Student Theses and Dissertations

corn

Test Test

in rockefeller

Abstract

Increases continue in the numbers of individuals identified with autism spectrum disorder (ASD) in the United States, now estimated by the Centers for Disease Control and Prevention as one in 68 children. The majority of children with ASD function in the normal intellectual range; thus, we should expect many more children to be educated in general education classrooms, and increasing numbers of adults to enter the work force. Given our limited knowledge about children with ASD in inclusive settings, and adults in general, these are areas of high research priority.

Regardless of age and intellectual ability, social difficulties are characteristic of individuals with ASD including challenges in social engagement, language, and play. It is these social difficulties that often hinder success in the general education classroom or work environment. However, there is also great heterogeneity among individuals with ASD, and it is important to not assume impairment or need for interventions based on diagnostic status alone. For example, in a study of social skills delivered in schools, 20 % of children with ASD were engaged with other children on the playground for more than 80 % of recess, equivalent to time engaged of neurotypical classmates [1]. Moreover, about 20 % of children also report reciprocated friendships, and well-connected social networks in school [2]. For these children with ASD, interventions for engaging with peers or developing friendships would seem unnecessary.

For the majority of individuals, however, social skills interventions are necessary to achieve optimal adaptive and social outcomes. Social skills interventions continue to be the fastest growing class of interventions for individuals with ASD. We noted in 2012 that interventions for social impairment had greatly expanded over previous years, with broader participation by stakeholders and under represented groups, including a focus on parent-mediated interventions, interventions for more cognitively impaired individuals, and interventions with siblings [3]. The themes among these studies included a focus on early developing skills including: 1) joint attention (discrete skills including gestures and gaze to coordinate attention between an object and a social partner to share an awareness of the activity [4]) and joint engagement (a state/episode where a child coordinates his/her attention between a shared activity and a social partner [5]), 2) a focus on knowledge and understanding of social concepts by high functioning children and adolescents with ASD, and 3) peer relationships. In this update, we examined whether these same themes continued, and whether there were new advancements.

The Current Review of Psychosocial interventions 2012-2014

Identification of Core Targets

Psychosocial interventions for individuals with ASD have traditionally been aimed at impairments that are uniquely affected by autism. Identified targets include joint attention, imitation, emotion recognition and understanding, mentalizing (understanding the perspective of others), as well as peer relationships and friendships. In the past couple of years, reviews of the evidence have provided new insights on the extent to which some of these targets are impaired in ASD. For example, imitation has been the focus of several early interventions but a recent review finds limited evidence that imitation skills are uniquely impaired in ASD [6]. Similarly, emotion recognition is an important component as well as an outcome of many social skills interventions. Yet, a recent meta-analysis finds that emotion recognition only marginally accounts for group differences [7]. Rather, it is emotion regulation that appears to be impaired. Emotion regulation may rely more on mentalizing abilities of both self and other, skills beyond simple identification of emotions [811]. For example, difficulties in mentalizing, a potentially core impairment, may result in early disruptions in the coordination of intentions in play, [12] and social misunderstandings resulting in poor peer relationships and limited friendships. Social skills interventions may be most successful when they address core impairments. Ameliorating some of these areas of core difficulty may improve immediate social relationships and prevent further downstream social impairments.

Advancements

Advancements in the current review of social skills interventions include examples of longitudinal follow up, as well as interventions carried out in the context in which changes are desired, a focus lacking in the previous review period. In addition, interventions have been extended to under-studied subgroups of children including children who are minimally verbal, and siblings of children with ASD. Further, during this period of review, we have learned more about the underlying neural networks that mediate social behaviors in typically- and atypically-developing children [13]. Future studies most certainly will include methods for investigating changes in neural network function as a result of behavioral interventions.

Methods

Search Protocol

A systematic search was conducted across ten electronic databases focused on the domains of education, medicine, and social welfare. The search was conducted in March 2014 and restricted to articles published between July 2012 and March 2014. Keyword search terms were selected using the following terms related to autism (autis* or pervasive develop* or Asperger*), social skill outcomes (social skill* or social interaction* or joint attention or social communication or social behavior*), as well as intervention protocols and agents (intervention or social skills training or parent* or peer* or teacher or para*). Gray literature was included through examination of dissertations and theses. Additional searches of online first articles in relevant journals were also conducted (e.g., Journal of Autism and Developmental Disorders).

