A hybrid effectiveness-implementation trial of a school based executive function treatment for transition age youth with autism

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PROJECT SUMMARY The proposed study is highly relevant to the 2017 Interagency Autism Coordinating Committee priorities to improve transition to adulthood in autism spectrum disorders (ASD). It also advances NIMH’s mission to develop interventions that: 1) assess the mechanisms through which an intervention produces therapeutic change (Strategy 3.1); and 2) have been tested for effectiveness through pragmatic community-based trials that examine implementation factors to improve the fit of the intervention (Strategy 3.3). Caring for transition- age youth with ASD is a significant public health concern and the exit from high school is a period of amplified risk. Individuals without intellectual disabilities (ID) comprise the fastest-growing subgroup of ASD and account for two-thirds of the total population. Due to rising prevalence, there will be a 123% increase in the number of youth with ASD exiting secondary school in the next decade. The educational system is increasingly the primary service access point for youth with ASD, with as many of 90% served in public school settings. As such, the transition from high school is often characterized as “falling over a cliff,” as youth with ASD lose these educational and social supports. As few as 9% of autistic individuals without ID reach full functional independence as adults, resulting in a loss to society, as well as to the youth and their families. Impaired executive functions (EF) in ASD occur as a result of abnormalities in neural networks involving prefrontal cortex, and are related to poor adult outcome. EF problems are pivotal targets for intervention because they are common, linked to independence, and responsive to treatment. The proposed study will test the effectiveness of a school-based cognitive behavioral EF intervention, Flexible Futures (FF), for transition- age youth with ASD (AIM 1) and evaluate mechanisms of treatment change (AIM 2). FF targets flexibility and planning skills and focuses on key functions needed for adult success: understanding one’s own thinking style and advocating for accommodations; flexible problem-solving; time management; goal setting; developing plans; monitoring progress. FF was designed from inception to be embedded in high schools and delivered by school staff to improve generalization of skills, increase access to mental health care, and fill a gap in a lack of evidence-based approaches to support postsecondary transition. A small, pilot randomized controlled trial found students receiving FF made greater gains in planning, flexibility, adaptive, and classroom behavior when compared to students receiving the usual ASD supports at school. This project capitalizes on the opportunity to utilize pragmatic community trials to probe mechanisms of treatment change and explore barriers and facilitators to implementation (AIM 3) to improve sustainable adoption and implementation of effective, generalizable, evidence-based interventions. If successful, the proposed project will demonstrate the widespread effectiveness and feasibility of an accessible intervention to improve transition outcomes for youth with ASD that can be rapidly disseminated and implemented by schools across the nation.