Use of the Weekly Calendar Planning Activity to Assess Executive Function in Adolescents With Autism Spectrum Disorder.

IMPORTANCE: Youths with autism spectrum disorder (ASD) have challenges with executive function (EF). However, there are few measures to objectively assess EF, such as time management and prioritization. The Weekly Calendar Planning Activity (WCPA) is a promising performance-based EF measure that has rarely been used with youths with ASD. OBJECTIVE: To characterize the performance of youths with ASD on the WCPA and the association of WCPA performance with caregiver-rated EF. DESIGN: Observational and summary data obtained during a baseline evaluation for a research study. SETTING: Middle school. PARTICIPANTS: Thirty-nine adolescents with ASD and without an intellectual disability. METHOD: Youth were administered the WCPA; caregivers completed EF ratings. Descriptive statistics characterized WCPA performance. Correlations between WCPA scores and age, IQ, and EF ratings were computed. RESULTS: The majority of youth performed poorly on the WCPA and lacked insight into their poor performance. Many struggled to enter appointments. Appointment accuracy was <30%. The most common errors were location errors. Appointment accuracy and planning time were moderately associated with IQ but not with caregiver-rated EF or age. CONCLUSIONS AND RELEVANCE: Overall, the WCPA was cognitively demanding for youths with ASD without an intellectual disability. These results have implications for using evidence-based strategies to teach adolescents with ASD how to manage their time and plan and prioritize homework assignments, upcoming tests or quizzes, and extracurricular activities. Plain-Language Summary: Youths with autism spectrum disorder have significant problems with executive function, particularly organization, prioritization, time management, and planning. There are few objective, performance-based measures of executive function, especially those that can be used with autistic youths. To our knowledge, this study is the first to use the Weekly Calendar Planning Activity (WCPA) with autistic adolescents who do not have an intellectual disability. The WCPA captured their deficits related to executive function and could be a useful tool for assessment and treatment planning.

The Role of Maternal Anxiety in Treatment Response for Youth with ASD and Co-occurring Anxiety.

Anxiety disorders occur at higher rates in youth with ASD than in neurotypical youth. Although the efficacy of CBT for anxiety in children with ASD is widely supported, factors that influence treatment outcomes are not well understood. This study examined the role of maternal anxiety in treatment outcomes for youth with ASD. Youth with ASD and anxiety (ages 8 to 14), along with their mothers (n = 87), participated in a group CBT intervention. Results indicated that maternal anxiety did not improve over the course of treatment. However, findings suggest that high levels of maternal anxiety at pre-treatment predicted higher levels of youth anxiety post-treatment. Importantly, the relationship between parent anxiety and youth outcomes was moderated by child age. The findings of the present study may provide initial insight into the role that maternal anxiety plays in treatment outcomes for children with ASD and co-occurring anxiety, particularly when considering child age.

Can low-cost motion-tracking systems substitute a Polhemus system when researching social motor coordination in children?

Functionally stable and robust interpersonal motor coordination has been found to play an integral role in the effectiveness of social interactions. However, the motion-tracking equipment required to record and objectively measure the dynamic limb and body movements during social interaction has been very costly, cumbersome, and impractical within a non-clinical or non-laboratory setting. Here we examined whether three low-cost motion-tracking options (Microsoft Kinect skeletal tracking of either one limb or whole body and a video-based pixel change method) can be employed to investigate social motor coordination. Of particular interest was the degree to which these low-cost methods of motion tracking could be used to capture and index the coordination dynamics that occurred between a child and an experimenter for three simple social motor coordination tasks in comparison to a more expensive, laboratory-grade motion-tracking system (i.e., a Polhemus Latus system). Overall, the results demonstrated that these low-cost systems cannot substitute the Polhemus system in some tasks. However, the lower-cost Microsoft Kinect skeletal tracking and video pixel change methods were successfully able to index differences in social motor coordination in tasks that involved larger-scale, naturalistic whole body movements, which can be cumbersome and expensive to record with a Polhemus. However, we found the Kinect to be particularly vulnerable to occlusion and the pixel change method to movements that cross the video frame midline. Therefore, particular care needs to be taken in choosing the motion-tracking system that is best suited for the particular research.

Evidence-Based Interventions in Autism.

