Effectiveness of a Novel Outdoor Behavioral Health Treatment Intervention for ASD: A Single Subject Design

Background:   Recent estimates have indicated that autism spectrum disorder (ASD) affects approximately 1 in 68 children (Baio, 2014); epidemiological data suggests that this figure represents a marked increase in prevalence rates observed over the past decades (Duchan, & Patel, 2012).  Social behavior deficits, a core diagnostic criterion of ASD, negatively impact youth’s functioning in many ways.  Struggles to develop relationships, rigid behavioral routines, affective dysregulation, and hyperactivity reduce social learning opportunities and compound functional difficulties (Bauminger, Shulman, & Agam, 2003). Thus, there has been a renewed interest in the development of comprehensive, psychosocial treatment for youth with ASD.  The current feasibility study explored the effectiveness of a multi-modal, intensive, residential treatment program, delivered in a naturalistic wilderness setting, for adolescents with ASD.  Quasi-experimental data has supported the use of similar programming for adolescents with psychiatric disorders (e.g., Russell, 2002; Lewis, 2013); however, this is the first study of its kind to examine the effectiveness of such programming for youth with ASD. 

Objectives:   The purpose of the current research was to conduct a feasibility study, investigating the therapeutic response of a single subject to a novel treatment intervention for youth with ASD.  It was hypothesized that the participant would evidence improvements in overall psychological functioning and social skills, as well as associated behavioral excesses and deficits during 8-weeks of intensive residential treatment.

Methods:   A 15-year-old male with diagnoses of ASD and ADHD was enrolled in a residential treatment program, delivered in the naturalistic setting of the NC national forest.  Data were collected pre- and post-treatment, as well as weekly throughout the duration of the program; data included standardized, normative instruments completed by therapist and youth (i.e., Treatment Outcome Package [TOP; Kraus et al., 2005] and Social Skills Improvement System [SSIS; Gresham and Elliot, 2008]), behavioral documentation conducted by trained staff, and partial-interval behavioral recording, conducted weekly by staff trained in behavior analysis. 

Results: Results supported primary hypotheses. Clinically meaningful reductions in externalizing behaviors, ADHD symptoms, internalizing problems, and overall ASD-related behavioral symptoms were observed, from baseline to discharge.  Comparisons of pre- to post-treatment therapist ratings indicate that the participant demonstrated significant, clinically meaningful improvements in adaptive social skills (13^th percentile, baseline; 55^th percentile discharge) and significant reductions in problem behaviors (99^th percentile, baseline; 77^th percentile, discharge). Specifically, improvements were noted in communication, responsibility, empathy, social engagement, and self-control.  Further, behavioral observation data indicated greater frequency of positive social behaviors (e.g., contributing to group discussion, helping peers, starting/joining a conversation) and decreased frequency of negative social behaviors (e.g., verbal impulsivity) over 8-weeks of treatment. 

Conclusions:  The results indicate that in the current single-subject feasibility study, the participant evidenced significant improvements in functioning broadly— including psychological symptomatology, social skills, prosocial behavior, peer relatedness— from baseline to post-treatment.  These results offer encouraging preliminary evidence for the effectiveness of a novel, multi-modal, intensive treatment for adolescents with ASD and comorbid behavioral and mental health disorders.