Systematic Review of Intervention
for Adolescents with Autism
Spectrum Disorders
T A McDonald
Integrated Autism Education, Treatment, and
Leadership
University of Wisconsin – Madison
Advisors
Wendy Machalicek
Colleen Moore
Background
➢
➢
Early intervention
➢
Increase in type
➢
Increase in empirical designs
Teen intervention
➢
Adaptations from child interventions
➢
Few tested with adolescents
➢
Many of these not empirical designs
Implications for Adolescence
➢
Negative consequences
“As students with autism spectrum disorder reach
adolescence, the potential impact of inappropriate social
behavior increases” (Graetz, Mastropieri, & Scruggs; 2009).
➢
Developmental Changes
“...adolescence may be a particularly difficult time for higher
functioning youth with ASD due to increasing anxiety and
awareness of social difficulties” (White et al.; 2009).
Implications for Adolescence
➢
Increased expectations with age
“...since writing skills may affect later job performance, it is
essential to identify effective writing interventions for this
population” (Delano, 2007)
“Among employment age adults with disabilities, some of the
lowest employment rates are individuals on the autism
spectrum” (Burke et al., 2010).
Stakeholders
➢
Stakeholders
➢
➢
Parents, teachers, clinicians, therapists, the
adolescent with ASD
Evidence Based Practice
➢
Does it work?
➢
Evidence with children
➢
➢
Carry over to teen?
Locating what works
➢
Individual articles, reviews?
Articles and Reviews
➢
Organized around intervention
➢
Social Stories, Video Modeling, Functional
Communication, Cognitive-Behavioral
➢
➢
Many on ASD but mostly with children
➢
Will the tx generalize to adolescence?
➢
Mixed data of children and adolescents
➢
➢
What about target concerns?
Unable to determine outcomes for adolescents
Many interventions for adolescents
➢
But not with ASD
Current Study
➢
Review adolescent interventions
➢
Empirical designs
➢
➢
➢
ASD
Identify target concerns
Organize interventions around target
concerns
Methods
RedOffice.com
templates
Data Base Search
Data Bases
MedLine
PsychINFO
ERIC
Presentation
Total Articles
Located
1) 429 articles
2) 7 articles
3) 122 articles
4) 2 articles
5) 305 articles
6) 60 articles
Reviews
38
Search Terms
1) Autism, intervention,
teen
2) Pervasive developmental
disorder, intervention,
adolescen*
3) Autism, intervention,
adolescen*
4) Pervasive developmental
disorder, teen
5) Autism, intervention, adult
6) Pervasive developmental
disorder, intervention, adult
ASD Included
Autism, PDD-NOS,
Asperger's Syndrome
Adolescent Age Range
12 - 22
Slide No. 9
Criteria for Inclusion
a) Peer Review Journal
b) At least one participant
with ASD diagnosis
AND adolescent age
range
c.) Empirical design
d.) Outcome data
presented
e.) Adolescent(s)
outcome data
distinguishable
Exclusion
●Dissertations
●Non English
●Animal
●Phamacological &
Electroconvulsive
●Case Studies and
Reports
●Rett's & Fragile X
Certainty of Evidence
Conclusive/Inconclusive (Millar et. al. 2006)
Empirical designs
➢
➢
➢
Interobserver Agreement
Group design with control
➢
➢
Multiple baseline
➢
Reversal
➢
Alternating treatment
➢
➢
Significant improvement for
at least one adolescent
participant with ASD
➢
➢
80% or more agreement
Operationally defined
➢
Visual inspection
➢
20% of experimental
sessions
DV's & IV's
Clear description of
procedures
Results
Characteristics of Participants- Age
•
Age of participants with ASD (In single subject)
5
1
3
12 years
16
13 years
3
14 years
15 years
6
16 years
17 years
18 years
5
11
19 years
20 years
22 years
7
11
Characteristics of ParticipantsDiagnosis
•
(In single subject designs)
1
6
2
Autism
4
1
Asperger's Syndrome
Autism MR
34
6
Autism nonverbal
Autism mild
Autism moderate
Autism severe
PDD-NOS
9
Multiple
12
Gender Ratio
•
(all designs)
18
Males
Females
99
Settings
Classroom
20
School
8
Clinic
7
Work Location
3
Home
3
Residential Home
3
In patient facility
1
Community sites
2
After school program
1
Public pool
2
Unfamiliar room
1
0
5
10
15
20
25
Design Types
3
2
3
Multiple design/probe
4
Reversal design
Combined MBP/R
Control Trial
28
9
Other
Alternating Treatment
Conclusive
➢
Total interventions: 49
➢
Conclusive: 44
➢
Inconclusive: 4
➢
Reliability: 4
One had only 5% of experimental sessions
Need to consult regarding other 3 findings
➢ Multiple participants or targets
➢ One participant or target under 80% agreement
Empirically Investigated Treatments
Major Target Areas of Concern
•
(In all designs) (Articles often contained multiple targets)
Social Skills
28
Behavior Issues
26
