Longitudinal Outcomes of Unstuck and on Target Executive Function Intervention Trial in Children with ASD

Background:

Executive dysfunction is common in autism spectrum disorders (ASD) and is linked to academic, social and adaptive problems. Unaware of any contextually based executive function (EF) intervention for children with ASD without ID, we developed a school/home-based intervention targeting flexibility, goal-setting and planning called Unstuck and On Target (UOT). UOT remediates EF deficits in ASD through a cognitive/behavioral program that emphasizes self-regulatory scripts, guided/faded practice, and visual/verbal cueing in school and at home. We found that UOT improved flexibility, planning, and efficiency of problem solving even when compared to a social skills intervention of equal intensity in a randomized control trial (RCT).  Whether improvements related to UOT are sustained beyond the duration of the intervention is unknown. 

Objectives:   To evaluate whether gains in flexibility, planning and problem solving attributed to UOT are maintained 1 year after the completion of the intervention. 

Methods:

Thirty-one (28 male, 18 White, mean age 11.4+0.96 years) of the 47 children with ASD who received UOT in an RCT were evaluated for follow-up 12-13 months after the completion of the intervention. All children had IQ>70 (mean=111+17), and met criteria for ASD on ADOS or ADI and clinician impression upon entrance into the RCT. The UOT intervention was delivered in school by school staff in small groups; classroom teachers and parents were trained to reinforce lessons. Results of the RCT indicated significantly greater pre-post improvement in the UOT participants than the comparison equal-intensity social skills intervention participants on the following measures: Wechsler Abbreviated Scale of Intelligence Block Design (BD) subtest; a play interview task posing flexibility and planning challenges called The Executive Function Challenge Task (EFCT; The EFCT yields Flexibility, Planning, and Social Appropriateness scores); parent ratings on the Behavior Rating Inventory of Executive Function (BRIEF) and the Flexibility Scale Interference score, which measures parent observed interference from inflexibility in daily activities.  These measures were re-administered 12-13 months after the completion of the RCT and longitudinal post-intervention scores were compared to pre-intervention scores with paired sample t tests.

Results:  

Benefit from UOT was maintained at longitudinal follow-up when compared to pre-intervention performance on the following measures: EFCT Planning, Flexibility and Social Appropriateness scores (t’s>4.02,p’s<.001); and parent BRIEF Shift (t=3.16,p=0.004) and Flexibility Questionnaire Interference (t=3.16,p=0.004) scores. Gains reported from pre- to post-UOT intervention on BD and parent BRIEF Plan/Organization were not sustained at a statistically significant level. 

Conclusions:  

One year following completion of the UOT intervention, gains in flexibility as observed in the laboratory and reported by parents were sustained.   Gains in the area of planning and organization were also sustained as measured in the laboratory but not by parent report, and the improvement in efficiency of problem solving as assessed by the Wechsler Block Design subtest was not sustained. Replication of these data is required as the longitudinal follow-up data were collected under un-blinded conditions. These results are encouraging regarding the maintenance of flexibility skills learned in UOT and its on-going benefit in terms of reduced interference at home from inflexible behaviors.