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Systematic Review of Intervention for Adolescents with Autism Spectrum Disorders

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Title: Systematic Review of Intervention for Adolescents with Autism Spectrum Disorders


1
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

2
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

3
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).

4
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).

5
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?

6
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

7
Current Study
  • Review adolescent interventions
  • Empirical designs
  • ASD
  • Identify target concerns
  • Organize interventions around target concerns

8
  • Methods

9
(No Transcript)
10
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

11
  • Results

12
Characteristics of Participants- Age
  • Age of participants with ASD (In single subject)

13
Characteristics of Participants- Diagnosis
  • (In single subject designs)

14
Gender Ratio
  • (all designs)

15
Settings
16
Design Types
17
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

18
Empirically Investigated Treatments
19
Major Target Areas of Concern
  • (In all designs) (Articles often contained
    multiple targets)

20
Specific Area Examples
21
Specific Area Examples
22
Elimination of Drooling by an Adolescent Student
with Autism Attending Public High School
23
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

24
Method Procedure 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

25
Results (Kay, Harchik, Luiselli, 2006)
26
Method Discussion 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?

27
Method Participant (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

28
Method Measurement 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)

29
Method Design 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

30
Parent-Assisted Social Skills Training to Improve
Friendships in Teens with Autism Spectrum
Disorders Laugeson, E. A., Frankel, F., Mogil,
C., Dillon, A. R. (2008)
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31
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)

32
Background
  • Previous Research
  • Mostly children
  • Lower functioning range
  • Not formally tested (social competence)
  • Exceptions
  • Ozonoff and Miller (1995)
  • Tse et al (2007)

33
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

34
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

35
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

36
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)

37
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

38
Friendship Qualities Scale
  • Yes / No Questions
  • Think of Best Friend
  • My friend and I spend all of our free time
    together

39
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)

40
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

41
The Quality of Play Questionnaire
  • Frequency of play dates
  • Number of Dates
  • invited vs. hosted
  • Level of conflict
  • Criticized or teased each other

42
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

43
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

44
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

45
Results
Non-Significant Differences at Baseline Between
Treatment Group and Delayed Treatment Groups
46
Results
  • Statistically Significant scores for Pre and
    Post-test outcome variables for Treatment and
    Delayed Treatment

47
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

48
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

49
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

50
Thank You!
  • T A Marie McDonald
  • Advisors
  • Wendy Machalicek- RPSE
  • Colleen Moore- Psychology
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