical to ask what additional supports are needed to improve child response. Furthermore, despite considerable early intervention efforts, approximately 30% of autistic children remain minimally verbal in kindergarten (Tager-Flusberg & Kasari, 2013). The first author is currently conducting an NIDCD funded 5-year multi-site study to investigate how to best adapt and combine peer-mediated and SGD components to improve outcomes for a large sample of autistic preschool-age children (goal of N=132) and peer partners (N=246), with implementation provided by a range of early service providers. The study will evaluate peer-mediated interventions using an innovative Sequential Multiple Assignment Randomized Trial (SMART) design. Using a SMART design extends our prior work by testing the systematic addition of selected peer-mediated strategies in combination with an SGD that allows for adapted interventions based on child response measured at important nodal points.

Procedural manuals for implementing peer network interventions and PMI AAC approaches were developed within the context of the research studies (for further information, please contact the first author, Dr. Kathy Bourque). A series of three educational videos were created called Autism Connections - Connecting Kids, Connecting Teens, and Connecting Parents for service providers, friends, and families of autistic individuals (available through K-CART http://autismconnections.ku.edu/, funded by the Young Matrons of Kansas City). The “lessons” for kids, teens, and family members were developed to be fun, entertaining, and aimed at peers and potential friends with autism.

Current OASIS Implementation

OASIS parent training is delivered through the Bridge Clinic at the KUMC (https://oasis.ku.edu). Additionally, to facilitate greater adoption, direct service providers in 17 states and nine countries have been trained and certified as OASIS coaches. The training is supported through Moodle, a customized open-source learning management system. To maintain a secure environment that integrates current and rigorously tested Moodle features, it is hosted on MoodleCloud^® to ensure a seamless and accessible user experience. The training includes 16 units of interactive web-based tutorials, pre- and post-knowledge assessments for each tutorial, and tools for parents to submit data for coach review about their use of OASIS strategies during daily routines. Live coaching is delivered using common, secure video conferencing software such as Zoom or Teams, depending on the parent and/or agency’s preferences.

Through a current NIDILRR-funded project, the OASIS team at JGCP and KUMC is developing and implementing an OASIS dissemination model. This model, depicted in Figure 2, is intended to increase the number of certified OASIS Coaches at local programs. By certifying coach trainers for these programs, OASIS implementation will be more likely to be sustained as programs grow and staff turnover of existing OASIS coaches is experienced.

Figure 2.

Dissemination model for the Online and Applied System of Intervention Skills (OASIS) training to support adoption by direct service providers external to staff at Juniper Gardens Children’s Project and University of Kansas Medical Center.

Future Implications

Peer-related social competence is vital to a range of child outcomes; children who experience positive peer interactions in preschool show improved social communication and fewer behavioral problems in elementary school (Spivak & Farran, 2016). We know that peers can serve as a valuable resource to enhance communication opportunities in social settings where children need them the most. Less clear are the long-term outcomes of PMIs, especially when provided over more than one school year. The randomized control trial examining peer network interventions for elementary school-age autistic students reviewed in this chapter is one study that addressed this need. Kamps and colleagues (2015) observed that children showed significantly more growth in some social behaviors over two versus one year of intervention. Unfortunately, PMI studies measuring change over multiple school years are the exception.

Outcomes demonstrating treatment effectiveness with larger samples of autistic children are important for practical implications and uptake of approaches by community and school programs. We have diligently adapted intervention approaches based on the social validity or reported perceptions of school staff. For example, after Year 1 of investigating the integration of peer training and SGD instruction (Thiemann et al., 2018), we changed the voice output app on the iPad based on school staff feedback that children’s SGD vocabulary acquisition was surpassing the app’s programmed vocabularies. Other adaptations were made to examine and measure clinically meaningful outcomes such as how children communicate (communication modes), the reasons why (communication functions), if they are participating in reciprocal exchanges with peers (immediate communication turns), and if improvements generalize to novel settings and untrained partners (Bourque, 2020; Bourque & Goldstein, 2020). Additional data on child variables that predict response to peer-mediated treatment and completion of current research on how children respond to peer interventions with adaptations to key components will further enhance our understanding of how to tailor intervention approaches for this heterogeneous population.

Another necessary step to individualize peer-mediated approaches for young autistic children educated in inclusive settings would be measuring peer-related social communication competence vs. testing these skills within standardized testing situations with adults. Future assessment research at JGCP may guide new developments in novel assessment tools that can provide a valid depiction of social competence with peers in authentic social contexts (Thiemann-Bourque et al., 2019). This would allow special and general classroom educators to obtain a more comprehensive picture of early social communication skills (i.e., early gestures, vocalizations, and joint attention) and intentional communication skills linked to later social development (Crais et al., 2004; Koegel et al., 2001). This type of novel evaluation of child social competencies could be used to better understand how autistic English Language Learners communicate in the classroom with peers, with outcomes used to created culturally-appropriate peer-mediated programs for this underrepresented group.

Along these lines, a key area that the OASIS team at JGCP and KUMC is targeting in the future is improving access to OASIS for diverse and underserved populations, specifically Latino families. Historically, Latino children have been significantly less likely to receive an autism diagnosis than non-Latino children (CDC, 2018). Kuhn and colleagues (2021) found that Latino children are less likely to receive recommended diagnostic care after a positive screen during a primary care visit. Also, when they do receive a diagnosis, it is much later than other groups (i.e., about 8 years old vs. about 2–3 years old for non-Latino children; Daniels & Mandell, 2014; Zuckerman et al., 2014). In a recent survey we conducted of local Latino families with a child with or at risk for a disability, 67.6% reported at least a 7-month delay between the time they had a serious concern about their child’s development to the time they received a diagnosis, with over half of those taking longer than a year. The three most reported barriers to getting a diagnostic evaluation were a lack of information in Spanish (37.3%), being on a waitlist (21.6%), and a lack of knowledge about where/how to get an assessment (11.8%; Buzhardt et al., 2023). Parent training materials, coach manuals, fidelity checklists, and other materials are available to parents and coach trainees as they begin training.

In response to this need, we culturally adapted OASIS for Spanish-speaking Latino families (Buzhardt et al., 2016). In addition to translating training materials into Spanish, adaptations included: Providing a Spanish-speaking Latino coach rather than an interpreter, providing extended definitions and more time to learn technical terms that do not have direct Spanish translations (e.g., pre-corrects, shaping), adding culturally relevant examples and scenarios in training, and including extended family members in training when appropriate. However, few Latino families reach out for OASIS services relative to the number expected based on local demographics. Therefore, we are preparing to develop a model of disseminating information about autism diagnostic and intervention services to Latino families based on the promotoras (Alaya et al., 2010; Magaña et al., 2020; Sherrill et al., 2005; WestRasmus et al., 2012), a community health worker model that has been widely used and shown to improve health and decrease health care disparities among Latino populations (United States Department of Health and Human Services, 2022). Our proposed Embajadora (ambassadors) program will train Latino service providers (e.g., home visitors, early educators, social workers, health navigators, etc.) to disseminate information about autism, diagnostic services, advocacy strategies, and EBPs, including OASIS-L parent training. Utilizing existing service providers for this role increases the likelihood that it will be sustainable, which has been a challenge for some promotoras programs that depend on parents who have an autistic child to volunteer their time as promotoras (Lopez et al., 2020; Schwingel et al., 2017).