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.     

Evaluating the effects of discriminability on behavioral persistence during and following time‐based reinforcement

With four children with autism we evaluated a refinement to time‐based reinforcement designed to reduce response persistence when we simultaneously introduced time‐based reinforcement and extinction. We further evaluated whether this refinement mitigated response recurrence when all reinforcer deliveries ceased during an extinction‐only disruptor phase. The refinement involved increasing the saliency of the contingency change from contingent reinforcement (during baseline) to time‐based reinforcement by delivering different colored reinforcers during time‐based reinforcement. Behavioral momentum theory predicts that increasing the discriminability of the change from variable‐interval to variable‐time reinforcement should lead to faster reductions in responding. We present data on four participants, three of whom displayed response patterns consistent with the predictions of behavioral momentum theory during time‐based reinforcement. However, the participants showed more varied patterns of recurrent behavior during extinction. We discuss these results within a translational research framework focusing on strategies used to mitigate treatment relapse for severe destructive behavior, as time‐based reinforcement is one of the most commonly prescribed interventions for destructive behavior displayed by individuals with intellectual and developmental disabilities.     

Disciplinary sanctioning of students with intellectual disabilities: revisiting the status liability hypothesis

We examined the impact of disability status on disciplinary sanctioning of a student committing a minor versus severe behavioral infraction. We used the status liability hypothesis as a framework. This hypothesis suggests that individuals with a higher personal status receive sanctioning differentially based on the severity of offense. Specifically, individuals of high status are predicted to be sanctioned less severely than persons with lower status given a minor offense. The hypothesis also predicts that individuals accorded high status will receive more punitive sanctioning when the act of deviance from social norms is perceived as severe. Pre-service teachers were randomly assigned to judge the behavior of a student with or without an intellectual disability committing a behavioral offense. A student with an intellectual disability was seen as influenced by dispositional factors, regardless of the offense, while a student without a disability who committed a minor offense was seen as influenced by situational factors. The behavior of a student with an intellectual disability was judged as less severe, and the student was 50% less likely to incur an in-school suspension. When a student with an intellectual disability was sanctioned, the length of suspension was equal to that of a student without a disability.

A randomized controlled trial of an internet-based treatment for chronic headache

Chronic headache is a significant public health problem in Western nations. Although controlled trials demonstrate the efficacy and cost-effectiveness of face-to-face behavioral therapy, most headache sufferers have limited access to these treatments. Delivery of behavioral interventions using Internet technology has the potential to reach a larger number of headache sufferers and reduce the burden of disease. This randomized controlled study evaluated an Internet-delivered behavioral regimen composed of progressive relaxation, limited biofeedback with autogenic training, and stress management versus a symptom monitoring waitlist control. Treatment led to a significantly greater decrease in headache activity than symptom monitoring alone. Thirty-nine percent of treated individuals showed clinically significant improvement on self-report measures of headache symptoms at post-treatment. At two-month follow-up, 47% of participants maintained improvement. Treatment had a significant impact on general headache symptoms and headache-related disability. There was a 35% within-group reduction of medication usage among the treated subjects. The Internet program was more time-efficient than traditional clinical treatment. Treatment and follow-up dropout rates, 38.1% and 64.8%, respectively, were typical of behavioral self-help studies. This approach to self-management of headache is promising; however, several methodological and ethical challenges need to be addressed.     

Association between restricted and repetitive behaviors and nonverbal IQ in children with autism spectrum disorders.

The present study explored the relationship between nonverbal IQ and restricted and repetitive behaviors (RRBs) in 830 children with Autism Spectrum Disorders. The role of chronological age as a moderator of this relationship was also investigated. For many behaviors, there was a significant interaction between nonverbal IQ and chronological age, such that nonverbal IQ (NVIQ) was more strongly related to the prevalence of RRBs in older children. For the majority of such behaviors (e.g. repetitive use of objects, hand and finger mannerisms), RRB prevalence was negatively associated with NVIQ. However, the prevalence of certain behaviors (e.g. circumscribed interests) showed positive relationships with NVIQ, which provides some support for the idea of different classes of RRBs. For the severity of different RRBs, there were several significant effects for age and NVIQ, but few interactions.     

