Psychoeducational Interventions for Adults With Level 3 Autism Spectrum Disorder: A 50-Year Systematic Review

Mental health in autistic adults: A rapid review of prevalence of psychiatric disorders and umbrella review of the effectiveness of interventions within a neurodiversity informed perspective

BACKGROUND

Autistic adults have high risk of mental ill-health and some available interventions have been associated with increased psychiatric diagnoses. Understanding prevalence of psychiatric diagnoses is important to inform the development of individualised treatment and support for autistic adults which have been identified as a research priority by the autistic community. Interventions require to be evaluated both in terms of effectiveness and regarding their acceptability to the autistic community.

OBJECTIVE

This rapid review identified the prevalence of psychiatric disorders in autistic adults, then systematic reviews of interventions aimed at supporting autistic adults were examined. A rapid review of prevalence studies was completed concurrently with an umbrella review of interventions. Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines were followed, including protocol registration (PROSPERO#CRD42021283570).

DATA SOURCES

MEDLINE, CINAHL, PsycINFO, and Cochrane Database of Systematic Reviews.

STUDY ELIGIBILITY CRITERIA

English language; published 2011-2022; primary studies describing prevalence of psychiatric conditions in autistic adults; or systematic reviews evaluating interventions for autistic adults.

APPRAISAL AND SYNTHESIS

Bias was assessed using the Prevalence Critical Appraisal Instrument and AMSTAR2. Prevalence was grouped according to psychiatric diagnosis. Interventions were grouped into pharmacological, employment, psychological or mixed therapies. Strength of evidence for interventions was assessed using GRADE (Grading of Recommendations, Assessment, Development and Evaluation). Autistic researchers within the team supported interpretation.

RESULTS

Twenty prevalence studies were identified. Many included small sample sizes or failed to compare their sample group with the general population reducing validity. Prevalence of psychiatric diagnoses was variable with prevalence of any psychiatric diagnosis ranging from 15.4% to 79%. Heterogeneity was associated with age, diagnosis method, sampling methods, and country. Thirty-two systematic reviews of interventions were identified. Four reviews were high quality, four were moderate, five were low and nineteen critically low, indicating bias. Following synthesis, no intervention was rated as 'evidence based.' Acceptability of interventions to autistic adults and priorities of autistic adults were often not considered.

CONCLUSIONS

There is some understanding of the scope of mental ill-health in autism, but interventions are not tailored to the needs of autistic adults, not evidence based, and may focus on promoting neurotypical behaviours rather than the priorities of autistic people.

An evaluation of intervention research for transition-age autistic youth

LAY ABSTRACT

In this study, we assess the quality of intervention research that focuses on autistic youth who are 14-22 years old. We found 193 different studies on this topic, and carefully reviewed them. Most of these studies tested strategies that were behavioral. This means that they used procedures like prompting and rewards to change participants' behavior. We found that the majority of studies had problems that make it hard to determine whether or not the intervention worked. The problems related to how researchers designed their studies, and how they measured the study outcomes. We also found that researchers rarely tried to find out if the strategies they studied had unintended negative effects for participants. Because of these issues, we make suggestions for how researchers might design better studies that will let people know how well the strategies worked.

Self-management interventions for reducing challenging behaviors among school-age students: A systematic review

BACKGROUND

Challenging classroom behaviors can interfere with student social and academic functioning and may be harmful to everyone in schools. Self-management interventions within schools can address these concerns by helping students develop necessary social, emotional, and behavioral skills. Thus, the current systematic review synthesized and analyzed school-based self-management interventions used to address challenging classroom behaviors.

OBJECTIVES

The current study aimed to inform practice and policy by (a) evaluating the effectiveness of self-management interventions at improving classroom behaviors and academic outcomes and (b) examining the state of research for self-management interventions based on existing literature.

