Executive Function Intervention for High School Students With ASD
| Status: | Enrolling by invitation |
|---|---|
| Conditions: | Neurology, Psychiatric, Autism |
| Therapuetic Areas: | Neurology, Psychiatry / Psychology |
| Healthy: | No |
| Age Range: | 14 - 22 |
| Updated: | 2/3/2019 |
| Start Date: | July 11, 2015 |
| End Date: | June 30, 2020 |
Behavioral and Neural Outcomes of a New Executive Function Treatment for Transition-age Youth With ASD
The purpose of this project is to test the effectiveness of a novel school-based intervention
targeting executive function skills, including flexibility and planning, in college-track,
transition-age youth with ASD. Evaluating treatment change through behavior and brain
activity provides important information on how the treatment works and who will best benefit
from it.
targeting executive function skills, including flexibility and planning, in college-track,
transition-age youth with ASD. Evaluating treatment change through behavior and brain
activity provides important information on how the treatment works and who will best benefit
from it.
With half of the $3.2 million lifetime per capita cost of autism spectrum disorder (ASD)
attributable to care and productivity loss during adult life, the Interagency Autism
Coordinating Committee has identified a pressing need to improve adult outcomes. Even in
individuals without intellectual disability who make up 2/3 of children with ASD, as few as
9% reach full functional independence as adults. Failure in college is related to weaknesses
in executive function (EF), specifically with flexibility and planning. As such, the
transition from high school is a period of amplified risk characterized by poor educational
and vocational attainment that persists in adulthood. EF problems are pivotal targets for
intervention because they are common, linked to independence, and responsive to treatment in
younger children. There are three barriers to treatment outcome research in transition-aged
youth with ASD: (1) a lack of proven EF treatments for this age, (2) pervasive failure to
generalize skills learned in the clinic to real-world settings, and (3) inadequate objective
measures of outcome. This proposal tests the effectiveness of Flexible Futures a new
phenotype specific, cognitive behavioral EF intervention to increase flexibility and planning
skills for college-track high school students with ASD. It is novel and innovative because
its use of translational methods comprehensively evaluates treatment change at the
behavioral, cognitive, and neural level.
Cognitive flexibility and planning are impaired in ASD, linked to core ASD symptoms, and
embedded in anomalies of brain structure and function. Individuals with ASD fail to activate
local cortical regions such as dorsolateral prefrontal cortex (DLPFC) and anterior cingulate
cortex (ACC) on set-shifting (flexibility) tasks and show global abnormalities in the default
mode, salience, and attentional networks associated with EF problems in attending to
important information and implementing goal-directed behavior. In typical development,
greater segregation between and greater connectivity within these networks is associated with
better cognitive and behavioral regulation. Dr. Pugliese aims to determine whether treatment
change can be objectively measured in the brain using functional MRI (fMRI). This cutting
edge methodology is critical to identifying processes of treatment change at the neural
level, consistent with the NIMH Research Domain Criteria framework, and may yield findings
that impact the large variety of psychiatric and developmental disorders linked to EF
deficits. Specifically, this study aligns with NIMH K23 guidance soliciting proposals for the
development of pilot studies of novel treatments eliciting mechanisms of change.
AIM 1: Refine the Flexible Futures treatment manual and test acceptability, feasibility, and
effectiveness in a school setting.
Dr. Pugliese will refine the Flexible Futures manual based on expert opinion and feedback
from our in-clinic pilot via an iterative process and run a school-based trial comparing
Flexible Futures to social skills treatment. It is hypothesized that intervention
acceptability, feasibility, and fidelity will reach an 80% benchmark (H1.1) and students who
receive Flexible Futures will show improved EF flexibility and planning abilities in
laboratory, school, and home settings post-treatment and at 5-month follow up compared to
students who receive treatment as usual (H1.2).
AIM 2: Identify neural correlates of treatment change using fMRI.
Task-evoked and resting-state activation of prefrontal cortex networks will be assessed
pre-/post-intervention. It is hypothesized that post-treatment, students receiving Flexible
Futures will display increased (normalized) DLPFC and ACC activation during a
well-established set-shifting task compared to those receiving social skills training (H2.1),
and that activation will be positively correlated with behavioral/cognitive measures of EF
(H2.2). It is also hypothesized that post-treatment, students receiving Flexible Futures will
display increased connectivity within, and decreased connectivity across default mode,
salience, and attentional networks compared to the control group (H2.3).
AIM 3: Identify biomarkers of later EF outcomes at the behavioral, cognitive, and neural
level.
Baseline data will be combined across participants to provide a comprehensive EF profile in
transition-age youth and identify predictors of later EF and global outcomes. It is
hypothesized that baseline measures of EF (behavioral/ cognitive); DLPFC/ACC activation; and
greater connectivity within and greater segregation between salience, attentional and default
mode networks (neural) will all predict EF outcome and adaptive function. (H3.1).