Virtual conversation partner for adults with autism

Autistic Spectrum Disorder (ASD) is notable for severely impaired reciprocal social interaction skills relative to language and intellectual abilities, presenting a major barrier to social integration and vocational success. Evidence-based interventions to address these needs are lacking. We report on the development of a small, prototype conversation simulation to teach conversational skills to adolescents and adults with ASD and average to superior intellectual abilities. We also report on a test of the feasibility and acceptability of the simulation approach with a sample of the target population. The simulation engages the user in a virtual conversation with an on-screen partner whose reactions provide naturalistic feedback geared to the appropriateness of the learner's response choices. The prototype simulation, which provides for up to 12 potentially unique multi-turn conversations, was used over a period of 2 weeks by 16 adolescents and adults who then rated statements about the system on a linear scale of 1 (disagreement) to 5 (high agreement). The participants highly endorsed the majority of positive statements about the quality and credibility of the interaction and the virtual conversation partner. In contrast, agreement with positive statements about instructional features external to the conversation was moderate. Unexpectedly, most participants strongly agreed that using the simulation had been helpful to them. Further development and testing in the context of a controlled study with randomized assignment to control and experimental groups are needed to determine whether this approach is effective in improving real-world pragmatic language behavior of high-functioning adults with ASD.     

Implementing a differential reinforcement of low rates schedule to alter vocal stereotypy and task engagement in two adolescents with autism spectrum disorder

Vocal stereotypy (VS) is often observed in individuals with autism spectrum disorder (ASD) which at high rates can interfere with socialization or functioning in structured settings. There are multiple effective interventions available; yet, many procedures target the complete omission of the behavior or are only assessed at short intervals, making it unclear how they will generalize in applied settings. One intervention yet to be assessed as an individual intervention for automatically reinforced VS is differential reinforcement of low rates of behavior (DRL). In the present study, a functional analysis determined that the VS of two female adolescents with ASD was maintained by automatic reinforcement. A DRL procedure was implemented which incorporated: (a) a specified interval for reinforcement; (b) the behavioral expectations; (c) the permissible instances of VS within the interval; (d) learner feedback; and (e) the reset/non-reset aspect of the schedule. As the targeted behavior decreased across sessions, the DRL interval was systematically increased in order to thin out the schedule of reinforcement. The intervention reduced VS and increased untargeted task engagement for both participants. Applied and theoretical implications of the study as well as social validity, limitations, and future research are discussed.     

Restricted interests and teacher presentation of items

Restricted and repetitive behavior (RRB) is more pervasive, prevalent, frequent, and severe in individuals with autism spectrum disorders (ASDs) than in their typical peers. One subtype of RRB is restricted interests in items or activities, which is evident in the manner in which individuals engage with items (e.g., repetitious wheel spinning), the types of items or activities they select (e.g., preoccupation with a phone book), or the range of items or activities they select (i.e., narrow range of items). We sought to describe the relation between restricted interests and teacher presentation of items. Overall, we observed 5 teachers interacting with 2 pairs of students diagnosed with an ASD. Each pair included 1 student with restricted interests. During these observations, teachers were free to present any items from an array of 4 stimuli selected by experimenters. We recorded student responses to teacher presentation of items and analyzed the data to determine the relation between teacher presentation of items and the consequences for presentation provided by the students. Teacher presentation of items corresponded with differential responses provided by students with ASD, and those with restricted preferences experienced a narrower array of items.     

孤独症谱系障碍患者对种族情境中本异族面孔的眼动模式

本研究采用眼动技术探讨孤独症谱系障碍(ASD)患者对背景中的本异族面孔的加工特点。研究采用2（组别）×2（面孔种族）×3（背景）的混合设计,让16名16-25岁的ASD患者和17名生理年龄匹配的正常人完成变化检测任务,并记录他们的眼动。结果显示：与正常人相比,ASD患者的面孔辨别力更低;他们的眼动呈现更多的面孔-背景眼跳和更多的上下半脸眼跳;两组被试的上下半脸眼跳的次数受到面孔种族以及面孔和背景是否一致的影响。结论：在行为指标上,正常人出现了本族效应,而ASD患者没有出现本族效应;在眼动上,ASD患者呈现与正常人相似的面孔注视时间,但比正常人呈现更多的眼跳。面孔的背景影响了面孔辨别力以及上下半脸眼跳轨迹。     

Teaching social perception skills to adolescents with autism and intellectual disabilities using video‐based group instruction

Few interventions focus on teaching social skills to adolescents with autism spectrum disorder (ASD) and intellectual disabilities (ID) that are consistently used during interactions with peers ( Carter et al., 2014). The present study evaluated the effects of video‐based group instruction (VGI) on the acquisition of social perception skills of five adolescents with ASD or ID in a public school setting. Social perception involves observing affective behaviors of others, discriminating relevant environmental stimuli, and differentially reinforcing the affective behavior of another person. Typically developing peers supported VGI implementation as social partners for participants. A multiple probe design across behaviors demonstrated the effectiveness of VGI for teaching social perception skills. Four of five participants acquired and maintained the targeted social perception skills, and we observed some transfer to a nontreatment setting. Results of this study suggest VGI may support the acquisition of social perception among adolescents with ASD or ID.     

