systematic review of intervention for adolescents with autism spectrum disorders

Systematic Review of Intervention for Adolescents with Autism

Spectrum DisordersT A McDonald

Integrated Autism Education, Treatment, and Leadership

University of Wisconsin – Madison

Advisors

Wendy Machalicek

Colleen Moore

Image from: http://www.mcghealth.org/for-professionals/McgContentPage.aspx?nd=2011

Background

➢ Early intervention➢ Increase in type➢ Increase in empirical designs

➢ Teen intervention➢ Adaptations from child interventions➢ Few tested with adolescents

➢ Many of these not empirical designs

Implications for Adolescence

➢ Negative consequences“As students with autism spectrum disorder reach

adolescence, the potential impact of inappropriate social behavior increases” (Graetz, Mastropieri, & Scruggs; 2009).

➢ Developmental Changes“...adolescence may be a particularly difficult time for higher

functioning youth with ASD due to increasing anxiety and awareness of social difficulties” (White et al.; 2009).

Implications for Adolescence

➢ Increased expectations with age“...since writing skills may affect later job performance, it is

essential to identify effective writing interventions for this population” (Delano, 2007)

“Among employment age adults with disabilities, some of the lowest employment rates are individuals on the autism spectrum” (Burke et al., 2010).

Stakeholders

➢ Stakeholders➢ Parents, teachers, clinicians, therapists, the

adolescent with ASD

➢ Evidence Based Practice➢ Does it work?➢ Evidence with children

➢ Carry over to teen?

➢ Locating what works➢ Individual articles, reviews?

Articles and Reviews

➢ Organized around intervention➢ Social Stories, Video Modeling, Functional

Communication, Cognitive-Behavioral➢ What about target concerns?

➢ Many on ASD but mostly with children➢ Will the tx generalize to adolescence?➢ Mixed data of children and adolescents

➢ Unable to determine outcomes for adolescents

➢ Many interventions for adolescents➢ But not with ASD

Current Study

➢ Review adolescent interventions➢ Empirical designs

➢ ASD

➢ Identify target concerns➢ Organize interventions around target

concerns

MethodsMethods

RedOffice.com Presentation templates Slide No. 9

ASD IncludedAutism, PDD-NOS,

Asperger's Syndrome

Adolescent Age Range12 - 22

Criteria for Inclusiona) Peer Review Journalb) At least one participant with ASD diagnosis AND adolescent age rangec.) Empirical designd.) Outcome data presentede.) Adolescent(s) outcome data distinguishable

Data Base Search

Search Terms1)1) Autism, intervention, teenAutism, intervention, teen2) Pervasive developmental Pervasive developmental disorder, intervention, disorder, intervention, adolescen* adolescen*3) Autism, intervention, Autism, intervention, adolescen* adolescen*4) Pervasive developmental Pervasive developmental disorder, teen disorder, teen5)5) Autism, intervention, adultAutism, intervention, adult6)6) Pervasive developmental Pervasive developmental disorder, intervention, adult disorder, intervention, adult

Data BasesMedLine

PsychINFOERIC

Exclusion●Dissertations●Non English●Animal●Phamacological & Electroconvulsive●Case Studies and

Reports●Rett's & Fragile X

Total Articles Located

1) 429 articles1) 429 articles2) 7 articles2) 7 articles3) 122 articles3) 122 articles4) 2 articles4) 2 articles5) 305 articles5) 305 articles6) 60 articles6) 60 articles

Reviews 38

Certainty of Evidence

➢ Empirical designs➢ Group design with control

➢ Multiple baseline

➢ Reversal

➢ Alternating treatment

➢ Visual inspection➢ Significant improvement for

at least one adolescent participant with ASD

➢ Interobserver Agreement➢ 20% of experimental

sessions

➢ 80% or more agreement

➢ Operationally defined➢ DV's & IV's

➢ Clear description of procedures

Conclusive/Inconclusive (Millar et. al. 2006)

ResultsResults

Characteristics of Participants- Age

• Age of participants with ASD (In single subject)

Characteristics of Participants- Diagnosis

• (In single subject designs)

Gender Ratio

• (all designs)

Settings

Design Types

Conclusive

Empirically Investigated Treatments

Major Target Areas of Concern

• (In all designs) (Articles often contained multiple targets)