Communication Skills
18
Academic Skills
12
Independence/Self Care
11
On task / Task completion
7
Self Injury
6
Leisure / Play Skills
5
Occupational Skills
4
0
5
10
15
20
25
30
Specific Area Examples
Specific Area Examples
Elimination of Drooling
by an Adolescent Student with Autism
Attending Public High School
Appearance and Social Opportunities
(Kay, Harchik, & Luiselli, 2006)
Poor Appearance
Infrequent positive relationships
Ostracization
Reduced number of friendships
Decreased social acceptability
Drooling
Unsanitary
Unattractive
Foul Odor
Interfere with communication
Method
Procedure: duration & steps
(Kay, Harchik, & Luiselli, 2006)
Duration
Baseline sessions began prior to intervention
Classroom: 1 week
Community vocation: 3 days
Cooking class: 1 day
Session length 5 – 7 mins
Concluded 20 correct teaching trials
Steps
Check participant every 5 mins
Dry mouth: praise + edible (DRO)
Saliva present: “wipe your mouth” + “swallow”
Dependent measure: pools of saliva
After 2 consecutive days of fewer than
2 pools/hour, 5 min intervals increased
Results
(Kay, Harchik, & Luiselli, 2006)
Method
Discussion & Limitations
(Kay, Harchik, & Luiselli, 2006)
Conclusive
Drooling behavior eliminated
Limitations
Contribution of components
Intervention setting specific
Data not recorded: lips & chin saliva; mouth wipes
Hygiene issues in cooking class: 15 min checks
maintained
No follow-up
No measure of social change
One-on-one aide; what about self- management?
Method
Participant
(Kay, Harchik, & Luiselli, 2006)
Participant
Male age 17
Autism & mental retardation
Public High School (inclusive setting)
Single words & phrases
Self care with adult assistance
Drooling Behavior
Apparent since childhood
Interfering with school
Education: work surfaces
Social: ostracized
No medical intervention
Phobia
Method
Measurement & Agreement
(Kay, Harchik, & Luiselli, 2006)
Measurement
Number of saliva pools
Work environment surfaces
Diameter of 1 inch or more
Included 95% of all saliva pools
Recorded, then wiped clean
Three locations daily:
Classroom (3hrs)
Community vocational site (2hrs)
Cooking class (1hr)
Number of pools converted to average/hour
Interobserver agreement
Classroom: 96% (93- 100%)
Community vocational site 91% (89- 94%)
Method
Design & Procedure
(Kay, Harchik, & Luiselli, 2006)
Design
Multiple baseline across three locations
Classroom, community vocational site, cooking class
Procedure
Baseline
Aide wiped surface clean after detecting pool
Chin accumulation
Behavior disregarded
Intervention
Preteaching
“Swallow”
“Wipe your mouth”
Verbal instructions, partial physical
guidance, contingent praise to prompt,
Parent-Assisted Social Skills Training to
Improve Friendships in Teens with
Autism Spectrum Disorders
Laugeson, E. A., Frankel, F., Mogil, C., & Dillon, A. R. (2008)
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Background
●
Typical Teens vs. Teens with ASDs
Typical Teens:
●
–Best Friends
th grade*
●By 4
●Aids resilience to life events**
●Aids self esteem***
●Aids social competence & social problem solving****
●Neg correlated with anxiety and depression***
Teens with ASDs
●
–Missing
out on these experiences
–Need extra support and instruction
–(*Fankel,
1996; *McGuire & Weisz, 1982; **Miller & Ingham, 1976; ***Buhrmester,
1990, ****Nelson & Aboud, 1985)
Background
●
Previous Research
Mostly children
●Lower functioning range
●Not formally tested (social competence)
●
●
Exceptions:
Ozonoff and Miller (1995)
●Tse et al (2007)
●
PEERS
Program for the Education and Evaluation of
Relational Skills
●
Adapted from Children's Friendship Training
●
–Evidence
base: ADHD, Fetal Alcohol Spectrum, children with
ASD
(Frankel & Myatt, 2003), (O'Connor et. al., 2006), (Frankel & Myatt, 2007)Small Group
Format
●
Small Group Format
●
Parent instruction
●
Separate concurrent sessions
●
Current Study
●
PEERS intervention content:
Evidence base practices
●
–Didactic
instruction, role playing, modeling, behavioral rehearsal,
coaching with performance feedback, weekly socialization
assignments with consistent homework review
Social etiquette
●
–Social
situations with accompanying rules & steps
–Teens provided instruction in steps
Parents provided information to supervise
●
Participants
●
Teens (n = 33)
13-17 years of age, mean 14.6
●Male (28), Female (5)
●Diagnosis of ASD
●
–HFA, Asperger's,
PDD-NOS
Caucasian (14), Hispanic/Latino (6), African American (3), Asian
(4), Middle Eastern (3), Mixed ethnicity (3)
●Regular Ed (17), Special Ed (8), Pull out (2), Home-school (3),
other Ed (3).
