Systematic Review of Intervention for Adolescents with Autism Spectrum Disorders

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Systematic Review of Intervention for Adolescents
with Autism Spectrum Disorders

• T A McDonald
• Integrated Autism Education, Treatment, and
  Leadership
• University of Wisconsin Madison
• Advisors
• Wendy Machalicek
• Colleen Moore
• Image from http//www.mcghealth.org/for-professio
  nals/McgContentPage.aspx?nd2011

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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

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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).

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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).

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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?

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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

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Current Study

• Review adolescent interventions
• Empirical designs
• ASD
• Identify target concerns
• Organize interventions around target concerns

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• Methods

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Certainty of Evidence

• Conclusive/Inconclusive (Millar et. al. 2006)

• 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

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• Results

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Characteristics of Participants- Age

• Age of participants with ASD (In single subject)

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Characteristics of Participants- Diagnosis

• (In single subject designs)

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Gender Ratio

• (all designs)

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Settings
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Design Types
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Conclusive

• Total interventions 49
• Conclusive 44
• Inconclusive 4
• Reliability 4
• One had only 5 of experimental sessions
• Need to consult regarding other 3 findings
• Multiple participants or targets
• One participant or target under 80 agreement

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Empirically Investigated Treatments
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Major Target Areas of Concern

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

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Specific Area Examples
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Specific Area Examples
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Elimination of Drooling by an Adolescent Student
with Autism Attending Public High School
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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

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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

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Results(Kay, Harchik, Luiselli, 2006)
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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?

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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

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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)

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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

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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)

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Background

• Previous Research
• Mostly children
• Lower functioning range
• Not formally tested (social competence)
• Exceptions
• Ozonoff and Miller (1995)
• Tse et al (2007)

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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

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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

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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

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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)

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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

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Friendship Qualities Scale

• Yes / No Questions
• Think of Best Friend
• My friend and I spend all of our free time
  together

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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)

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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

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The Quality of Play Questionnaire

• Frequency of play dates
• Number of Dates
• invited vs. hosted
• Level of conflict
• Criticized or teased each other

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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

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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

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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

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

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

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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

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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

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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

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Thank You!

• T A Marie McDonald
• Advisors
• Wendy Machalicek- RPSE
• Colleen Moore- Psychology