Specific Area Examples

Specific Area Examples

Elimination of Drooling by an Adolescent Student with Autism

Attending Public High School

Appearance and Social Opportunities(Kay, Harchik, & Luiselli, 2006)

Poor Appearance Infrequent positive relationships Ostracization Reduced number of friendships Decreased social acceptability

Drooling Unsanitary Unattractive Foul Odor Interfere with communication

MethodProcedure: duration & steps

(Kay, Harchik, & Luiselli, 2006)

Duration Baseline sessions began prior to intervention

Classroom: 1 week Community vocation: 3 days Cooking class: 1 day

Session length 5 – 7 mins Concluded 20 correct teaching trials Steps

Check participant every 5 mins Dry mouth: praise + edible (DRO) Saliva present: “wipe your mouth” + “swallow” Dependent measure: pools of saliva After 2 consecutive days of fewer than 2 pools/hour, 5 min intervals increased 15 min

Results(Kay, Harchik, & Luiselli, 2006)

MethodDiscussion & Limitations

(Kay, Harchik, & Luiselli, 2006)

Conclusive Drooling behavior eliminated

Limitations Contribution of components Intervention setting specific Data not recorded: lips & chin saliva; mouth wipes Hygiene issues in cooking class: 15 min checks

maintained No follow-up No measure of social change One-on-one aide; what about self- management?

MethodParticipant

(Kay, Harchik, & Luiselli, 2006)

Participant Male age 17 Autism & mental retardation Public High School (inclusive setting) Single words & phrases Self care with adult assistance

Drooling Behavior Apparent since childhood Interfering with school

Education: work surfaces Social: ostracized

No medical intervention Phobia

MethodMeasurement & Agreement

(Kay, Harchik, & Luiselli, 2006)

Measurement Number of saliva pools

Work environment surfaces Diameter of 1 inch or more

Included 95% of all saliva pools Recorded, then wiped clean Three locations daily:

Classroom (3hrs) Community vocational site (2hrs) Cooking class (1hr)

Number of pools converted to average/hour

Interobserver agreement Classroom: 96% (93- 100%) Community vocational site 91% (89- 94%) Cooking class 93% (91- 95%)

MethodDesign & Procedure(Kay, Harchik, & Luiselli, 2006)

Design Multiple baseline across three locations

Classroom, community vocational site, cooking class

Procedure Baseline

Aide wiped surface clean after detecting pool Chin accumulation Behavior disregarded

Intervention Preteaching

“Swallow” “Wipe your mouth”

Verbal instructions, partial physical guidance, contingent praise to prompt, positive reinforcement of correct response

Parent-Assisted Social Skills Training to Improve Friendships in Teens with

Autism Spectrum DisordersLaugeson, E. A., Frankel, F., Mogil, C., & Dillon, A. R. (2008)

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Background●Typical Teens vs. Teens with ASDs

●Typical Teens:–Best Friends●By 4th grade*●Aids resilience to life events**●Aids self esteem***●Aids social competence & social problem solving****●Neg correlated with anxiety and depression***

●Teens with ASDs–Missing out on these experiences–Need extra support and instruction

–(*Fankel, 1996; *McGuire & Weisz, 1982; **Miller & Ingham, 1976; ***Buhrmester, 1990, ****Nelson & Aboud, 1985)

Background

●Previous Research●Mostly children●Lower functioning range●Not formally tested (social competence)

●Exceptions:●Ozonoff and Miller (1995)●Tse et al (2007)

PEERS

●Program for the Education and Evaluation of Relational Skills●Adapted from Children's Friendship Training–Evidence base: ADHD, Fetal Alcohol Spectrum, children with ASD●(Frankel & Myatt, 2003), (O'Connor et. al., 2006), (Frankel & Myatt, 2007)Small Group Format

●Small Group Format

●Parent instruction●Separate concurrent sessions

Current Study

●PEERS intervention content:●Evidence base practices–Didactic instruction, role playing, modeling, behavioral rehearsal, coaching with performance feedback, weekly socialization assignments with consistent homework review

●Social etiquette–Social situations with accompanying rules & steps–Teens provided instruction in steps