SEARCH METHODS

Comprehensive search procedures included electronically searching online databases (e.g., EBSCO Academic Search Premier, MEDLINE, ERIC, PsycINFO), hand-searching 19 relevant journals (e.g., School Mental Health, Journal of School Psychology), reference-list searching 21 relevant reviews, and searching gray literature (e.g., contacting authors, searching online dissertation/theses databases and national government clearinghouses/websites). Searches were completed through December of 2020.

SELECTION CRITERIA

Included studies employed either a multiple group-design (i.e., experimental or quasi-experimental) or single-case experimental research design and met the following criteria: (a) utilized a self-management intervention, (b) conducted in a school setting, (c) included school-aged students, and (d) assessed classroom behaviors.

DATA COLLECTION AND ANALYSIS

Standard data collection procedures expected by the Campbell Collaboration were used in the current study. Analyses for single-case design studies incorporated three-level hierarchical models to synthesize main effects, and meta-regression for moderation. Further, robust variance estimation was applied to both single-case design and group-design studies to account for dependency issues.

MAIN RESULTS

Our final single-case design sample included 75 studies, 236 participants, and 456 effects (i.e., 351 behavioral outcomes and 105 academic outcomes). Our final group-design sample included 4 studies, 422 participants, and 11 total behavioral effects. Most studies occurred in the United States, in urban communities, in public schools, and in elementary settings. Single-case design results indicated that self-management interventions significantly and positively impacted both student classroom behaviors (LRRi = 0.69, 95% confidence interval [CI] [0.59, 0.78]) and academic outcomes (LRRi = 0.58, 95% CI [0.41, 0.76]). Single-case results were found to be moderated by student race and special education status, whereas intervention effects were more pronounced for African American students (F = 5.56, p = 0.02) and students receiving special education services (F = 6.87, p = 0.01). Single-case results were not found to be moderated by intervention characteristics (i.e., intervention duration, fidelity assessment, fidelity method, or training). Despite positive findings for single-case design studies, risk of bias assessment indicated methodological shortcomings that should be considered when interpreting findings. A significant main effect of self-management interventions for improving classroom behaviors was also revealed for group-design studies (g = 0.63, 95% CI [0.08, 1.17]). However, these results should be interpreted with caution given the small number of included group-design studies.

IMPLICATIONS FOR POLICY PRACTICE AND RESEARCH

The current study, conducted using comprehensive search/screening procedures and advanced meta-analytic techniques, adds to the large amount of evidence indicating that self-management interventions can be successfully used to address student behaviors and academic outcomes. In particular, the use specific self-management elements (i.e., self-determining a performance goal, self-observing and recording progress, reflecting on a target behavior, and administering primary reinforcers) should be considered within current interventions as well as in the development of future interventions. Future research should aim to assess the implementation and effects of self-management at the group or classroom-level within randomized controlled trials.

From Research to Practice: Toward the Examination of Combined Interventions for Autism Spectrum Disorders

The use of biological (i.e., medications) in conjunction with applied behavior analysis is relatively common among people with ASD, yet research examining its benefit is scarce. This paper provides a brief overview of the existing literature on the combined interventions, including promising developments, and examines the existing barriers that hinder research in this area, including the heavy reliance on RCTs. Recommendations for possible solutions, including the creation of health homes, are provided in order to move toward a more integrated approach.

Pervasive Undisclosed Conflicts of Interest in Applied Behavior Analysis Autism Literature