Behavior Problems at 5 Years of Age and Maternal Mental Health in Autism and Intellectual Disability

We examined child behavior problems and maternal mental health in a British population-representative sample of 5 year-old children with an autism spectrum disorder (ASD), controlling for the presence of an intellectual disability (ID). Behavior problems were significantly higher in children with ASD with/out ID compared to typically developing children, but compared to children with ID only hyperactivity was significantly higher in children with ASD/ID. After controlling for ID and maternal mental health, the presence of ASD significantly increased the odds for hyperactivity, conduct problems and emotional symptoms. Negative maternal outcomes (serious mental illness, psychological distress, and physical health limitations) were not consistently elevated in ASD. The findings highlight the early age at which behavior problems emerge in ASD, and suggest that at this age , there may not be a clear disadvantage for maternal mental health associated with having a child with ASD in the family, over and above that conferred by child behavior problems.     

A Comparison of Within- and Across-Activity Choices for Reducing Challenging Behavior in Children with Autism Spectrum Disorders

Offering children with autism spectrum disorders (ASD) choices between activities (e.g., working on math or English), instructional materials (e.g., using a pen or pencil), or environmental arrangements (e.g., where to sit) has been shown to reduce challenging behavior maintained by escape from task demands. However, the majority of research investigating choice-based interventions for challenging behavior has examined across-activity choices (i.e., choosing between activities) and relatively few studies have examined within-activity choice (i.e., choosing between instructional materials or environmental arrangements). The purpose of this study is to replicate and extend previous research on choice-based challenging behavior interventions by comparing the effects of across-activity choices and within-activity choices on the escape-maintained challenging behavior of 4 children with ASD. An alternating treatment design was embedded within the “B” phase of an ABAB design in which the “A” phase represented a no-choice baseline condition. Both choice formats resulted in less challenging behavior than the baseline condition for all participants. Across-activity choice resulted in less challenging behavior than within-activity choice for 3 participants. Implications for research and practice are discussed.     

Beery VMI performance in autism spectrum disorder

Few studies have examined the visuomotor integration (VMI) abilities of individuals with autism spectrum disorder (ASD). An all-male sample consisting of 56 ASD participants (ages 3–23 years) and 36 typically developing (TD) participants (ages 4–26 years) completed the Beery-Buktenica Developmental Test of Visual-Motor Integration (Beery VMI) as part of a larger neuropsychological battery. Participants were also administered standardized measures of intellectual functioning and the Social Responsiveness Scale (SRS), which assesses autism and autism-like traits. The ASD group performed significantly lower on the Beery VMI and on all IQ measures compared to the TD group. VMI performance was significantly correlated with full scale IQ (FSIQ), performance IQ (PIQ), and verbal IQ (VIQ) in the TD group only. However, when FSIQ was taken into account, no significant Beery VMI differences between groups were observed. Only one TD participant scored 1.5 standard deviations (SDs) below the Beery VMI normative sample mean, in comparison to 21% of the ASD sample. As expected, the ASD group was rated as having significantly higher levels of social impairment on the SRS compared to the TD group across all major domains. However, level of functioning on the SRS was not associated with Berry VMI performance. These findings demonstrate that a substantial number of individuals with ASD experience difficulties compared to TD in performing VMI-related tasks, and that VMI is likely affected by general cognitive ability. The fact that lowered Beery VMI performance occurred only within a subset of individuals with ASD and did not correlate with SRS would indicate that visuomotor deficits are not a core feature of ASD, even though they present at a higher rate of impairment than observed in TD participants.     

