A Meta-Analysis of Behavioral Interventions for Adolescents and Adults with Autism Spectrum Disorders

Evaluation of evidence-based treatments is important for adolescents and adults with autism spectrum disorders (ASD) given the increasing number of interventions available and the prevalence of ASD. In this study, we sought to evaluate the effectiveness of behavioral interventions for this population by conducting a meta-analysis of published single-case research studies. A new metric for calculating effect size in single-case research, nonoverlap of all pairs, was utilized. In addition, the certainty of evidence, a system to evaluate research methodology, was applied to the reviewed articles. Forty-three articles were identified in the study. Results suggested that the behavioral interventions in the areas of academic skills, adaptive skills, problem behavior, phobic avoidance, social skills, and vocational skills have medium-to-strong effect sizes. Medium-to-high confidence in findings was noted for 81 % of the studies in the meta-analysis; however, three-fourths of the reviewed studies did not include treatment integrity, which may affect the ability to draw conclusions about the effectiveness of the interventions. Overall, the evidence is promising for the use of behavioral interventions for this population; however, additional research and dissemination are needed to fill the gap between research and practice in order for practitioners to meet the increasing demand as individuals with ASD age.     

Inclusion and Students with Emotional/Behavioral Disorders

Summary

This article presents a point/counterpoint approach to the issue of full inclusion of all students with emotional/behavioral disorders. To set the stage for the discussion that follows, the academic, social, and behavioral characteristics of these students pertinent to classroom performance are reviewed. The pros and cons of these four issues are then presented: (a) appropriateness of the general education curriculum for students with EBD; (b) social acceptance and other social competence issues; (c) mental health interventions and supports in general education settings; and (d) legality of full inclusion. Under the legality issue, case law on full inclusion pertaining to students with EBD is briefly reviewed. The basic premise of the authors who are full inclusion opponents is that a continuum of placements, including full-time placement in general education classrooms, should be preserved so that decisions about appropriate settings can be made on an individual basis. The basic premise of the author who is a full inclusion proponent is that, rather than maintaining two separate systems, we should direct our energies toward correcting the inadequacies of the general education classroom for the benefit of all students, including those with EBD.     

Applying Utilization Management Principles to a Comprehensive Service System for Children with Emotional and Behavioral Disorders and Their Families: A Feasibility Study

The Comprehensive Services Act for At Risk Youth and Families of Virginia (CSA), is a service, funding, and organizational reform initiative designed to improve the provision of child centered and family focused services within a community setting. We conducted this study in order to assess the feasibility of applying utilization management principles to the CSA in order to improve the appropriateness, quality, and cost effectiveness of this service delivery system. Data were gathered through focus groups, surveys, clinical profiling, and analysis of costs, and service utilization. While overall program costs increased since inception of the program, the costs per child served rose less than the rate of inflation. CSA appeared to be serving children with a high degree of emotional and behavioral difficulties. There was considerable variation among localities in placement patterns. A majority of survey and focus group respondents were willing to consider the application of utilization management principles to the CSA as long as decision making remained within localities. We concluded that there is a constructive role for utilization management approaches to improve the appropriateness and quality of services as well as enhancing efficiency in child mental health.     

Adolescents and Young Adults Living with Congenital Heart Disease: Coping,Stress Reactivity,and Emotional Functioning

Living with congenital heart disease (CHD) presents survivors with numerous stressors, which may contribute to emotional problems. This study examined (a) whether coping with CHD-related stress predicts symptoms of depression and anxiety, and (b) whether associations between coping and emotional distress are moderated by involuntary stress reactivity. Adolescents and young adults diagnosed with CHD (M_age?=?26.4) were recruited from pediatric and adult outpatient cardiology clinics. Participants (N?=?168) completed online self-report measures. Hierarchical multiple regression analyses revealed that secondary control coping (e.g., cognitive restructuring, positive thinking) predicted lower depression and anxiety. Primary control coping (e.g., problem-solving) and stress reactivity (e.g., rumination, emotional numbing) interacted to predict depression and anxiety: the higher individuals were in involuntary stress reactivity, the stronger was the association between primary control coping and lower depression and anxiety. These results can inform clinical efforts to prevent or reduce emotional distress among CHD survivors.     

An Exploration of Moral Rebelliousness with Adolescents and Young Adults

The present pair of studies investigated the assessment, correlates, and evaluation of “moral rebels” who follow their own moral convictions despite social pressure to comply. In Study 1, self, peer, and teacher ratings of adolescents' tendencies to be a moral rebel were positively intercorrelated. In Study 2, young adults' tendencies to be a moral rebel were associated with relatively high self-esteem scores and relatively low willingness to engage in minor moral violations and need to belong scores. Both adolescents and young adults reported relatively favorable attitudes toward a morally rebellious peer, especially when they themselves had heightened ratings on this characteristic.     

