PCORI funds implementation projects to promote the use of findings from PCORI-funded studies. This project focuses on implementing findings from the PCORI-funded research project: Improving Classroom Behaviors among Students with Symptoms of Autism Spectrum Disorder or Attention Deficit Hyperactivity Disorder
1. What were the results from the original PCORI-funded research study?
The project team’s Addressing Disparities CER provided 148 third- to fifth-grade students in 24 schools with ADHD or autism spectrum disorder (ASD) evidence-based interventions to improve their executive functioning (EF). EF is a set of brain-based abilities, such as planning and flexibility, that help people regulate their behavior to reach important goals. The team compared two proven interventions aimed at improving EF: Unstuck and On Target! (UOT), which teaches children to think and act flexibly, set goals and make plans, and a Contingency Behavior Management (CBM) program that rewards children when they are focused, flexible, and show other EF-related behaviors. Only ~30 percent of the children in the study identified as white, non-Hispanic/non-Latinx, and 14 different languages were spoken in their homes. The treatments were given in 21 small group sessions by school staff. Outcomes were measured at pre, post, and one-year follow-up. Improved flexibility, participation, and ability to follow directions during academic classes were the primary outcomes measured, because these skills are essential for learning and inclusion in mainstream settings. Secondary outcomes included number of nonroutine medical visits needed, and child EF and problem-solving skills. More children with ADHD improved from their baseline classroom behaviors than got worse following both interventions (UOT; p<.0001; CBM; p=.008). The same was true for children with ASD who received UOT (p<.0001), but not for those who received CBM (p=.648). Children who received UOT showed, on average, 1.24 new pivotal EF behaviors during a short classroom observation. Both treatments significantly (p=.003) reduced nonroutine medical visits by a group average of half of a visit, but with a standard deviation that included more than one less visit. Both treatments were effectively implemented with fidelity by school staff from a variety of professions. Parents (p<.001) and children (p=.020) rated UOT more positively than they did CBM. IQ, age, race, income, and language spoken at home did not significantly relate to classroom outcome, suggesting that UOT works for all kinds of children. These findings indicate that UOT is an effective, feasible, and acceptable intervention to improve EF and school functioning with positive results maintained one year later.
2. Why is this research finding important?
Parents and schools wanted to know how to best help children develop better EF, as EF is a vital self-regulatory ability. Poor EF is a strong predictor of long-term problems in quality of life, health (physical and mental), education, and independent living. Better EF in childhood predicts better health and lower incarceration rates in adults, even after accounting for IQ and socioeconomic status. In the project team’s previous study, the investigators wanted to solve the problems of fewer treatment choices and worse outcomes for poor children with ADHD or ASD and EF problems. Many lack access to clinic-based services, a problem solved by providing treatment in schools. Reviews of research and national standards indicate that programs given in schools with parent training are the best way to help children, but EF programs for elementary-aged children with ASD or ADHD are lacking. This study filled major gaps in showing the success of UOT, which is effective yet very low-cost, easy for school staff to implement with good fidelity (correctly), and accessible to the schools and children who need it the most.
3. What is the goal of this project?
The researcher/stakeholder team will build on its previous study’s success and address a major barrier the stakeholder advisory board (SAB) described regarding access to UOT: research study staff provided in-person training to the school implementers. The goal is to automate the training for UOT to allow for greater sustainability and broader, effective implementation. In this project, the team is not changing the content and procedures of UOT; it will be implemented with children just as in the team’s previous work. However, the team will be transferring its UOT school-staff training content from an in-person to an online platform, so that schools and implementers can access training from anywhere with internet access. The specific aims are:
- Transfer the content of the team’s successful implementer trainings into free online training modules. The investigators propose to enhance effective training materials from CER with the creation of new open-access online training modules and provide a unified platform for flexibly accessing all training tools and support.
- Broaden the reach of UOT. Through online training tools, the team will provide all US school systems access to training to implement a new effective EF intervention.
- Determine the effects of online training implementation. The team will measure the degree of adoption of the online training model of UOT, the feasibility, appropriateness, acceptability, and sustainability of its implementation and its effectiveness in enhancing EF and broad outcomes.
4. What is the project team doing?
The team’s goal is to improve EF for more children by broadening the implementation model to use remote training and support to increase the number of schools that can effectively use UOT. The UOT manual to be extended with online training components is published (i.e., dissemination is already underway). This project team, including UOT authors, trainers from the previous trial, and experts in adult learning and online delivery of content will transfer the in-person implementer training content to online trainings and telementoring supports in order to allow all schools access to UOT, and to promote its effective use for the large percentage of children (about 11 percent in any school) with ADHD or ASD who most need an EF intervention. Total reach in this project is up to 2,000 children. The team will collect implementation outcomes from a subset of 200 implementers and 100 children. This project works with school districts that serve over 14,000 third- to fifth-graders with ADHD or ASD who could potentially receive UOT. Like all projects aimed at delivering effective interventions into school settings, this one requires a multi-stage process. It will occur over three years: transferring the already developed school staff trainings onto online platforms in Year 1; trying out the trainings and the intervention in Year 2; and evaluating whether gains are kept up and if UOT spreads in Year 3.
5. How is the team evaluating this project?
The team will first find out whether school-based implementers and the SAB find the online UOT training acceptable, appropriate for their needs, and make UOT easy to carry out the way it was intended. Consistent with the team’s implementation model, RE-AIM, the investigators will measure the project’s reach and scalability, effectiveness (as measured in the CER), school systems’ adoption, implementers’ adoption, knowledge and satisfaction, implementation fidelity and effectiveness, adaptations, and school systems’ and implementers’ maintenance one year after initial implementation.
6. How is the team involving patients and others in making sure the findings reach people who can use them?
The team’s previous SAB chair, Yetta Myrick, a parent of a child with ASD, will continue to lead the SAB and the team’s PI, Co-PI, and Co-I all have children with ADHD. The school systems that participated in the CER have already described barriers to implementation that this project is designed to address, and they will be on the SAB in the proposed project, providing tips for ongoing sustainability and implementation that the team can use to ensure this project’s success. The team will also be adding new stakeholders to help ensure the expansion in reach that the investigators hope to achieve in this implementation project: The National Institute for Innovation and Implementation and several state-level education policy makers.
7. How will this project help ensure future uptake and use of findings from patient-centered outcomes research?
UOT is low-cost, has been effectively implemented with fidelity by a variety of school staff, and resulted in long-lasting improvements in behaviors required for positive school and adult health outcomes. The project team seeks to increase the number of children who can benefit from UOT by providing free (with free Continuing Education Credits), sustained, accessible, online, and telementoring supports to implement this intervention. The team will improve outcomes for children with reduced access to clinic-based services by developing a model for feasible and sustainable nationwide implementation.
Related PCORI-funded Research Project
*All proposed projects, including requested budgets and project periods, are approved subject to a programmatic and budget review by PCORI staff and the negotiation of a formal award contract.