Many autistic people (including researchers and non-researchers) are becoming increasingly involved in, and increasingly critical of, autism intervention research. They have expressed concerns regarding applied behavior analysis (ABA) interventions on a number of grounds, one of which is the prevalence of conflicts of interests (COIs) among autism intervention researchers. These concerns are now also being addressed by non-autistic researchers. COIs can introduce bias into the research process, and allow researchers to demonstrate positive effects for interventions that are not actually effective. Despite these concerns, there are no studies to date that examine the prevalence of COIs in behavioral journals. Because ABA services are routinely provided to autistic people in the United States as a means to address difficulties experienced by autistic people, this is an important area of investigation. We tallied author COIs in articles published over a 1-year period that tested, commented on, or reviewed ABA autism intervention strategies, extracted from eight journals devoted to publishing behavioral research. We coded included studies for COIs related to researcher employment as an ABA clinical provider or a training consultant to ABA clinical providers. We found that 84% of studies had at least one author with this type of COI, but they were only disclosed as COIs in 2% of studies. Additionally, 87% of studies with statements claiming the authors did not have COIs, were authored by researchers found to have clinical/training consultancy COIs. Pervasive, undisclosed COIs likely lead to researcher bias, and could at least partially account for persistent poor quality research in this area. The high prevalence of COIs among this research corroborates the concerns expressed by many autistic people. The autism community - including autistic people, autism researchers, and other stakeholders - should be aware of the prevalence of undisclosed COIs in this literature and take this into account when using, providing, or recommending ABA services.

Enhancing the social networks of adults with ASD: a low level community intervention

Purpose

This paper aims to design and evaluate an innovative community-based service for adults with autism in a rural region of Northern Ireland. The goal was to reduce their social isolation through gaining social skills and building social networks.

Design/methodology/approach

Over three years, 54 persons with a median age of 21 years received 12 months of one-to-one, personalised support and opportunities to participate in peer groups and social activities which are detailed in the paper. Quantitative and qualitative information about the impact of the service was obtained from its users, their relatives, as well as service personnel.

Findings

Service users rated themselves to have changed in more ways than did their relatives and staff although there was a consensus that the changes were most marked in terms of spending more time out of the house, engaging in more community activities, being more independent and increased confidence. The main benefits they perceived from participation in the project were socialising, new experiences and learning new things.

Research limitations/implications

As with many service projects, a longer term follow-up of service users was not possible due to resource constraints.

Practical implications

The service could be replicated with suitable staff although current constraints on social care budgets have limited its expansion to more users and extension to other areas in Northern Ireland.

Social implications

Reducing the social isolation of adult persons with autism spectrum disorders needs to be personalised to the person, their living circumstances and the community in which they live. Family carers also stand to gain from community support services.

Originality/value

This low level, low cost service was implemented in a predominantly rural area with a majority of users from socially deprived areas.

Treatment of Aggression in Adults with Autism Spectrum Disorder: A Review

BACKGROUND

Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by markedly impaired social interaction, impaired communication, and restricted/repetitive patterns of behavior, interests, and activities. In addition to challenges caused by core symptoms, maladaptive behaviors such as aggression can be associated with ASD and can further disrupt functioning and quality of life. For adults with ASD, these behaviors can portend adverse outcomes (e.g., harm to others or to the individual with ASD, hindering of employment opportunities, criminal justice system involvement). This article reviews the scientific literature to provide an update on evidence-based interventions for aggression in adults with ASD.

METHOD

A search of the electronic databases CINAHL, EMBASE, and PsycINFO was conducted using relevant search terms. After reviewing titles, abstracts, full-length articles, and reference lists, 70 articles were identified and reviewed.

RESULTS

The strongest (controlled trial) evidence suggests beneficial effects of risperidone, propranolol, fluvoxamine, vigorous aerobic exercise, and dextromethorphan/quinidine for treating aggression in adults with ASD, with lower levels of evidence supporting behavioral interventions, multisensory environments, yokukansan, and other treatments.

CONCLUSIONS

Additional randomized, controlled trials using consistent methodology that adequately addresses sources of bias are needed to determine which treatments are reliably effective in addressing aggression in adults with ASD. In the meantime, considering efficacy and adverse effect/long-term risk profiles, a practical approach could start with functional assessment-informed behavioral interventions along with encouragement of regular, vigorous aerobic exercise to target aggression in adults with ASD, with pharmacotherapy employed if these interventions are unavailable or inadequate based on symptom acuity.