REBT Used with Children and Adolescents who have Emotional and Behavioral Disorders in Educational Settings: A Review of the Literature

This article discusses the need for a comprehensive intervention strategy for students who experience difficulty managing self-defeating emotions and behaviors in educational settings. The review of the literature identifies related research and describes how the application of Rational Emotive Behavior Therapy (REBT), as a comprehensive educational intervention, has been implemented with children and adolescents who have been identified as having emotional disturbance in various educational settings.     

Inconsistent Self-Report of Delinquency by Adolescents and Young Adults with ADHD

The purpose of the current study was to test the ability of adolescents and young adults with childhood ADHD to reliably self-report delinquency history. Data were examined from the Pittsburgh ADHD Longitudinal Study (PALS), a follow-up study of children diagnosed with ADHD between 1987 and 1996. Self-report of lifetime delinquency history was compared to concurrent parent-report and to self-report 1 year later. Participants included 313 male probands and 209 demographically similar comparison individuals without ADHD. Results indicated that adolescents and young adults with childhood ADHD were more likely than comparison participants to fail to report delinquent acts reported by a parent and to recant acts they endorsed 1 year earlier. This trend was most apparent for acts of mild to moderate severity. After controlling for several covariates, current ADHD symptom severity and parent-report of the participant’s tendency to lie predicted reporting fewer delinquent acts than one’s parent. Current ADHD symptom severity also predicted more recanting of previously endorsed acts. Based on these findings, several recommendations are made for the assessment of delinquency history in adolescents and young adults with childhood ADHD.     

Effectiveness of a Cognitive Behavioral Intervention for Young Adults with Cystic Fibrosis

This study examined the effectiveness of a cognitive behavioral intervention for young adults with cystic fibrosis (CF). Four young adults were referred for the therapy by medical staff because of perceived problems with anxiety, anger, or coping. Treatment impact was assessed on measures of anxiety, anger, perceptions of functional disability, and coping. A multiple baseline design across subjects was used. Overall, the impact of the cognitive behavioral intervention for young adults with CF was mixed. If participants had elevated baseline scores on anxiety, anger, or perceived functional disability, then some improvement was shown. However, only one participant had elevated baseline anxiety and anger scores, while two had higher functional disability scores. For coping, only one participant clearly displayed a greater use of approach relative to avoidance coping by the end of treatment. Results are discussed in terms of treatment implications, assessment, and coping issues.     

Emotional Intelligence as a Basis for Self-Esteem in Young Adults

As self-esteem is likely to build on favorable social experiences, such as those derived from achievement (i.e., GPA) and social competence, emotional intelligence is likely to be pivotal in fostering social experiences conducive to self-esteem. Accordingly, emotional intelligence is likely to underlie social competence and mediate the contribution of achievement to self-esteem. This uncharted role is the focus of this study, which surveyed 405 undergraduates in Hong Kong, China. Results demonstrated the pivotal role of emotional intelligence. Essentially, emotional intelligence appeared to be a strong determinant of self-esteem and explain away the positive effect of social competence on self-esteem. The results imply the value of raising emotional intelligence in order to consolidate the basis for the young adult's self-esteem.     

The Prevention of Rehospitalization of Adolescents and Young Adults

This paper presents a family-oriented therapy approach for the prevention of rehospitalization of adolescents and young adults with diverse diagnoses. The dilemma of the family is presented in terms of the incongruities evident in the organizational hierarchy of these families. The main premise is that if the hierarchy is corrected so that the parents are jointly in charge of the youth and the extended kin cooperate, rehospitalization can be prevented. A therapeutic strategy is presented with the emphasis on overcoming the family's attempt to avoid a hierarchy in which the parents are in charge of the family.     

A Review of Self-Management Interventions Targeting Academic Outcomes for Students with Emotional and Behavioral Disorders

The purpose of this review was to report on the effectiveness and focus of academic self-management interventions for children and adolescents with emotional and behavioral disorders. Twenty-two studies published in 20 articles and involving 78 participants met inclusionary criteria. The overall mean effect size (ES) across those studies was 1.80 (range –0.46 to 3.00), indicating effects were generally large in magnitude and educationally meaningful. Self-monitoring interventions were the predominant type of self-management technique used by researchers. The mean ES for intervention types were self-evaluation (1.13), self-monitoring (1.90), strategy instruction techniques (1.75), self-instruction techniques (2.71), and multiple-component interventions (2.11). Interventions targeted improvement in math calculation skills more than any other area. The mean ES by academic area were math interventions (1.97), writing (1.13), reading (2.28), and social studies (2.66). There was evidence to support a claim of the generalization and maintenance of findings. Implications, limitations, and areas for future research are discussed.     

