Behavioral Intervention for Social Challenges in Children and Adolescents: A Systematic Review and Meta-analysis

Importance

Social deficits are a common and disabling feature of many pediatric disorders; however, whether behavioral interventions are associated with benefits for children and adolescents with social deficits is poorly understood.

Objective

To assess whether behavioral interventions in children and adolescents with neurodevelopmental or mental health disorders are associated with improvements in social function and social cognition, and whether patient, intervention, and methodological characteristics moderate the association.

Data Sources

For this systematic review and meta-analysis, the PsycINFO, MEDLINE, and PubMed electronic databases were searched in December 2020 for randomized clinical trials published from database inception to December 1, 2020, including terms related to neurodevelopmental or mental health disorders, social behavior, randomized clinical trials, and children and adolescents. Data were analyzed in January 2021.

Study Selection

Randomized clinical trials that enrolled participants aged 4 to 17 years with social deficits and examined the efficacy of a clinician-administered behavioral intervention targeting social functioning or social cognition were included. A total of 9314 records were identified, 78 full texts were assessed for eligibility, and 33 articles were included in the study; 31 of these reported social function outcomes and 12 reported social cognition outcomes.

Data Extraction and Synthesis

Articles were reviewed using the Cochrane Risk of Bias Assessment for randomized clinical trials. Data were independently extracted and pooled using a weighted random-effects model.

Main Outcomes and Measures

The main outcome was the association of behavioral intervention with social function and social cognition. Hedges g was used to measure the standardized mean difference between intervention and control groups. Standardized effect sizes were calculated for the intervention group vs the comparison group for each trial.

Results

A total of 31 trials including 2131 participants (1711 [80%] male; 420 [20%] female; mean [SD] age, 10.8 [2.2] years) with neurodevelopmental or mental health disorders (autism spectrum disorder [ASD] [n = 23], attention-deficit/hyperactivity disorder [n = 4], other conditions associated with social deficits [n = 4]) were analyzed to examine differences in social function between the intervention and control groups. Significantly greater gains in social function were found among participants who received an intervention than among the control groups (Hedges g, 0.61; 95% CI, 0.40-0.83; P < .001). The type of control condition (wait list vs active control vs treatment as usual) was a significant moderator of effect size (Q2, 7.11; P = .03). Twelve studies including 487 individuals with ASD (48 [10%] female; 439 [90%] male; mean [SD] age, 10.4 [1.7] years) were analyzed to examine differences in social cognition between intervention and control groups. The overall mean weighted effect was significant (Hedges g, 0.67; 95% CI, 0.39-0.96; P < .001), indicating the treatment groups had better performance on social cognitive tasks.

Conclusions and Relevance

In this systematic review and meta-analysis, significantly greater gains in social function and social cognition were reported among children and adolescents who received behavioral interventions for social deficits compared with participants receiving the control conditions. These findings suggest that children and adolescents with social deficits might benefit from social skills training regardless of their specific neurodevelopmental or mental health diagnosis.

Predictors and Moderators of Treatment Efficacy in Children and Adolescents with Autism Spectrum Disorder

OBJECTIVE

The heterogeneous symptom presentation of autism spectrum disorder (ASD) requires clinicians to consider each child's unique constellation of symptoms and tailor intervention accordingly. Treatment moderators, though necessary to guide evidence-based treatment decisions, are significantly under-studied. This brief report aims to expand on previous literature by providing an overview of characteristics which may influence treatment outcome and specifying future directions to build on this preliminary evidence base.

METHOD

A subset of treatment modalities was identified from the National Clearinghouse on Autism Evidence and Practice Review Team's most recent report including discrete trial early intensive behaviorally based treatment, social skills training, and cognitive behavioral interventions. Within these treatment modalities, individual interventions with significant support were specifically discussed. Due to the lack of research on treatment moderators, a discussion of significant predictors of treatment outcome is also included.

RESULTS

Preliminary evidence suggests that overall, treatment intensity, duration, and parent involvement are the most consistently identified predictors (and in some studies, moderators) of treatment outcome; sessions which occur more frequently, continue for longer periods of time, and include parent training or coaching may yield the best outcomes. Other characteristics, including age and IQ, have been widely debated, with differing results found across treatment modalities.

CONCLUSIONS

The sparsity of research demonstrates a clear need for continued research on moderators to guide clinical judgment. Future studies that recruit larger samples targeting specific ASD symptoms at specific ages may be more adequately powered to detect these moderating effects.

Educational and Diagnostic Classification of Autism Spectrum Disorder and Associated Characteristics

Research continues to highlight discrepancies between clinical diagnoses of Autism Spectrum Disorder (ASD) and determination of special education eligibility for services within school settings. However, limited research has been conducted on the impact of those discrepancies for the identification of appropriate services within schools. The aim of the current study is to examine students' characteristics (e.g., language, social emotional) associated with educational eligibility and clinical diagnoses. More specifically, the study examines characteristics differentially associated with ASD diagnoses to inform targeted evidence-based interventions. The study accessed data from a four-year cluster-randomized trial of 283 students with and without reported ASD diagnosis. The results of the study demonstrate that the educational eligibility of Autism did not differentiate between students with and without autism on any of the measured characteristics including language, peer and social competence, academics, and aggressive behaviors. However, the Autism Diagnostic Observation Schedule, second edition (ADOS-2; Lord et al. in Autism diagnostic observation schedule. Western Psychological Services, Torrance, CA, 2012) classification was a more sensitive diagnostic measure for characteristics associated with autism. Implications for research, practitioners, and schools are discussed.

Advances in School-Based Interventions for Students With Autism Spectrum Disorder: Introduction to the Special Issue

As the diagnosis of autism spectrum disorder has increased, so too has research on interventions to address core and associated features of autism. Although many methodologically rigorous studies on interventions have been reported, their relevance to educators is somewaht unclear. For example, only about 32% of evidence-based strategies identifed in these reviews were conducted in k-12 settings. Current literature also is limited in that, although many studies show that interventions can improve the communication and social interaction skills of individuals with autism, most of this work has been conducted with pre-school children; questions remain about the generality of these findings to school-aged children. Further, there are relatively few studies demonstrating effective interventions for restricted and repetitive behavior and much of this work was conducted in clinical settings. There is a need for studies documenting effective interventions that are feasible in school settings. The purpose of this special issue is two-fold. First, to highlight the need for school-based research with students with autism and second to highlight recent work delineating intervention strategies found to be effective in school settings.