●Parents provided information to supervise

Participants

●Teens (n = 33)●13-17 years of age, mean 14.6●Male (28), Female (5)●Diagnosis of ASD–HFA, Asperger's, PDD-NOS●Caucasian (14), Hispanic/Latino (6), African American (3), Asian (4), Middle Eastern (3), Mixed ethnicity (3)●Regular Ed (17), Special Ed (8), Pull out (2), Home-school (3), other Ed (3).●Participants were randomly assigned to either the Treatment or the Delayed Treatment Group

Outcome Measures

●Test of Adolescent Social Skills Knowledge TASSK●Teen●22 items, Sentence stems with 2 choices●Knowledge of teen social skills

●(TASSK; Laugeson and Frankel, 2006)

●Friendship Qualities Scale●Teen●23 yes/no questions regarding their best friend(ship)

●(FQS; Bukowski et al, 1994)

TASSK Example Items

●The goal of a conversation is to●Make the other person like you●Find common interests

●One of the rules for having a two way conversation is●To be an interviewer●Do not be an interviewer

●If you try to join a conversation and the people ignore you:●Move on●Speak louder so they can hear you

Friendship Qualities Scale

●Yes / No Questions●Think of Best Friend

●My friend and I spend all of our free time together

Outcome Measures

●Social Skills Rating Scale●Parent & Teacher●38 item questionnaire, never, sometimes, very often●Social skills scale, problem behavior scale

●(SSRS: Gresham and Elliott, 1990)

●The Quality of Play Questionnaire●Parent & Teen●12 item questionnaire, frequency of get-togethers & conflict●Hosted & invited get-togethers

●(QPQ; Frankel and Mintz, 2008)

SSRS Info and Sample Items

●Social Skills●Cooperation–Follows your direction●Assertion–Invites others to join in activities●Responsibility–Requests permission before leaving the house●Self Control–Responds appropriately when pushed or hit

●Problem Behaviors●Externalizing–Fights with others●Internalizing–Is easily embarrassed●Hyperactivity–Acts impulsively

●** Likert–Never–Sometimes–Always

The Quality of Play Questionnaire

●Frequency of play dates

●Number of Dates●invited vs. hosted

●Level of conflict●Criticized or teased each other

Treatment

Completely manualized & delivered over 12 weeks

●Teen Sessions–Reciprocity in conversation–Diminishing importance of rejecting peer group–Reversing negative reputations–Instruction to promote get-togethers–Competence with teasing, bullying, conflicts–Didactic lessons–Modeling, Role-playing, Performance feedback–Homework assigned

Treatment

●Parent Sessions●Review of homework assignments●Troubleshoot homework problems●Instruction to help teen overcome homework problems

●Teen and Parents reunited●Teens deliver review for parents●Homework finalized

Quick Recap

●Random Assignment●Treatment & Delayed Treatment Group●Demographic information gathered●Pre-test outcome measures gathered–Teens, Parents, Teachers●Treatment●Post-test outcome measures gathered–Teens, Parents, Teachers

Results

Non-Significant Differences at Baseline Between Treatment Group and Delayed Treatment Groups

Results

●Statistically Significant scores for Pre and Post-test outcome variables for Treatment and Delayed Treatment

Discussion

●Findings●Knowledge of social etiquette●Hosted get-togethers●Quality of friendships●Parent report of overall social skills

●Limitations●Bias in Parent Report?–Increase Teacher report●Need Maintenance Data●Would have liked ADOS or ADI-R●SSRS not designed for ASD

Are the interventions comprehensive enough?

➢ Recap of Adolescent Implications➢ Increasing valence of negative behaviors

➢ Large amount on problem behaviors & self-injury

➢ Developmental changes with adolescence➢ Very little description of change. What about

sexuality? Dating?

➢ Increasing expectations➢ Very little for

➢ Academics (beyond on task, initiation, completion)➢ Occupation

➢ More (but still not much!)➢ Independence and self-care

Other Concerns & Future Directions

➢ Standard measure of autism across studies

➢ Ideally: Assessment at time of study

➢ Report of ethnicity➢ Very little reported

➢ Next step: Hand search of journals

Thank You!

T A Marie McDonald

Advisors

Wendy Machalicek- RPSE

Colleen Moore- Psychology