Preliminary Outcomes of a New Executive Function Treatment for Transition-Age Youth with ASD

Background: Individuals without intellectual disability make up the fastest-growing subgroup of ASD, but as few as 9% reach full functional independence as adults (Farley, McMahon, & Fombonne, 2009). Executive Function (EF) problems are pivotal targets for intervention (Hume, Loftin & Lantz, 2009) because they are common (Hill, 2004), linked to independence (Pugliese et al., 2015), and responsive to treatment (Kenworthy et al., 2015). Flexible Futures (FF) is a new 20 session CBT delivered by trained teachers in the school setting. FF targets self-advocacy, flexible problem solving, planning, time management, and independent goal-setting through scripts and routines that are to be applied to real-world situations. Generalization is maximized with school staff as interventionists, parent training, and home and classroom extension activities.

Objectives: This project tests the effectiveness of FF in improving EF skills, including flexibility and planning, in transition-age youth with ASD compared to students who received the usual care in their school environment.

Methods: The trial compared Flexible Futures (FF) to treatment as usual (TAU) in 8 high schools across the DC Metro Area using a randomized, clustered, parallel clinical trial design. All participants (n=43, 8 female) were aged 14-20 (M=16.4, SD=1.3) had an FSIQ ³80 (M=105.8, SD=14.7) on the WASI-2 and diagnoses were verified using parent report & school classification of ASD supported by the Social Communication Questionnaire (n=35) or ADOS (n=21). Independent samples t-tests and corresponding effect sizes were used to examine between group change on WASI Block Design (problem solving), Tower of London (ToL; planning), parent Behavior Rating Inventory of EF (BRIEF, Plan/Organization & Shift scales), and Adaptive Behavior Assessment System (ABAS; Global and Practical domains).Paired samples t-tests were used to measure change from baseline to endpoint within each group. There were no significant differences between intervention group in age, gender, full-scale IQ, ethnicity, or race (Table 1).

Results: When examining the effect size differences between the groups, students in the FF group improved more than the TAU with small to medium effect sizes on Block Design (d=.5), ToL Total Correct (d=.4)/Total Move (d=.3), ABAS Global (d=.4) and Practical (d=.6), and BRIEF Shift scales (d=.6). However, it is important to note that these differences did not reach statistical significance. Students within the FF group significantly improved from baseline to endpoint on all domains with medium to large effect sizes (.5-1.0), while students within the TAU significantly improved on BRIEF planning (d=.6; Table 1).

Conclusions: This pilot RCT provided evidence that FF implemented at school led to improvement in key EF outcomes. Although between group analyses were not significant, and likely affected by the small sample size, effect size calculations demonstrated that students receiving FF improved on several key outcomes above those receiving TAU, and the pattern of results within the FF group was also in the expected direction. Small to medium improvements in the TAU are not unexpected given that students at these schools also received autism specific supports at school. Next steps include refining the FF curriculum and testing in a larger RCT.