Adapting the preschool environment to the needs of children on the autism spectrum in Sweden: A quasi-experimental study

Figures & data

Figure 1. Overview of stakeholders at organizational and individual level.

Table 1. Median of the total number of EIBI programs supervised by habilitation supervisors before study participation (supervisor experience). Means and standard deviation of total number of supervision sessions during the study (EIBI supervision sessions).

	Supervisors’ experience	EIBI supervision sessions	EIBI total implementation hours	EIBI pre-school implementation hours
EIBI only (n = 8)	1.5	17.25 (3.85)	17.50 (3.54)	12.13 (2.96)
EIBI/APERS-P-SE preschools (n = 9)	1	18.22 (3.23)	19.06 (6.47)	12.33 (4.26)

Means and standard deviation of weekly EIBI implementation hours reported for home- and pre-school setting combined (EIBI total implementation hours), and specifically for the pre-school setting (EIBI pre-school implementation hours) during the course of the study.

Table 2. Overview of usual practice, and the addition of the intervention provided.

EIBI Only	EIBI/APERS-P-SE
APERS-P-SE feedback	APERS-P-SE feedback
EIBI supervision	EIBI supervision
	In-service training based on APERS-P-SE assessments concerning ASD, improving learning environment, goal scaling, and evidence-based practices to support learning and participation
	On-site coaching based on APERS-P-SE assessments to improve learning environment and support children’s learning and participation

Table 3. Overview of secondary outcome measures.

Instrument	Type of scale	Description
Pre-school learning environment
APERS-P-SE	Likert scale (1–5) where 1 is ‘poorest quality’ and 5 is ‘highest quality’, comprising 56 items.	A scale designed to assess the pre-school learning environment for children on the autism spectrum in Sweden. The scale is translated and cross-culturally validated, showing high levels of content validity (CVIs = 0.97 − 1.0).
Children’s outcomes
Vineland Adaptive Behaviour Scales – Second Edition (Vineland-II) – Teacher ratings	Likert scale (0–2) where 0 is ‘never occurs’, and 2 is ‘occurs often’, comprising 177 items in the current study.	A scale designed to assess children’s adaptive behaviours within various domains such as Independence and Communication skills. The scale is translated to Swedish and cross-culturally validated, but raw data are not normalised for the teacher ratings. In the current study all domains are rated except for the motor skills domain
Children's Engagement Questionnaire (CEQ)	Likert scale (1–4), where 1 is ‘not at all typical’, and 4 is ‘very typical’, comprising 29 items.	A scale designed to assess children's level of engagement in various situations. It has previously been translated and validated in Sweden [61,62] showing high internal consistency (α = 0.86–0.93). In the current study one version is rated by pre-school staff about the level of children’s engagement in the pre-school setting, and another version is rated by parents about the level of children’s engagement in the same situations outside of the pre-school setting (e.g. at home).
Clinical Global Impression-Autism (CGI-AUT)	Likert scale (1–7), where 1 is ‘no autism symptoms’, and 7 is ‘maximum symptom severity’, comprising 1 item.	An instrument designed to assess the symptom severity of pre-school age children with ASD. It has previously been validated in a Swedish context [63] with moderate intraclass correlations found among 16 experts (rit.= 0.59 − 0.72).
Goal Attainment Scale (GAS)	Ordinal scale (0–4), where 0 is baseline measure, 1 is ‘meets initial objective’ 2 is ‘meets secondary objective’, 3 is ‘meets annual goal’, and 4 is ‘exceeds annual goal’.	A scale originally designed to be used for treatment of psychiatric disorders which is now used in a broad range of areas. The scale has been translated to Swedish, and in the current study’s EIBI/APERS-P-SE preschools three goals for each child were decided upon in collaboration between participating pre-school staff, habilitation supervisors, and children’s parents.
