Improving the Executive Functioning of Adolescents with ASD through School-Based Intervention: The on Target for Life Curriculum

Oral Presentation
Thursday, May 10, 2018: 10:30 AM
Willem Burger Zaal (de Doelen ICC Rotterdam)
J. F. Strang1, L. Anthony2, C. E. Pugliese3, L. Cannon4, M. A. Werner5, S. Seese3, M. F. Skapek6 and L. Kenworthy3, (1)Center for Autism Spectrum Disorders, Children's National Health System, Washington, DC, (2)University of Colorado, Denver, Aurora, CO, (3)Children's National Health System, Washington, DC, (4)Ivymount School, Rockville, MD, (5)Program Development and Training, Ivymount School, Rockville, MD, (6)Psychological Sciences, University of Connecticut, Storrs, CT
Background: Executive function (EF) challenges increase as youth with ASD enter the teen years, and executive dysfunction is related to long-term adaptive outcomes. The On Target for Life (OTL) school-based curriculum is the upward age-extension of the empirically supported Unstuck and On Target curriculum.

Objectives: OTL is a Cognitive Behavioral Therapy intervention employing a neurodiversity framework, drawing on specific learning strengths in autism, such as the particular ability to get “stuck” on key details, in this case self-regulatory EF scripts (e.g., “stuck on a detail”, “big picture”, “flexible thinking”, etc.) OTL was developed through a community-based participatory process, engaging key stakeholders (autistic youth and their parents, teachers and administrators) in the objectives and design of the curriculum.

Methods: A randomized comparative trial (n=33) was conducted in 9 public middle schools (five schools receiving OTL and four schools receiving the school version of PEERS, an empirically supported social skills intervention). Intervention “dosages” were matched across the two treatments, and curricula were administered by school staff. The fidelity of intervention delivery was measured twice through in vivo observations. Masked (i.e., blinded to treatment condition) pre-post assessments were conducted with youth and their families, including classroom observations in the students’ English classes conducted at the beginning and end of the school year and a masked in vivo behavioral assessment measure of flexibility and planning skills in a one-on-one interactive context (Executive Function Challenge Task; EFCT). Youth and parents also completed a standardized pre- and post-battery: Behavioral Rating Inventory of Executive Function II (BRIEF II; parent and self report); Social Responsiveness Scale II (SRS II); and the Tower of London DX (TOL DX), a measure of a high-order planning skills. A newly developed autism-specific anxiety measure (Scahill et al., 2016) was completed by the parents.

Results: Pre-post paired sample t-tests indicated significant improvement for both intervention groups in social functioning as measured by masked classroom observations of social functioning, standardized parent report (SRS II), and autism-specific anxiety symptoms (all p’s < 0.05). Both groups also showed increased convergence between standardized parent and youth self-report of everyday behavioral functioning (BRIEF II; p=.035), considered a marker of increased self-awareness in the youth. The OTL group, but not the comparison intervention group, made significant gains (p’s < 0.05) on classroom observations of executive functioning, the EFCT, as well as on the average of key indices of the TOL DX.

Conclusions: Both treatments were associated with greater convergence between parent and youth report of a young person’s functioning, suggesting improved insight/self-awareness in the youth. Similarly, both interventions were associated with improvements in the youth’s social functioning and anxiety; OTL-related gains in social skills are in accordance with previous evidence linking EF intervention and improved socialization. OTL was uniquely associated with improvements in flexibility and planning skills measured with treatment blind tools across multiple modalities, including observed classroom behaviors, suggesting that CBT-informed EF treatment with repeated exposure to/practice with self-regulatory scripts may have a generalized effect on EF-related behaviors across real-world settings.