Pediatricians have a critically important role in the care of children with autism, including conducting developmental screening to support early diagnosis and intervention, advising families about evidence-based treatments for autism spectrum disorder, and supporting families' emotional health as they care for a child with a developmental disability. The purpose of this article is to provide pediatricians with information about evidence-based autism treatments and how to determine which interventions are appropriate for children across the autism spectrum at different ages and developmental stages.

Improving academic performance through a school-based intervention targeting academic executive functions - a pilot study.

Background: Academic challenges such as losing/not turning in assignments, misplacing materials, and inefficient studying are common in middle-school students with autism spectrum disorder (ASD) without intellectual disability. Deficits in organization, planning, prioritizing, memory/materials management, and studying skills [i.e. academic executive functioning (EF) deficits] contribute to these challenges. Objectives: To assess the feasibility, satisfaction, and initial efficacy of the school-based version of the Achieving Independence and Mastery in School (AIMS) intervention in a proof-of-concept trial with 6 students with ASD. Methods: 6 middle-schoolers with ASD without ID participated in AIMS. Parents and teachers rated academic EFs and functioning. Results: Results suggest high feasibility, youth satisfaction, and improved EF skills and academic behaviors by parent and teacher report. Conclusion: These promising results support further intervention development and suggest that academic EF skills are malleable in students with ASD.

A cluster analysis of daily living skills in school aged children with autism spectrum disorder.

For individuals with autism spectrum disorder (ASD) daily living skills (DLS) fall below chronological age and have been linked to factors such as language. Given the impact of DLS on daily life, it is critical to gain a comprehensive understanding of DLS profiles in children to guide effective treatment. Using a large dataset from the Autism Speaks Autism Treatment Network, the current study sought to (1) examine whether there are subgroups of children with ASD defined by both their Vineland-II DLS scores and language abilities and (2) explore the relationship between internalizing and externalizing symptoms on subgroups using the Child Behavior Checklist. A five-cluster solution was found, but one group was subsequently dropped. Four clusters were examined: Low Language-Low DLS (n = 143); Low-Language High DLS (n = 170); High Language-Low DLS (n = 189); and High Language-High DLS (n = 203). The High Language-Low DLS group had significantly higher internalizing and externalizing symptoms as compared to the other groups. The results highlight the importance of targeting DLS in school-age children with ASD, especially for those with comorbid internalizing and externalizing symptom to ensure that the gap between age and functional DLS does not continue to widen.

Microanalysis of Daily Living Skills in adolescents with Autism Spectrum Disorder without an intellectual disability.

Adolescents with autism spectrum disorder (ASD) without an intellectual disability (ID) have daily living skills (DLS) that fall below their chronological age and affect their ability to achieve successful adult outcomes, but little is known about their specific DLS challenges. Utilizing the Vineland Adaptive Behavior Scales, 3rd Edition (VABS-3) in a sample of 151 adolescents with ASD without an ID, we explored the VABS-3 DLS domain, subdomains, interview topics, and individual items. Results indicated that Community DLS was a relative strength, followed by Domestic DLS, and then Personal DLS. Adolescents with ASD demonstrated significant challenges in many age appropriate DLS subdomain interview topics and individual items, indicating a need for interventions to increase acquisition of DLS to improve adult outcomes.

A Randomized Clinical Trial Targeting Daily Living Skills in Autistic Adolescents Without an Intellectual Disability Before the Transition to Adulthood.

OBJECTIVES: In the United States, more than 75,000 autistic adolescents graduate from high school each year, and many lack the skills to successfully transition to college, work, and independent living. Daily living skills (DLS) in autistic adolescents without an intellectual disability (ID) fall 6 to 8 years behind peers. Better DLS are linked to more positive adult outcomes for autistic individuals. Surviving and Thriving in the Real World (STRW) is the only known evidence-based intervention that targets age-appropriate DLS in autistic adolescents without ID. The study objective was to evaluate STRW's efficacy compared with an active comparator (Program for the Evaluation and Enrichment of Relational Skills [PEERS]). METHOD: Autistic adolescents in their last 2 years of high school were randomized to STRW or PEERS. Outcome measures were the Vineland Adaptive Behavior Scales, Third Edition (VABS-3), DLS domain and subdomains (Personal, Domestic, Community), and DLS Goal Attainment Scaling (DLS-GAS) areas (Morning Routine, Cooking, Laundry, Money). RESULTS: Adolescents were randomly assigned to STRW (n = 34) or PEERS (n = 30). Owing to COVID-19, 28.1% received in-person intervention and 71.9% received telehealth intervention. STRW youth made significant gains on the VABS-3 DLS domain ( p = 0.01) and Domestic subdomain ( p = 0.005) and DLS-GAS Total, Laundry, and Money areas (all p 's < 0.05) compared with PEERS. CONCLUSION: STRW shows promise for acquiring age-appropriate DLS compared with PEERS. Adolescents in STRW progressed toward achieving DLS in the average range and closing the gap between chronological age and DLS. By improving DLS, STRW may facilitate more successful adult outcomes.