Pre-school staff’s outcomes
Ethics, Values and Allegiance (EVA)	Likert scale (0–4) where 0 is ‘I do not agree’ and 4 is ‘I completely agree’, comprising 11 items in the current study.	A scale designed to assess allegiance towards EIBI. Cronbach’s alpha for the internal consistency of the scale was found to be high (α = 0.90) in previous research using the scale [45,47].
Evidence Based Practices Questionnaire (EBP-Q)	Likert scale (0–3) where 0 is ‘not all all/never/not at all’, and 3 is ‘very well/very often/completely’, comprising 15 items.	A scale designed for pre-school staff to self-assess knowledge about, use of, and implementation skills of 15 evidence-based practices for children with ASD. The practices were chosen from the 27 evidences-based practices identified by Odom, Cox & Brock [36], and Hall [64], because of their relevance for working with pre-school age children in pre-school settings. It is translated from the original English version, and no psychometric properties of the instrument are currently established.
Autism Knowledge Questionnaire (AKQ)	A questionnaire comprising 18 statements which can be answered ‘true’, ‘false’, or ‘I don’t know’.	A questionnaire designed to assess pre-school staff’s knowledge about ASD. Example of statements include ‘All children with ASD are uninterested in playing with other children’. The questionnaire is a revised edition of an earlier version used in a study on knowledge about ASD among grandparents to children with ASD receiving education at a habilitation centre [65].  No psychometric properties of the instrument are currently established.
Self-Efficacy, Stress and Satisfaction Questionnaire (SESSQ)	Likert scale (0–5) where 0 is ‘I do not agree at all/no stress/not at all/I do not agree at all’ and 5 is ‘I completely agree/extreme stress/very much/completely/I completely agree’, comprising a total of 34 items/statements.	A scale designed to assess self-efficacy for working with children in pre-school, self-efficacy for working with children with ASD, and perceived levels of work-related stress and satisfaction, among pre-school teachers, paraprofessionals, and other pre-school staff. It contains the translated short, 12-item version of the Ohio State Teacher Efficacy Scale (OSTES; [66]), a translated and abbreviated version (14 items) of the Autism Self-Efficacy Scale for Teachers (ASSET; [67]), translated version of the three item Job Satisfaction Survey [68], as well as five translated items about stress from the Teacher Stress Inventory [69]. ASSET has in its original English version shown high internal consistency (α = 0.96), and items loading on one dominant factor, the internal consistency of modified version used in the current study was (α = 0.89). OSTES has in its original, short form, displayed a high level of internal consistency (α = 0.90), as well as sound factor loading, and satisfying construct validity. Internal consistency found in the current study was (α = 0.94).
Social Validity Scale (SVS)	Likert scale (0–5), where 0 is ‘I don’t not agree at all’ and 5 is ‘I completely agree’, comprising 5 statements/items.	A scale developed for the current study which is designed for pre-school staff in the EIBI/APERS-P-SE preschools to assess the relevance and acceptability of the goals targeted within the study, of the methods used, of the APERS-P-SE feedback provided, the contents of the in-service training and coaching, and the usefulness of the knowledge and skills acquired when working with other children in the future. One example of items is ‘The procedure and methods we have used have been helpful for working with children with ASD in the pre-school’ No psychometric properties of the instrument are currently established.

