Unstuck and On Target: An Executive Functioning Intervention for Children with High-Functioning Autism Spectrum Disorders

Background:  

Difficulties with executive functioning are a commonly observed associated feature of high-functioning autism spectrum disorders (ASD). We have developed a school-based intervention to improve flexibility, goal-setting and planning in students with ASD, the Unstuck and On Target intervention. Our team developed this new intervention using a participatory process informed by a theoretical framework that emphasizes real world interventions to remediate executive function deficits in ASD through cognitive training, self-regulatory scripts, and faded practice and cueing in home and classroom settings.

Objectives:  

1) Develop an innovative classroom intervention targeting flexibility in children with ASD

2) Evaluate the feasibility of the intervention by examining preliminary data collected during the development trial

Methods:  

The intervention was developed through the participatory method, including a feasibility trial with 13 children in a special education program for children with ASD.  The intervention was delivered by school staff during the children’s social skills groups in about 35 sessions of 40 minutes each.  The intervention teaches what flexibility is, why it is important to be flexible, how to be flexible, goal-setting/prioritizing and coping skills.  As part of this feasibility trial, we gathered extensive feedback from the teachers, students and parents and revised and streamlined the intervention significantly.  We also conducted a preliminary test of the intervention as it was being developed, comparing the change in multi-modal assessments from pre- to post-intervention.  Data was collected via parent and teacher questionnaires (BRIEF, Flexibility Questionnaire), and a new group measure assessing EF, especially flexibility, in a socially-demanding context (observing groups of four children working together to complete tasks).

Results:  

The resulting intervention is feasible and acceptable to participants (90% enrollment rate; no children dropped out or refused, though 2 left the school for other reasons, and 1 child did not complete the intervention before the end of the school year because of a late start).

The children who have completed the intervention demonstrated significant change in flexibility as rated by teacher (t=2.23; df=10) and by parent (t=2.54; df=9).  The children also showed some change in EF as rated by parent: BRIEF Shift (t=23.81; df=9) and Plan/Organize (t=2.03; df=9; p=.07 trend).  On a blind coded group-based assessment of EF skills (N=8), the children were significantly more collaborative with each other after the intervention (t=-3.00), but also made fewer positive comments to each other (t=6.28).  On this same measure, the children trended towards used fewer coping strategies after the intervention (t=1.96; p=.09 trend) and receiving an overall rating of flexibility reflecting an improvement in flexibility (t=-1.99; p=.09 trend).

Conclusions:  

These results suggest that an EF intervention implemented in schools is feasible and acceptable by school staff and students with ASD.  Further, parents and teachers see promise in such a program, and a blind rater also detects differences.  The next step in this intervention development process is currently underway to evaluate the effectiveness of this curriculum in mainstream schools with a comparison group.  We are also developing a companion parent manual and training program to be used in conjunction with the school-based intervention.