Achieving Independence and Mastery in School: A School-Based Executive Function Group Intervention for Autistic Middle Schoolers.

Executive functioning (EF) deficits, such as challenges with planning, organization, and materials management, negatively impact academic performance, particularly for middle-school students with autism spectrum disorder (ASD) without intellectual disability (ID). The aim was to assess the initial efficacy of the school-based version of the Achieving Independence and Mastery in School (AIMS) intervention in a pilot randomized clinical trial. 47 autistic middle-schoolers without ID attending nine different schools were randomized to participate in AIMS or to wait to receive AIMS the following semester (waitlist control = WLC). Youth, caregivers, and teachers rated academic EFs and academic functioning, and youth completed an objective EF measure, at baseline and outcome (post). Effect sizes were computed comparing baseline and post measures within each group. Individuals randomized to AIMS improved from baseline to post on academic EF outcome measures with small to moderate effect sizes, compared to WLC, who made some improvements but with generally smaller effect sizes. Analyses with academic functioning measures showed a similar pattern of results. These promising results suggest that AIMS delivered in the school by school-based personnel to small groups of students with ASD without ID can improve academic EF skills.

Effect of Co-occurring Psychiatric Disorders on Treatment of Children with Autism Spectrum Disorder and Anxiety.

Co-occurring psychiatric diagnoses are very common in individuals with ASD. Little is known about the effect that co-occurring psychiatric conditions may have on treatment response to CBT for children with ASD and anxiety. The present study examined the relationship between co-occurring psychiatric diagnoses and response to CBT for anxiety in ninety youth with ASD. Psychiatric complexity did not appear to differentially impact treatment response. A notable portion of youth with anxiety and externalizing disorders such as ADHD, no longer met criteria for those externalizing diagnoses following intervention. Results indicate that youth with ASD and anxiety present with complex psychiatric profiles and CBT for anxiety may positively affect co-occurring diagnoses. In addition, thorough and nuanced assessment of psychiatric symptoms in youth with ASD is needed to ensure the differentiation between diagnoses of anxiety and other co-occurring psychiatric symptoms.

School Challenges and Services Related to Executive Functioning for Fully Included Middle Schoolers with Autism.

The educational services available for fully included middle schoolers with autism spectrum disorder (ASD) in the general education setting are not well known. Even less is known about how the executive functioning (EF) deficits of such youth are addressed in the classroom. The current study sought to identify the challenges, including EF, that middle schoolers with ASD face and the services that they receive on their Individualized Education Program (IEP), and also explore specific strategies used to build EF skills at school. A convenience data sample was obtained from focus groups with educational personnel (n = 15), and qualitative analyses of IEPs were conducted in middle schoolers with ASD with EF deficits (n = 23). Results confirmed that social communication and EF challenges are common. Multiple services and accommodations were identified, although EF challenges were rarely targeted on IEPs. Factors that may facilitate the success of EF strategies in the classroom are discussed.

Comparison of Adaptive Functioning Measures in Adolescents with Autism Spectrum Disorder Without Intellectual Disability.

There is limited literature examining the adaptive functioning of adolescents with autism spectrum disorder (ASD). This study aimed to (a) document Vineland Adaptive Behavior Scales (VABS-3) and Adaptive Behavior Assessment System (ABAS-3) adaptive behavior profiles of adolescents with ASD; (b) examine the comparability of the two measures; and (c) assess potential discrepancies between IQ and adaptive behaviors. Participants included 14- to 18-year-olds with ASD without intellectual disability. Significant adaptive skills deficits were observed with most scores at least one standard deviation below the mean. Relative weaknesses were observed for social and daily living skills. The absolute magnitude of VABS-3 and ABAS-3 scores differed. There were significant discrepancies between IQ and adaptive functioning. These findings have implications for clinicians and researchers.