Significance: Establishing the first effective school-based EF treatment for high-schoolers
will provide critical and generalizable transition-related support, and a model for treatment
in other prevalent disorders with known EF deficits (e.g. ADHD, anxiety). This training award
will launch me toward Dr. Pugliese's ultimate career goals of 1) developing and implementing
innovative interventions personalized for specific cognitive profiles, 2) developing
school-based treatments to overcome disparities in access to healthcare; and 3) utilizing
treatment studies as vehicles to identify biomarkers and provide insight into neural
correlates of treatment change.
attributable to care and productivity loss during adult life, the Interagency Autism
Coordinating Committee has identified a pressing need to improve adult outcomes. Even in
individuals without intellectual disability who make up 2/3 of children with ASD, as few as
9% reach full functional independence as adults. Failure in college is related to weaknesses
in executive function (EF), specifically with flexibility and planning. As such, the
transition from high school is a period of amplified risk characterized by poor educational
and vocational attainment that persists in adulthood. EF problems are pivotal targets for
intervention because they are common, linked to independence, and responsive to treatment in
younger children. There are three barriers to treatment outcome research in transition-aged
youth with ASD: (1) a lack of proven EF treatments for this age, (2) pervasive failure to
generalize skills learned in the clinic to real-world settings, and (3) inadequate objective
measures of outcome. This proposal tests the effectiveness of Flexible Futures a new
phenotype specific, cognitive behavioral EF intervention to increase flexibility and planning
skills for college-track high school students with ASD. It is novel and innovative because
its use of translational methods comprehensively evaluates treatment change at the
behavioral, cognitive, and neural level.
Cognitive flexibility and planning are impaired in ASD, linked to core ASD symptoms, and
embedded in anomalies of brain structure and function. Individuals with ASD fail to activate
local cortical regions such as dorsolateral prefrontal cortex (DLPFC) and anterior cingulate
cortex (ACC) on set-shifting (flexibility) tasks and show global abnormalities in the default
mode, salience, and attentional networks associated with EF problems in attending to
important information and implementing goal-directed behavior. In typical development,
greater segregation between and greater connectivity within these networks is associated with
better cognitive and behavioral regulation. Dr. Pugliese aims to determine whether treatment
change can be objectively measured in the brain using functional MRI (fMRI). This cutting
edge methodology is critical to identifying processes of treatment change at the neural
level, consistent with the NIMH Research Domain Criteria framework, and may yield findings
that impact the large variety of psychiatric and developmental disorders linked to EF
deficits. Specifically, this study aligns with NIMH K23 guidance soliciting proposals for the
development of pilot studies of novel treatments eliciting mechanisms of change.
AIM 1: Refine the Flexible Futures treatment manual and test acceptability, feasibility, and
effectiveness in a school setting.
Dr. Pugliese will refine the Flexible Futures manual based on expert opinion and feedback
from our in-clinic pilot via an iterative process and run a school-based trial comparing
Flexible Futures to social skills treatment. It is hypothesized that intervention
acceptability, feasibility, and fidelity will reach an 80% benchmark (H1.1) and students who
receive Flexible Futures will show improved EF flexibility and planning abilities in
laboratory, school, and home settings post-treatment and at 5-month follow up compared to
students who receive treatment as usual (H1.2).
AIM 2: Identify neural correlates of treatment change using fMRI.
Task-evoked and resting-state activation of prefrontal cortex networks will be assessed
pre-/post-intervention. It is hypothesized that post-treatment, students receiving Flexible
Futures will display increased (normalized) DLPFC and ACC activation during a
well-established set-shifting task compared to those receiving social skills training (H2.1),
and that activation will be positively correlated with behavioral/cognitive measures of EF
(H2.2). It is also hypothesized that post-treatment, students receiving Flexible Futures will
display increased connectivity within, and decreased connectivity across default mode,
salience, and attentional networks compared to the control group (H2.3).
AIM 3: Identify biomarkers of later EF outcomes at the behavioral, cognitive, and neural
level.
Baseline data will be combined across participants to provide a comprehensive EF profile in
transition-age youth and identify predictors of later EF and global outcomes. It is
hypothesized that baseline measures of EF (behavioral/ cognitive); DLPFC/ACC activation; and
greater connectivity within and greater segregation between salience, attentional and default
mode networks (neural) will all predict EF outcome and adaptive function. (H3.1).
Significance: Establishing the first effective school-based EF treatment for high-schoolers
will provide critical and generalizable transition-related support, and a model for treatment
in other prevalent disorders with known EF deficits (e.g. ADHD, anxiety). This training award
will launch me toward Dr. Pugliese's ultimate career goals of 1) developing and implementing
innovative interventions personalized for specific cognitive profiles, 2) developing
school-based treatments to overcome disparities in access to healthcare; and 3) utilizing
treatment studies as vehicles to identify biomarkers and provide insight into neural
correlates of treatment change.
Inclusion Criteria:
- College-track high school students
- Ages 14-22
- Verbal IQ estimate of ≥ 90 on the Wechsler Abbreviated Intelligence Scale-2
- Clinical diagnosis of ASD OR school classification of autism confirmed by clinical
impressions and the Social Responsiveness Scale-Revised total score ≥ 65. If the
research staff feels that clinical impressions indicate a diagnosis, but parent report
is below threshold, the Autism Diagnostic Observation Schedule-2 will be completed.
Exclusion Criteria:
- Bipolar disorder, schizophrenia, or major depression that is currently preventing from
participation in classroom activities
- MRI exclusion: contraindication (metal implant or medical device) for MRI
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