Effectiveness of the Wraparound Process for Children with Emotional and Behavioral Disorders: A Meta-Analysis

Wraparound is a team-based service planning and coordination process intended to improve outcomes for children and youth with serious emotional and behavioral disorders and support them in their homes, schools, and communities. Given the substantial resources devoted to implementing wraparound, a meta-analysis of outcome studies was conducted to better understand current empirical support for this process. A literature search identified seven studies between 1986 and 2008 that documented the effects of youth receiving wraparound compared to control groups. Mean treatment effects across outcome domains ranged from medium for youth living situation (0.44) to small for mental health outcomes (0.31), overall youth functioning (0.25), school functioning (0.27), and juvenile justice-related outcomes (0.21). The overall mean effect size across studies was 0.33. Interpretation of results was complicated by the lack of consistent documentation of implementation fidelity across studies and conditions, variations in target population and intended outcomes, and methodological concerns. The authors conclude that, though the published wraparound research base is expanding and findings are largely positive, it continues to be in a preliminary state of development. However, there are insufficient data to support calls for wraparound’s acceptance or dismissal based on the strength of existing studies.     

Reducing Time-Out Assignments for Students with Emotional/Behavioral Disorders in a Self-Contained Classroom

This study assessed the impact of a class-wide time-out/re-directing strategy on (a) the frequency of teacher-assigned time-outs and (b) the time students spent in disciplinary sanctions. Twelve students with emotional/behavioral disorders, enrolled in a self-contained elementary classroom were taught an alternative time-out strategy (Active Response Beads-Time Out), while teachers were taught a re-directing strategy, in an attempt to decrease the amount of student's time spent in time-out (TO) and the number of TO assigned by staff. Using a multiple baseline design across academic classroom periods, results showed that Active Response Beads Time-Out (ARB-TO) and teacher re-directions decreased the total time spent in time-out and number of TO assigned across the three class periods. Results maintained at one, two and four week follow-up sessions.     

Recognition of Facial Expressions of Emotion by Children with Emotional and Behavioral Disorders

Interpreting and responding appropriately to facial expressions of emotion are important aspects of social skills. Some children, adolescents, and adults with various psychological and psychiatric disorders recognize facial expressions less proficiently than their peers in the general population. We wished to determine if such deficits existed in a group of 133 children and adolescents with emotional and behavioral disorders (EBD). The subjects were receiving in-patient psychiatric services for at least one of substance-related disorders, adjustment disorders, anxiety disorders, mood disorders or disruptive behavior disorders. After being read stories describing various emotional reactions, all subjects were tested for their ability to recognize the 6 basic facial expressions of emotion depicted in Ekman and Friesen's (1976) normed photographs. Overall, they performed well on this task at levels comparable to those occurring in the general population. Accuracy increased with age, irrespective of gender, ethnicity, or clinical diagnosis. After adjusting for age effects, the subjects diagnosed with either adjustment disorders, mood disorders, or disruptive behavior disorders were significantly more accurate at identifying anger than those without those diagnoses. In addition, subjects with mood disorders identified sadness significantly more accurately than those without this diagnosis, although the effect was greatest with younger children.     

Adaptation of an HIV Medication Adherence Intervention for Adolescents and Young Adults

Rising rates of human immunodeficiency virus (HIV) infection among adolescents and young adults underscore the importance of interventions for this population. While the morbidity and mortality of HIV has greatly decreased over the years, maintaining high rates of adherence is necessary to receive optimal medication effects. Few studies have developed interventions for adolescents and young adults and none have specifically been developed for sexual minority (lesbian, gay, and bisexual; LGB) youth. Guided by an evidence-based adult intervention and adolescent qualitative interviews, we developed a multicomponent, technology-enhanced, customizable adherence intervention for adolescents and young adults for use in a clinical setting. The two cases presented in this paper illustrate the use of the five-session positive strategies to enhance problem solving (Positive STEPS) intervention, based on cognitive-behavioral techniques and motivational interviewing. We present a perinatally infected heterosexual woman and a behaviorally infected gay man to demonstrate the unique challenges faced by these youth and showcase how the intervention can be customized. Future directions include varying the number of intervention sessions based on mode of HIV infection and incorporating booster sessions.