Review
A systematic review of behavioral intervention research on adaptive skill building in high-functioning young adults with autism spectrum disorder

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Abstract

This review involved a systematic search and analysis of behavioral intervention studies aimed at improving adaptive skills in high-functioning young adults with autism spectrum disorders. Through electronic databases and hand searching, 20 studies were identified meeting pre-determined inclusion criteria. Studies were summarized and analysed in terms of (a) participants, (b) adaptive skill(s) targeted for intervention, (c) intervention procedures, and (d) intervention outcomes. Certainty of evidence was assessed through critical appraisal of each study's design and other methodological characteristics. Social interaction skills were the most common intervention targets (n = 8), followed by practical academic skills (n = 6), vocational skills (n = 5), and domestic skills (n = 1). Improvements in adaptive skills were reported by 19 studies. Interventions consisting of low or high tech assisted procedures (e.g., video modeling, visual cues, self-recording and self-reinforcement, self-prompting), reinforcement contingencies, and corrective feedback using prompts were found to be most promising. Five studies were identified as having the methodological rigor to provide conclusive results. Insufficient control for alternative explanations for behavior outcomes and reliance on pre- or quasi-experimental designs hindered the certainty of evidence for the remaining studies. Implications for clinical practice and future research are discussed.

Highlights

► We reviewed behavioral interventions on adaptive skills in adults with ASD (no ID). ► Twenty studies were identified and procedures, outcomes, and designs were analysed. ► Improvements were found in 19 studies. ► Interventions consisting of tech assisted procedures were found to be most promising. ► Five studies were rated as having methodological rigor to provide conclusive results.

Introduction

Independent functioning is an important issue for people with high-functioning autism spectrum disorders (ASD). Adults with ASD have difficulty developing reciprocal friendships, obtaining paid employment, engaging in recreational activities, and living independently (e.g., Billstedt et al., 2005, Eaves and Ho, 2008, Howlin et al., 2004, Orsmond et al., 2004). Consequently, many adults with ASD rely on support from parents or service agencies (e.g., Billstedt et al., 2005, Eaves and Ho, 2008, Farley et al., 2009, Howlin et al., 2004). Farley et al. (2009) analysed variables related to adult outcomes in 41 high-functioning adults with ASD and found that among a range of variables such as IQ and level of support, adaptive behavior measures (Vineland Adaptive Behavior Scales; VABS – Sparrow, Balla, & Cicchetti, 1984) were the variables most closely related to overall social and independent living functioning. Across adaptive behavior measures, the daily living skills domain (VABS) was found to be most closely related to better outcomes.

In studies on adaptive functioning in persons with high-functioning ASD a discrepancy has been found between level of adaptive skills and IQ. Specifically, the adaptive skills are lower than would be predicted by cognitive ability (Bolte and Poustka, 2002, Carter et al., 1998). Furthermore, there is evidence that this discrepancy between cognitive ability and adaptive function may increase with age (Bolte and Poustka, 2002, Carter et al., 1998, Kanne et al., 2011, Klin et al., 2007). Given the importance of adaptive skills and the tendency for deficits to grow more pronounced over the lifespan, it is not surprising that a great deal of intervention research has focused on teaching adaptive skills to people with ASD.

Most studies on adaptive skill building have focused on children and adolescents with ASD, with and without intellectual disability (ID), and behavioral techniques, such as task analyses, cue cards, modeling, self-management, prompt fading, and reinforcement have proven to be highly effective (e.g., Koegel et al., 2009, Paterson and Arco, 2007, Pierce and Schreibman, 1994, Taylor et al., 2004). The effectiveness of cognitive skills training (e.g., Theory of Mind – TOM or Executive Functioning) on improving daily life behavior has also been studied. However, results suggest that these procedures may be effective in improving conceptual skills, but they do not automatically (that is without explicit training) lead to improvement in daily life use of TOM or executive skills, such as responding to indirect hints, social tuning, orientation in time/place/activity, planning ahead, or following verbally given lists of instructions (Begeer et al., 2011, Fisher and Happé, 2005).

Several literature reviews have analysed behavioral interventions in adaptive skill building in children, indicating early intensive behavioral intervention (EIBI) is the most promising intervention approach for children (Granpeesheh et al., 2009, Makrygianni and Reed, 2010, Peters-Scheffer et al., 2011). Literature reviews on behavioral interventions in heterogeneous samples of children and youth have also been conducted. For example, Rao, Beidel, and Murray (2008) and Cappadocia and Weiss (2011) provided preliminary evidence for the efficacy of social skills training groups (SSTGs) in improving social skills in children and youth with Asperger syndrome and high-functioning ASD. Support has also been found for the efficacy of self-management (e.g., Lee, Simpson, & Shogren, 2007) and video (self)-modeling (e.g., Bellini & Akullian, 2007) in children and adolescents with ASD. Machalicek et al. (2008) reviewed adaptive skills interventions implemented only in schools (participants with ASD ranged in age from 3 to 21) and found that behavioral interventions had been effective in improving academic, communication, functional life, play and social skills. However, concerns regarding the variability of the skills targeted, participant characteristics, instructional procedures and the magnitude of behavioral change prevented definitive conclusions.

Surprisingly, research on adaptive skill building in young adults (16 years and above) is limited, despite their lifelong impairments in adaptive functioning. In a recent albeit not systematic review, Matson, Hattier, and Belva (in press) summarized behavioral intervention research on improving work skills, self-help, leisure, hygiene, and feeding in adolescents and adults with ASD. Authors concluded that, while behavioral procedures were effective, adaptive living skills of adolescents and adults are understudied and should be researched more intensively given the impact of these skills on quality of life and independent functioning. Almost all studies in Matson's et al. review focussed on persons with ASD and ID. As there is a need for intervention programs targeting adaptive skills in high-functioning young adults with ASD (e.g., Farley et al., 2009) additional research is needed on the efficacy of behavioral interventions in this target group.

At present, no systematic review covering behavioral interventions for adaptive skill building in high-functioning young adults with ASD has been published. Given the importance of independent functioning, the need to explicitly target adaptive skills, and the financial cost associated with long term care of individuals with ASD (Järbrink, McCrone, Fombonne, Zandén, & Knapp, 2007), a systematic review on this topic is warranted. The purpose of this review is to systematically examine the state of research on behavioral interventions in improving adaptive behavior in young adults with high-functioning ASD in order to (a) evaluate research areas, techniques, and outcome measures and to (b) identify limitations and promising areas in need of future research.

Section snippets

Search procedures

First, systematic searches were conducted in four electronic databases: Education Resources Information Center (ERIC), PsycINFO, PubMed, and Web of Science. In all four databases the search was limited to articles written in English and published between January 1990 and August 2010 in peer-reviewed journals. The keywords fields in all four databases were searched using various forms and combinations of the terms “autism”, “Asperger syndrome”, “pervasive developmental disorder”, “youth”,

Results

Table 1 provides a summary of participant characteristics, adaptive skills targeted, intervention procedures, outcomes, and certainty of evidence for each of the 20 included studies.

Discussion

Our systematic review summarized 20 studies involving behavioral interventions to improve the adaptive skills of young adults with high functioning ASD. Despite the increase in amount of research on behavioral treatment with persons with ASD (see Matson, Turygin, et al., in press), there is still a paucity of intervention studies targeting adaptive skills in adults (Matson, Hattier, et al., in press). However, in this review 16 of the 20 studies (80%) were published after January 2000 and six

Acknowledgement

We thank Maaike Jacobs for her assistance in systematic searches.

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