A Pilot Randomized Controlled Trial of a Daily Living Skills Intervention for Adolescents with Autism.

Adolescents with autism spectrum disorder (ASD) without an intellectual disability have daily living skills (DLS) impairments. An initial feasibility pilot of Surviving and Thriving in the Real World (STRW), a group intervention that targets DLS, demonstrated significant improvements. A pilot RCT of STRW was conducted to extend these findings. Twelve adolescents with ASD were randomized to the treatment or waitlist groups. The treatment group had significant DLS improvements on the Vineland Adaptive Behavior Scales, 3rd Edition and the DLS goal attainment scale. Four adolescents from the waitlist crossed over and completed STRW. Entire sample analyses with 10 participants demonstrated large DLS gains. Results provide further evidence of the efficacy of STRW for closing the gap between DLS and chronological age.

Iterative Development of a Daily Living Skills Intervention for Adolescents with Autism Without an Intellectual Disability.

Daily living skill deficits commonly co-occur in individuals with autism spectrum disorder (ASD). These deficits in adolescence are associated with poor outcomes, in both employment and independent living skills as adults. Currently, there are no interventions that directly target daily living skill acquisition in adolescents with ASD without an intellectual disability to facilitate a successful transition to adulthood. In this paper, we discuss the development, refinement, and initial efficacy studies of Surviving and Thriving in the Real World (STRW), a 14-session group treatment for both adolescents with ASD and their parent/caregiver that promotes attainment of critical daily living skills. We summarize initial feasibility studies that have been instrumental in the iterative development of STRW. The structure, core treatment elements, and content of STRW are described in detail. Lastly, we discuss the transition of the in-person STRW intervention to STRW-telehealth, which allows for adolescents with ASD to work on daily living skills in their own home with support from a therapist.

Achieving Independence and Mastery in School: An Open Trial in the Outpatient Setting.

Youth with autism spectrum disorders (ASD) without intellectual disability frequently experience academic problems, in part due to executive functioning (EF) deficits. There are currently no evidence-based interventions targeting academic EF skills (e.g., organization, prioritization, etc.) for middle school youth with ASD. The need is critical given increasing demands on these skills during the transition from elementary to middle school. An intervention targeting academic EF skills, Achieving Independence and Mastery in School (AIMS), was recently developed. This paper reports on an open trial of the AIMS-Outpatient intervention with 21 middle schoolers with ASD. Results suggest high feasibility/satisfaction, and improved EF, particularly in the domains of organization and materials management. These promising results support further intervention development work and suggest that academic EF skills are malleable in youth with ASD.

Academic Needs in Middle School: Perspectives of Parents and Youth with Autism.

Youth with autism spectrum disorders (ASD) without intellectual disability frequently experience academic problems, in part due to executive functioning (EF) deficits. There are currently no evidence-based interventions targeting academic EF skills for middle school youth with ASD. An intervention is currently in development. This paper reports on a "proof of concept" uncontrolled trial of the intervention, and focus groups with parents and youth to inform tailoring and adaptation of the intervention. Results of the trial suggest high feasibility/satisfaction, but a need for further adaptation to promote uptake by youth with ASD. Results from the focus groups confirmed the need for an intervention targeting academic EF skills, successful strategies in use, and the need to promote increased youth independence.

Social Communication and Structural Language of Girls With High-Functioning Autism Spectrum Disorder.

