Psychiatric Outcomes in an Addressing Disparities Comparative Effectiveness Trial for Elementary Students with ASD or ADHD

Background: Executive functions have been linked to real world behaviors, such as learning, adaptive behavior, and adult outcome. Cognitive flexibility, specifically, has been robustly linked to anxiety and oppositional defiant behavior in typically developing children and children with autism spectrum disorders. Clinical trials are natural vehicles for testing whether executive function mediates psychiatric outcomes, as well as to see whether effects vary based on diagnosis or intervention type offered.

Objectives: This study presents secondary analyses of change in psychiatric symptoms from a larger comparative effectiveness trial of two executive function interventions that targeted cognitive flexibility in a sample of youth diagnosed with ASD and ADHD who also had primary impairments in inflexibility.

Methods: The trial compared Unstuck and On Target (UOT) to Contingency Behavior Management (CBM) in 21 Title I (low-income) elementary schools in 3 school districts for students with ASD (n=43) or ADHD (n=79). All participants had an FSIQ above 70 (range: 70-138) on the WASI-2, and diagnoses were verified using gold standard diagnostic measures (the Autism Diagnostic Observation Schedule for ASD and the MINI-Kid for ADHD). Both interventions targeted executive functioning skills in the classroom. Participants were divided into four groups based on diagnosis (ASD vs. ADHD) and intervention received (CBM vs. UOT). Paired sample t-tests were used to measure change from baseline to endpoint via parent report on the CBCL within each group (Anxiety Problems, Oppositional Defiant, Rule Breaking, Attention Problems, ADHD Problems). Within diagnostic groups, there were no significant differences in age, gender, full-scale IQ, race, income, or percentage of parents attending at least one training across diagnostic groups (see Table 1).

Results: CBM treatment reduced Attention Problems in students with ASD (t=2.91, p=.008) and Attention Problems (t=2.06, p=.047), Anxiety Problems (t=2.43, p=.020), and Oppositional Defiant Problems (t=-2.08, p=.045) in students with ADHD. UOT reduced Rule Breaking (t=2.53, p=.021) behavior in ASD and Attention (t=2.81, p=.007) and ADHD Problems (t=3.29, p=.002) in students with ADHD.

Conclusions: Overall, both treatments were effective in reducing psychiatric symptoms, though the pattern of improvement differed in regards to diagnosis and intervention type. CBM is an evidenced based practice well-known for improving attention in ADHD, and this was replicated in the ASD group in this study. Benefits also extended past improving attention to decreasing anxiety and oppositional behaviors in the ADHD group. UOT, which has been shown to be effective in improving EF in youth with ASD, had a broader impact on externalizing rule breaking in ASD. In the ADHD group, UOT improved attention-related problems.