Inclusion and Exclusion Criteria

To update the prior review, studies published from July of 2012 through March 2014 with the following characteristics were included:

  1. 1)

    Used a quantitative experimental design including group or single subject research designs (SSRDs). Studies using pre-experimental designs (e.g., one group pre/post, case studies) were excluded.

  2. 2)

    Included participants of any age diagnosed with an autism spectrum disorder including autistic disorder/autism, pervasive developmental disorder or Asperger’s syndrome. Studies including a mix of participants with autism and participants with other diagnoses were excluded.

  3. 3)

    Examined an intervention for which a social skill was the primary outcome.

  4. 4)

    For studies using single subject research designs (SSRDs), the manuscript included graphical data for primary outcomes presented such that visual analysis of the data could be conducted.

  5. 5)

    Published in the English language.

Rating Methodological Quality

Published methodological rating scales for randomized control trials (RCTs), quasi-experimental studies, and single subject experimental designs (SSRDs) were used to assess the quality of the studies. First, to assess RCTs, a seven-item scale produced by the American Academy of Cerebral Palsy and Developmental Medicine examining participant inclusion criteria, intervention description, measurement, attrition, and analyses was applied [14]. This scale provides an overall quality rating of ‘weak’ (0-3 points), ‘moderate’ (4-5) or ‘strong’ (6-7). Second, to assess quasi-experimental studies, a scale by Gersten and colleagues [15] was applied. The scale divides 18 items into “essential” and “desirable” quality indicators and provides overall ratings of “acceptable” quality and “high” quality. Unfortunately none of the included studies met criteria for either acceptable or high ratings. These studies will be referred to as “low” quality. Last, to assess single subject experimental designs two scales were applied. The 14-item scale by Logan et al. [16] examines participant description, adherence to intervention condition, measures, design and analysis. Items total to provide overall quality scores of ‘weak” (0-6 points), ‘moderate” (7-10 points), and ‘strong’ (11-14 points). The second scale by Smith and colleagues [17] provides additional items not represented in the prior scale including examination of generalization and maintenance of intervention effects, as well as fidelity of intervention implementation. Twenty percent of the studies were rated by a second independent reviewer. Intra-class correlations (ICCs) were calculated for each scale, indicating high reliability for the single subject scales (Logan et al: α=.932; Smith et al: α=.978). Due to the small number of items, ICCs could not be calculated for the RCTs or quasi-experimental studies, so inter-rater agreement was calculated by dividing agreements by disagreements for each item. Agreement was 85.72 % for the AACPDM scale [14] and 88.89 % for the Gersten et al. [15] scale.

Results

A total of 1954 results were returned based on these terms. Review of titles and abstracts for relevant studies produced 265 manuscripts for full review against the review inclusion criteria. Removal of duplicate studies and examination of full text for inclusion resulted in 56 studies that met all inclusion criteria. The number of studies meeting inclusion criteria is up by 35 % over our review in 2012. Nearly equal numbers reported results using SSRD (n = 29) and group designs (n = 25).

Summary of Methodological Quality

RCTs

The 19 included RCTs were primarily of moderate quality (n = 10) [1827] or weak quality (n = 6) [2833]. Only three studies received a rating of “strong” methodological quality [3436]. Studies receiving “strong” ratings provided rich descriptions of the participants as well as the intervention, utilized blind outcome assessors, demonstrated balanced attrition less than 20 %, controlled for external confounds, and conducted appropriate analyses. For those studies receiving moderate or weak ratings, studies frequently lacked power analyses, blind assessors, as well as valid and reliable measurement tools.

Quasi-experimental

Eight studies using quasi-experimental designs were included in the review [3744]. To receive an overall rating of ‘high’ quality as defined by Gersten et al. [15], a study must demonstrate all but one ‘essential quality indicators’ and at least four of eight ‘desirable quality indicators’. Further, to receive a rating of ‘acceptable’ quality, the study must also meet all but one essential quality indicator in addition to one desirable indicator. No study included in this review met these requirements and, therefore, all are referred to as ‘low’ quality. Studies most frequently provided thorough descriptions of the intervention as well as comparison conditions, used multiple outcome measures and reported effect sizes for those outcomes. However, the studies most frequently lacked thorough description of participants, measures of treatment fidelity, blind assessors, and measures of generalization.