A Meta-Analysis of Working Memory Impairments in Autism Spectrum Disorders

Autism spectrum disorders (ASD) are characterized by executive dysfunction, and working memory (WM) comprises one core component of executive function. Many studies have investigated WM impairments in individuals with ASD, however, a conclusive agreement has not been reached. The present study provided a meta-analytic review of WM impairments in individuals with ASD and evaluated potential moderating variables of this problem. Twenty-eight studies were included in this study, and the participants comprised 819 individuals with ASD and 875 healthy controls. A significant WM impairment (Cohen’s d?=??0.61) was identified in the individuals with ASD, however, this impairment was not associated with age. Results of moderation analyses showed that (a) spatial WM was more severely impaired than verbal WM and (b) the component of cognitive processing (maintenance vs. maintenance plus manipulation) did not affect the severity of WM impairments. These findings suggest that WM is impaired in individuals with ASD and may have implications for interventions related to WM impairments in these individuals.     

Interaction of reinforcement schedules, a behavioral prosthesis, and work-related behavior in adults with mental retardation

The effects of variable-interval (VI) and fixed-ratio (FR) schedules of reinforcement for work-related behavior and an organizer for the work materials (behavioral prosthesis) were evaluated with 3 adults with severe or profound mental retardation. The participants had been recommended for study because of high rates of off-task and aberrant behavior in their daily vocational training programs. For 2 participants, VI and FR schedules resulted in the same outcome: more aberrant behavior than on-task and off-task behavior combined. The FR schedule nearly eliminated emission of aberrant and off-task behavior by the 3rd participant. Combining the behavioral prosthesis with FR reinforcement (FR+O) increased the proportion of time spent in on-task behavior by all participants under certain FR schedule parameters. Second-by-second analyses of the observation records revealed that FR schedules reduced off-task and aberrant behavior during work sequences (i.e., ratio runs), and FR+O led to a further reduction of these behaviors during postreinforcement pauses. Overall, the results show how organizer and schedule parameters can be adjusted to produce an optimized balance between productivity and reinforcement while undesirable behavior is minimized.     

An extension of commonly used toilet-training procedures to children with autism spectrum disorder

The current study evaluated a toilet-training treatment package described by Greer et al. (2016) with children diagnosed with autism spectrum disorder (ASD). Most of the current research on toilet-training interventions for children with ASD are replications and modifications of Azrin and Foxx (1971) or (more recently) LeBlanc et al. (2005). However, these procedures are composed of components that are not included in studies with typically developing (TD) children. For example, Greer et al. evaluated the effectiveness of three typical components within a toilet-training package, mostly with TD participants: a 30-min sit schedule, placing participants in underwear, and differential reinforcement. The primary purpose of the current study was to replicate and extend the treatment package described by Greer et al. to children with ASD. A secondary purpose was to evaluate modifications necessary for individualized toilet training when the commonly used components were ineffective. The results of Greer et al. were replicated for 11 participants with ASD in the current study, suggesting that intensive toileting interventions (e.g., interventions requiring overcorrection, reprimands, and dense sit schedules) may only be necessary for a subset of individuals with ASD.     

Teaching social play skills to adults and children with autism as an approach to building rapport

Adults with autism spectrum disorder (ASD) and no intellectual disabilities were taught to increase the social play skills of children with ASD as part of a vocational training program. Participants included 3 adults, aged 21 to 27 years, and 6 children with ASD. Probes conducted throughout the study evaluated whether play skills training affected a measure of rapport between the adult and child. Results demonstrated the effectiveness of behavioral skills training for teaching the adult participants the appropriate play skills. In addition, the children's social engagement increased. Finally, rapport probes showed that play skills training increased levels of proximity, our measure of rapport, between the adults and children.     

Comparing response blocking and response interruption/redirection on levels of motor stereotypy: Effects of data analysis procedures

Autism spectrum disorder (ASD) is marked by deficits in social communication and the presence of restrictive and/or repetitive behaviors or interests. Motor stereotypy is a form of repetitive behavior that is common in ASD. Response Interruption and Redirection (RIRD) and response blocking (RB) are two interventions found to be efficacious in reducing motor stereotypy. However, the current literature presents with inconsistencies regarding the relative efficacy of these two procedures. Thus, we sought to replicate and extend previous literature by evaluating the efficacy of both interventions on reducing motor stereotypy among 3 individuals with ASD. We also sought to evaluate how variations in data analysis affected the interpretation of treatment outcomes. Results indicated that both interventions were equally efficacious at reducing stereotypy when analyzing data exclusive of treatment‐implementation time. However, when analyzing total session time data, RB produced greater and more sustained reductions in stereotypy across all participants. These results emphasize the importance of data analysis decision‐making in evaluating intervention outcomes.