Randomized controlled effectiveness trial of executive function intervention for children on the autism spectrum

Abstract

Background: Unstuck and On Target (UOT) is an executive function (EF) intervention for children with autism spectrum disorders (ASD) targeting insistence on sameness, flexibility, goal-setting, and planning through a cognitive-behavioral program of self-regulatory scripts, guided/faded practice, and visual/verbal cueing. UOT is contextually-based because it is implemented in school and at home, the contexts in which a child uses EF skills.

Methods: To evaluate the effectiveness of UOT compared with a social skills intervention (SS), 3rd-5th graders with ASD (mean IQ = 108; UOT n = 47; SS n = 20) received interventions delivered by school staff in small group sessions. Students were matched for gender, age, race, IQ, ASD symptomotolgy, medication status, and parents' education. Interventions were matched for 'dose' of intervention and training. Measures of pre-post change included classroom observations, parent/teacher report, and direct child measures of problem-solving, EF, and social skills. Schools were randomized and evaluators, but not parents or teachers, were blinded to intervention type.

Results: Interventions were administered with high fidelity. Children in both groups improved with intervention, but mean change scores from pre- to postintervention indicated significantly greater improvements for UOT than SS groups in: problem-solving, flexibility, and planning/organizing. Also, classroom observations revealed that participants in UOT made greater improvements than SS participants in their ability to follow rules, make transitions, and be flexible. Children in both groups made equivalent improvements in social skills.

Conclusions: These data support the effectiveness of the first contextually-based EF intervention for children with ASD. UOT improved classroom behavior, flexibility, and problem-solving in children with ASD. Individuals with variable background/training in ASD successfully implemented UOT in mainstream educational settings.

Keywords: Autism; CBT; RRBI; executive function; intervention.

Conflict of interest statement

Conflict of interests statement: See acknowledgements for disclosures.

© 2013 The Authors. Journal of Child Psychology and Psychiatry © 2013 Association for Child and Adolescent Mental Health.

Figures

Figure 1. Study Participant Recruitment and Enrollment

Figure 2. 95% Confidence Intervals of the Proportion of Individuals in Unstuck and on Target (UOT) and Social Skills (SS) Interventions Who Improved on Post-intervention, as Compared to Pre-intervention, Assessment on Classroom (CO) and Challenge Task (CT) Observationsa, WASI Block Design, and parent and teacher BRIEF and SRS scoresb

aClassroom Observations and Challenge Task confidence intervals indicate the percent improved. bWASI, parent/teacher BRIEF, and SRS confidence intervals indicate the percent exceeding an 80% reliable change index.

Figure 3

Mean Scores, with Standard Error Bars, for Problem Solving Skills, Parent and Teacher Report of Flexibility, and Flexibility Ratings on the Challenge Task for the Unstuck and On Target (UOT) and Social Skills (SS) Groups at Pre- and Post-Intervention.