Table 4. APERS-P-SE (primary outcome measure) total score (calculated with two-factor mixed-design ANCOVA) and domain scores (calculated with two-factor mixed-design MANCOVA) at baseline and post-intervention in the control group (EIBI only) and experimental (EIBI/APERS-P-SE preschools).

APERS-P-SE total score and domain scores (min – max)	Mean (SD)		Group difference in change score	p value	Effect size (Partial η^2)*
	EIBI only (n = 8)	EIBI/APERS-P-SE preschools (n = 9)
APERS-P-SE total (1–5)
Baseline	2.87 (0.37)	2.82 (0.30)
Post-intervention	2.94 (0.25)	3.73 (0.65)**
Change score	0.07	0.91	0.84	0.003	0.47
Domain Learning Environments (1–5)
Baseline	3.18 (0.42)	2.81 (0.53)
Post-intervention	2.94 (0.34)	3.74 (0.70)**
Change score	–0.24	0.93	1.17	0.002	0.51
Domain Positive Learning Climate (1–5)
Baseline	3.39 (0.82)	3.72 (0.38)
Post-intervention	3.66 (0.38)	4.31 (0.56)
Change score	0.27	0.59	0.32	0.188	0.14
Domain Assessment and IEP Development (1–5)
Baseline	3.82 (0.48)	3.50 (0.66)
Post-intervention	3.78 (0.25)	4.16 (0.46)
Change score	–0.04	0.66	0.70	0.192	0.14
Domain Curriculum and Instructions (1–5)
Baseline	2.23 (0.48)	2.31 (0.48)
Post-intervention	2.48 (0.32)	3.54 (1.07)**
Change score	0.25	1.23	0.98	0.094	0.22
Domain Communication (1–5)
Baseline	2.19 (0.65)	2.47 (0.64)
Post-intervention	2.49 (0.53)	3.43 (1.22)
Change score	0.30	0.96	0.66	0.88	0.02
Domain Social Competence (1–5)
Baseline	3.06 (0.66)	3.42 (0.67)
Post-intervention	3.16 (0.79)	4.39 (0.47)**
Change score	0.10	0.97	0.87	0.24	0.11
Domain Personal Independence (1–5)
Baseline	2.50 (0.53)	1.93 (0.52)
Post-intervention	2.33 (0.25)	3.11 (0.55)**
Change score	–0.17	1.18	1.35	0.004	0.51
Domain Functional Behaviour (1–5)
Baseline	2.43 (1.03)	1.98 (0.60)
Post-intervention	2.31 (0.44)	3.12 (1.10)**
Change score	–0.12	1.14	1.26	0.034	0.32
Domain Family Involvement (1–5)
Baseline	4.67 (0.44)	4.81 (0.37)
Post-intervention	4.50 (0.36)	4.82 (0.24)
Change score	–0.17	0.01	0.18	0.70	0.01
Domain Teaming (1–5)
Baseline	2.83 (0.53)	2.80 (0.39)
Post-intervention	2.82 (0.52)	3.42 (0.69)
Change score	–0.01	0.62	0.63	0.962	0.01

Within-group differences calculated with paired t-tests.

*Positive effect sizes favour EIBI/APERS-P-SE preschools.

**Within-group change was statistically significant (p < 0.005) after false discovery rate correction for multiple comparisons.

Table 5. Child and pre-school staff secondary outcome measures (calculated with two-factor mixed-design MANOVA) at baseline and post-intervention in the control group (EIBI only) and experimental (EIBI/APERS-P-SE preschools).

Measure (min – max)	Mean (SD)	EIBI/APERS-P-SE preschools	Group difference in change score	p	Effect size (Partial η^2)^a
	EIBI only	EIBI/APERS-P-SE preschools
Children’s outcomes	(n = 8)	(n = 9)
Vineland-II (0–354)
Baseline	44.88 (30.88)	55.33 (39.88)
Post-intervention	65.50 (43.50)	87.22 (57.02)*
Change score	20.62	31.89	11.27	0.56	0.03
CGI-AUT (1–7)
Baseline	5.88 (0.97)	5.11 (0.78)
Post-intervention	5.38 (0.99)	4.87 (0.97)
Change score	–0.5	–0.24	–0.26	0.759	–0.006
CEQ-Pre-school (29–116)
Baseline	53.38 (14.01)	62.00 (18.55)
Post-intervention	57.13 (16.28)	67.67 (20.62)
Change score	3.75	5.67	1.92	0.808	0.004
CEQ-Parent (29–116)
Baseline	67.63 (15.14)	69.13 (13.37)
Post-intervention	71.75 (18.71)	76.87 (21.18)
Change score	4.12	7.74	3.62	0.544	0.027
GAS (0–4)
Baseline	–	0.00 (0.00)
Post-intervention	–	2.59 (1.42)		–	–
Pre-school teachers’ outcomes	(n = 16)	(n = 19)
EBP-Q (0–3)
Baseline	1.68 (0.80)	1.66 (0.55)
Post-intervention	1.82 (0.52)	1.92 (0.61)*
Change score	0.14	0.26	0.12	0.45	0.039
EVA (0–44)
Baseline	28.50 (6.41)	34.79 (6.40)
Post-intervention	28.63 (12.49)	32.53 (9.14)
Change score	0.13	–2.26	−2.39	0.493	−0.032
SESSQ-S-E (0–5)
Baseline	3.73 (0.55)	4.08 (0.71)
Post-intervention	3.63 (4.8)	4.08 (0.62)
Change score	–0.10	0	–0.10	0.55	0.024
SESSQ-S-E-ASD (0–5)
Baseline	3.49 (0.68)	3.72 (0.48)
Post-intervention	3.53 (0.67)	3.92 (0.74)
Change score	0.04	0.20	0.16	0.487	0.033
SESSQ-Stress (0–5)
Baseline	3.39 (0.70)	2.42 (1.07)
Post-intervention	3.31 (0.70)	2.51 (0.97)
Change score	–0.08	0.09	0.17	0.636	−0.015
SESSQ-Satisfaction (0–5)
Baseline	4.48 (0.57)	4.84 (0.37)
Post-intervention	4.40 (0.70)	4.73 (0.54)
Change score	–0.08	–0.11	−0.03	0.882	−0.002
AKQ (0–18)
Baseline	13.94 (3.44)	14.26 (2.96)
Post-intervention	14.25 (3.27)	15.37 (3.13)
Change score	0.31	1.11	0.80	0.466	0.036
SVS (0–5)
Baseline	–	–
Post-intervention	–	4.74 (0.11)		–	–

Within-group differences calculated with paired t-tests.