Purpose The purpose of this study was to characterize social communication and structural language of school-age girls with high-functioning autism spectrum disorder (HF-ASD) compared to a matched group of girls who are typically developing (TD). Method Participants were 37 girls between 7;5 and 15;2 (years;months)-18 HF-ASD and 19 TD. Children completed the Test of Pragmatic Language-Second Edition (TOPL-2) and Clinical Evaluation of Language Fundamentals-Fifth Edition. Parents completed the Children's Communication Checklist-2 United States Edition (CCC-2) and Receptive and Expressive Communication subdomains of the Vineland Adaptive Behavior Scales-Second Edition. Results In the area of social communication, girls with HF-ASD earned significantly lower scores and were more often classified as having an impairment on the TOPL-2 and the CCC-2. However, 28% and 33% earned average scores on the TOPL-2 and the CCC-2, respectively. In the area of structural language, no significant differences were found between groups on Clinical Evaluation of Language Fundamentals-Fifth Edition indexes. In contrast, girls with HF-ASD earned significantly lower scores and were more often classified as having an impairment on the Vineland Adaptive Behavior Scales-Second Edition. Sixty-one percent and 83% scored below average on the Receptive and Expressive Communication subdomains, respectively. Conclusions It has been argued that girls with HF-ASD, when compared to boys with HF-ASD, may have advantages for social communication and structural language that mask their impairments. However, when compared to girls who are TD, girls with HF-ASD demonstrated impaired social communication and structural language. Clinicians should include and carefully examine multiple sources of information when assessing girls with HF-ASD.

Clinical correlates of sluggish cognitive tempo in adolescents with autism spectrum disorder.

Adolescents with autism spectrum disorder frequently experience social communication difficulties, executive functioning deficits, and anxiety and depressive symptoms, which are similar to the symptoms and correlates of sluggish cognitive tempo. Although sluggish cognitive tempo is related to, but distinct from, the inattentive and hyperactive-impulsive symptoms of attention-deficit/hyperactivity disorder that commonly co-occur with autism spectrum disorder, few studies have examined sluggish cognitive tempo in autism spectrum disorder. We examined whether sluggish cognitive tempo and attention-deficit/hyperactivity disorder were differentially associated with autism symptomatology, daily life executive functioning, and internalizing and externalizing symptoms in 51 adolescents (ages 13-18 years) with autism spectrum disorder without intellectual disability. Regression analyses controlling for age and IQ showed that sluggish cognitive tempo symptoms, but not attention-deficit/hyperactivity disorder symptoms, were associated with increased autism symptomatology and internalizing symptoms. Attention-deficit/hyperactivity disorder symptoms, but not sluggish cognitive tempo symptoms, were associated with increased externalizing behaviors and behavior regulation deficits. Both sluggish cognitive tempo and attention-deficit/hyperactivity disorder were independently associated with increased metacognitive deficits. This study provides preliminary evidence that sluggish cognitive tempo symptoms are elevated in autism spectrum disorder and associated with key clinical correlates, with implications for the assessment and treatment in adolescents with autism spectrum disorder.

Preliminary efficacy of a daily living skills intervention for adolescents with high-functioning autism spectrum disorder.

Daily living skills deficits are strongly associated with poor adult outcomes for individuals with high-functioning autism spectrum disorder, and yet, there are no group interventions targeting daily living skills. Seven adolescents with autism spectrum disorder and their parents participated in a feasibility pilot of a 12-week manualized group treatment targeting specific daily living skills (i.e. morning routine, cooking, laundry, and money management). Outcomes included the Vineland Adaptive Behavior Scales, Second Edition (Vineland-II) age equivalence scores and four goal attainment scaling scores. Adolescents demonstrated significant improvement on two Vineland-II subdomains and on all goal attainment scaling scores at post-treatment and 6-month follow-up. The intervention has promise for improving critical daily living skills' deficits that affect independent living and employment. Limitations and implications for future studies are discussed.

Evidence of embodied social competence during conversation in high functioning children with autism spectrum disorder.

Even high functioning children with Autism Spectrum Disorder (ASD) exhibit impairments that affect their ability to carry out and maintain effective social interactions in multiple contexts. One aspect of subtle nonverbal communication that might play a role in this impairment is the whole-body motor coordination that naturally arises between people during conversation. The current study aimed to measure the time-dependent, coordinated whole-body movements between children with ASD and a clinician during a conversational exchange using tools of nonlinear dynamics. Given the influence that subtle interpersonal coordination has on social interaction feelings, we expected there to be important associations between the dynamic motor movement measures introduced in the current study and the measures used traditionally to categorize ASD impairment (ADOS-2, joint attention and theory of mind). The study found that children with ASD coordinated their bodily movements with a clinician, that these movements were complex and that the complexity of the children's movements matched that of the clinician's movements. Importantly, the degree of this bodily coordination was related to higher social cognitive ability. This suggests children with ASD are embodying some degree of social competence during conversations. This study demonstrates the importance of further investigating the subtle but important bodily movement coordination that occurs during social interaction in children with ASD.