●
Participants were randomly assigned to either
the Treatment or the Delayed Treatment Group
●
Outcome Measures
Test of Adolescent Social Skills Knowledge
TASSK
●
Teen
●22 items, Sentence stems with 2 choices
●Knowledge of teen social skills
●
(TASSK; Laugeson and Frankel, 2006)
●
●
Friendship Qualities Scale
Teen
●23 yes/no questions regarding their best friend(ship)
●
(FQS; Bukowski et al, 1994)
●
TASSK Example Items
The goal of a conversation is to
●Make the other person like you
●Find common interests
●
One of the rules for having a two way conversation is
●To be an interviewer
●Do not be an interviewer
●
If you try to join a conversation and the people ignore you:
●Move on
●Speak louder so they can hear you
●
Friendship Qualities Scale
Yes / No Questions
●Think of Best Friend
●
My friend and I spend all of our free time together
●
Outcome Measures
●
Social Skills Rating Scale
Parent & Teacher
●38 item questionnaire, never, sometimes, very often
●Social skills scale, problem behavior scale
●
(SSRS: Gresham and Elliott, 1990)
●
●
The Quality of Play Questionnaire
Parent & Teen
●12 item questionnaire, frequency of get-togethers & conflict
●Hosted & invited get-togethers
●
(QPQ; Frankel and Mintz, 2008)
●
SSRS Info and Sample Items
Social Skills
●
Cooperation
–Follows your direction
●Assertion
–Invites others to join in activities
●Responsibility
–Requests permission before
leaving the house
●Self Control
–Responds appropriately when
pushed or hit
●
Problem Behaviors
●
Externalizing
–Fights with others
●Internalizing
–Is easily embarrassed
●Hyperactivity
–Acts impulsively
●
** Likert
–Never
–Sometimes
–Always
●
The Quality of Play Questionnaire
●
Frequency of play dates
●
Number of Dates
invited vs. hosted
●
●
Level of conflict
Criticized or teased each other
●
Treatment
Completely manualized & delivered over 12 weeks
Teen Sessions
●
–Reciprocity
in conversation
–Diminishing importance of rejecting peer group
–Reversing negative reputations
–Instruction to promote get-togethers
–Competence with teasing, bullying, conflicts
–Didactic lessons
–Modeling, Role-playing, Performance feedback
–Homework assigned
Treatment
●
Parent Sessions
Review of homework assignments
●Troubleshoot homework problems
●Instruction to help teen overcome homework problems
●
●
Teen and Parents reunited
Teens deliver review for parents
●Homework finalized
●
Quick Recap
●
Random Assignment
Treatment & Delayed Treatment Group
●Demographic information gathered
●Pre-test outcome measures gathered
●
–Teens,
Parents, Teachers
Treatment
●Post-test outcome measures gathered
●
–Teens,
Parents, Teachers
Results
Non-Significant Differences at Baseline Between
Treatment Group and Delayed Treatment Groups
Results
Statistically Significant scores for Pre and Post-test outcome variables for Treatment
and Delayed Treatment
●
Discussion
●
Findings
Knowledge of social etiquette
●Hosted get-togethers
●Quality of friendships
●Parent report of overall social skills
●
●
Limitations
Bias in Parent Report?
●
–Increase
Teacher report
Need Maintenance Data
●Would have liked ADOS or ADI-R
●SSRS not designed for ASD
●
Are the interventions
comprehensive enough?
➢
Recap of Adolescent Implications
➢
Increasing valence of negative behaviors
➢
➢
Developmental changes with adolescence
➢
➢
Large amount on problem behaviors & self-injury
Very little description of change. What about
sexuality? Dating?
Increasing expectations
➢
Very little for
➢
➢
➢
Academics (beyond on task, initiation, completion)
Occupation
More (but still not much!)
Other Concerns & Future Directions
➢
Standard measure of autism across
studies
➢
➢
Report of ethnicity
➢
➢
Ideally: Assessment at time of study
Very little reported
Next step: Hand search of journals
Thank You!
T A Marie McDonald
Advisors
Wendy Machalicek- RPSE
Colleen Moore- Psychology