Note. Vineland-II. Vineland Adaptive Behaviour Scales – second edition – teacher ratings, CGI-AUT. Clinical Global Impression – autism, CEQ-Pre-school. Children's Engagement Questionnaire – pre-school version, CEQ-Parent. Children’s Engagement Questionnaire – parent version, GAS. Goal Attainment Scale, EBP-Q. Evidence-Based Practices Questionnaire, EVA. Ethics, Values and Allegiance, SESSQ-S-E. Self-Efficacy, Stress and Satisfaction Questionnaire – self efficacy for working with children in general, SESSQ-S-E-ASD. Self-efficacy, Stress and Satisfaction Questionnaire – Self Efficacy for Working with Children with ASD, SESSQ-Stress. Self-Efficacy, Stress and Satisfaction Questionnaire – Work Related Stress, SESSQ-Satisfaction. Self-Efficacy, Stress and Satisfaction Questionnaire – Work Related Satisfaction, AKQ. Autism Knowledge Questionnaire, SVS. Social Validity Scale, ^aPositive effect sizes favour EIBI/APERS-P-SE preschools.

*Within-group change was statistically significant (p < 0.05).

Almqvist L. Patterns of engagement in young children with and without developmental delay. J Policy Pract Intellect Disabil. 2006;3:65–75.

 Google Scholar

Lillvist A. Observations of social competence of children in need of special support based on traditional disability categories versus a functional approach. Early Child Dev Care. 2010;180:1129–1142.

 Google Scholar

Choque Olsson N, Bölte S. Brief report: “quick and (not so) dirty” assessment of change in autism – cross-cultural reliability of the developmental disabilities CGAS and the OSU autism CGI. J Autism Dev Disord. 2014;44:1773–1778.

 PubMed Web of Science ®Google Scholar

Långh U, Hammar M, Klintwall L, et al. Allegiance and knowledge levels of professionals working with early intensive behavioural intervention in autism. Early Interv Psychiatry. 2017;11:444–450.

 PubMed Web of Science ®Google Scholar

Klintwall L, Gillberg C, Bölte S, et al. The efficacy of intensive behavioral intervention for children with autism: a matter of allegiance? J Autism Dev Disord. 2012;42:139.

 PubMed Web of Science ®Google Scholar

Odom SL, Cox AW, Brock ME, et al. Implementation science, professional development, and autism spectrum disorders. Except Child. 2013;79:233–251.

 Web of Science ®Google Scholar

Hall LJ. Sustaining evidence-based practices by graduated special educators of students with ASD: creating a community of practice. Teach Educ Spec Educ. 2015;38:28–43.

 Web of Science ®Google Scholar

Zakirova-Engstrand R, Roll-Pettersson L, Andersson K, et al. Group psychoeducational intervention for grandparents of young children with ASD: An open feasibility study. J Autism Dev Disord. 2021. doi:10.1007/s10803-021-05189-0.

 PubMedGoogle Scholar

Tschannen-Moran M, Hoy AW. Teacher efficacy: capturing an elusive construct. Teach Teach Educ. 2001;17:783–805.

 Web of Science ®Google Scholar

Ruble LA, Toland MD, Birdwhistell JL, et al. Preliminary study of the autism self-efficacy scale for teachers (ASSET). Res Autism Spectr Disord. 2013;7:1151–1159.

 PubMed Web of Science ®Google Scholar

Spector PE. Measurement of human service staff satisfaction: development of the job satisfaction survey. Am J Community Psychol. 1985;13:693–713.

 PubMed Web of Science ®Google Scholar

Boyle GJ, Borg MG, Falzon JM, et al. A structural model of the dimensions of teacher stress. Br J Educ Psychol. 1995;65:49–67.

 PubMed Web of Science ®Google Scholar