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A Comparative Effectiveness Trial of a School- and Home-Based Executive Functioning Intervention Versus a Social Skills Intervention; Part One: Contextual Effects

Friday, 3 May 2013: 09:00-13:00
Banquet Hall (Kursaal Centre)
L. G. Anthony1, L. Cannon2, J. F. Strang1, M. Wills1, C. Luong-Tran3, J. L. Sokoloff1, E. Bal1, M. A. Werner2, K. C. Alexander2, K. K. Powell1, A. C. Sharber3, M. Rosenthal4, G. L. Wallace5 and L. Kenworthy6, (1)Center for Autism Spectrum Disorders, Children's National Medical Center, Rockville, MD, (2)Ivymount School, Rockville, MD, (3)Children's National Medical Center, Rockville, MD, (4)Child Mind Institute, New York, NY, (5)National Institute of Mental Health, Bethesda, MD, (6)Children’s Research Institute, Children's National Medical Center, Washington, DC

Difficulties with executive functioning (EF) are a commonly observed associated feature of ASD. We have developed a school-based group intervention to improve flexibility, goal-setting and planning in students with ASD, the Unstuck and On Target intervention (UOT; Cannon et al, 2011). UOT emphasizes real world interventions to remediate EF deficits through cognitive training, self-regulatory scripts, practice and cueing with visual supports in classroom and home settings. UOT teaches what flexibility is and why it is important, how to be flexible, goal-setting, planning and coping skills. 


To evaluate the effectiveness of this new intervention, we compared children’s social and EF skills before and after participation in either social skills training (SS) or UOT. The comparison intervention used selections from Baker’s (2003) Social Skills curriculum. To aid generalization, both groups were contextually-based (school), with classroom teacher and parent training to extend the skills in multiple contexts. 


The interventions were embedded in 14 mainstream elementary schools (12 public, 2 parochial) that serve students with ASD through inclusion. All children had IQ>70 (mean=108), met criteria for ASD on ADOS or ADI and clinician impression, and were in 3rd-5th grade. Children were randomly assigned to UOT (N=47) or to SS (N=20). The groups were well-matched on age, sex, type of school, parent education level, IQ, percent on psychotropic medication and race/ethnicity (35% minority/10% Hispanic/Latino). Both interventions were delivered by school staff to small groups of students in at least 27 sessions of 30-40 minutes each. The two interventions were matched for “dose” of intervention and amount of parent, teacher and interventionist training.

Contextual data were collected via classroom observations as well as parent and teacher questionnaires (Social Responsiveness Scale, Behavior Rating Inventory of Executive Functioning Shift and Plan/Organization Subscales). Observer’s fidelity ratings of the groups indicated high fidelity overall. There were some problems with cross-condition contamination, however, with some in the SS group having exposure to the UOT intervention. We compared change from pre- to post-intervention via repeated measures ANOVA and post-hoc paired samples t-tests. For each significant interaction, Cohen’s d is also presented as an estimate of effect size, as the group Ns were unequal.


Children in both groups improved with intervention in many areas, but children who participated in UOT groups improved more in flexibility as rated by both their classroom teacher (time*group F=8.82,p<.01; Cohen’s d=.62), and parents (time*group F=5.23,p<.05; d=.58), and parents noted that flexibility problems caused less interference (time*group F=4.02,p<.05; d=.51). UOT students also made greater improvements in the classroom as rated by an independent observer: they were better able to compromise (x2=6.96, p<.01), follow rules (x2=11.41, p<.001), transition from one activity to another (x2=15.75, p<.001), resist getting stuck (x2=6.38, p<.05), and they expressed less negativity (x2=3.74, p=.05). There was no significant difference in the improvement between the SS and UOT groups in social reciprocity (x2=1.76, ns) or classroom participation (x2=2.47, ns).


These data point to the real-world effectiveness of a contextually-based EF intervention over and above social skills training for children with ASD and without ID.

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