J Autism Dev Disord (2014) 44:719–729 DOI 10.1007/s10803-013-1914-8
BRIEF REPORT
Brief Report: Problem Solving Therapy in College Students with Autism Spectrum Disorders: Feasibility and Preliminary Efficacy Cara E. Pugliese • Susan W. White
Published online: 21 August 2013 Ó Springer Science+Business Media New York 2013
Abstract Students with autism spectrum disorder (ASD), though academically capable, can have difficulty succeeding in college. Evidence-based intervention to promote effective problem solving may improve quality of life, as well as success and satisfaction in college. This study adapted and piloted a group-based cognitive-behavioral intervention program, Problem Solving Skills: 101 (PSS: 101), to teach effective problem solving ability in college students with ASD. Therapists met all treatment integrity objectives across sessions, four of the five participants completed at least eight of the nine sessions, and between-session assignments were generally completed (83 % completion rate), indicating a high level of treatment adherence. Two participants demonstrated reliable improvement post-intervention in problem solving ability and subjective distress. Further evaluation to assess efficacy of the intervention is warranted. Keywords Autism College Intervention Problem solving
Introduction With improved identification of autism spectrum disorder (ASD), and greater recognition of the disorder among individuals who are not cognitively impaired, it is likely that the number of college students with ASD will increase (Adreon and DuRocher 2007; Smith 2007). Given that more young people with ASD uncomplicated by intellectual disability identify college as their primary desired post-secondary path C. E. Pugliese (&) S. W. White Department of Psychology, Virginia Polytechnic State Institute and University, 109 Williams Hall, Blacksburg, VA 24060, USA e-mail:
[email protected]
than in previous decades (Graetz and Spampinato 2008), colleges and university-affiliated mental health care providers need to become well-equipped to address the needs of this growing population. College students with ASD face stress related to managing the decrease in order and routine that is common in university life, handling increased academic demands, organizing their own time, and initiating new social relationships (Glennon 2001). Collectively, these stressors seem to contribute to early drop out and decreased satisfaction with the college experience, even if students demonstrate exceptional academic skills (Adreon and Durocher 2007; Harpur et al. 2004; White et al. 2011). The growing ASD population (United States CDC 2012) and cohort of students on college campuses with ASD (US Government Accountability Office 2009) underscores the need for the development of effective clinical treatment approaches for young adults with ASD (Lord et al. 2005). There is support for the efficacy of cognitive-behavioral therapy (CBT) for treating secondary problems such as anxiety and anger in children and teens with ASD without cooccurring intellectual disability (e.g., Bauminger 2002; Reaven et al. 2009; Sofronoff et al. 2007; White et al. 2010; Wood et al. 2009). Group-based problem solving therapy (PST; D’Zurilla and Nezu 2007), a CBT program, may be particularly effective in helping college students with ASD cope with problems they encounter in the university environment by developing appropriate problem solving skills. A core focus of PST is the individual’s problem orientation, a motivational process that addresses both the constructive and destructive consequences of emotions in social problem solving. This may be an important component of treatment for adults with ASD given the role that deficits in problem solving can have on stress, anxiety, and depression (see Gaus 2011). PST teaches skills for effective decision making and improved self-sufficiency. Additionally, time-limited
123
720
delivery in a group format is practical from a cost-reduction perspective (Bannan 2010) as well as conducive to improving social function, as the group provides a forum for participants to offer advice, share strategies, and provide feedback to each other. Youth with ASD have been shown to make gains in problem solving abilities after time-limited interventions in clinic and school settings, within both individual and group formats (Bauminger 2002; Solomon et al. 2004; Stichter et al. 2010). Executive functioning deficits and cognitive rigidity may inhibit effective problem solving in young people with ASD, evidenced by problems with hypothetical thinking, generating novel responses, generalizing skills from one context to another and interacting with others flexibly (Dunlop et al. 2008; Hill 2008; Ozonoff et al. 2004; Rinehart et al. 2001). However, research investigating the remediation of executive deficits in adults with ASD is almost nonexistent (Ozonoff et al. 2005), as is research on problem solving skills in adults with ASD. Consistent with recommendations from clinical trial methodologists (e.g., Leon et al. 2011) and experts in the field of ASD treatment research (Smith 2007) to establish feasibility of a new intervention prior to determining efficacy, the primary aim of this project was to develop an adapted PST manual for college students with ASD and assess feasibility, or integrity of implementation and acceptability to consumers (clients). An exploratory aim of the study was to collect preliminary data on the short-term efficacy of the intervention.
Method Design A pre- to post-treatment single subject design was used, allowing each participant to act as his or her own control (Bloom et al. 2006). Recruitment of participants occurred through the university disabilities office. After providing informed consent and determining inclusion criteria were met, participants completed an extended baseline evaluation. To be included, participants were required meet criteria for ASD based on the autism diagnostic observation schedule, module 4 (ADOS; Lord et al. 1999, 2000). A research-reliable evaluator administered and scored the ADOS. Exclusionary criteria included the presence of severe psychopathology, such as suicidal intent or a thought disorder. Participants also completed measures of problem solving and general symptom distress. In order to establish a stable baseline, participants completed two additional weekly administrations of the same questionnaires. Group therapy sessions were led by two advanced clinical psychology doctoral students. Therapy sessions
123
J Autism Dev Disord (2014) 44:719–729
were video recorded for coding of treatment integrity and adherence and, after each session, participants completed measures of consumer satisfaction. Approximately 1 week after the last treatment session, participants were administered the battery of problem solving and general distress measures, along with a program satisfaction questionnaire. After the in-session endpoint evaluation, participants completed 2 weekly administrations of the problem solving and general distress measures to establish a stable endpoint measurement. Two months later, participants completed follow-up administrations of these measures, along with questions regarding treatment satisfaction, for two consecutive weeks. A trained ‘independent evaluator’ (IE) (i.e., not involved in treatment delivery or familiar with the intervention) evaluated treatment integrity and treatment adherence. Experimental Treatment: PSS:101 It is generally accepted that CBT-based interventions require modification for successful delivery to clients with ASD (Moree and Davis 2010). Adaptations to PST for ASD included the use of psychoeducation about ASD as it relates to the problem solving process (e.g., identifying problems with social context, difficulty generating possible solutions), immediate, direct, and specific feedback on performance, more intensive and lengthy modeling of new skills by the group leaders, direct instruction of skills, structured delivery of the program (e.g., timers, use of a whiteboard, reminders of upcoming meetings, scheduling meetings at the disabilities office to keep participants in a routine of going to meetings), the use of shaping to teach skills, and multi-modal practice. As suggested by White (2011), a confidentiality clause was included in the written consent form indicating that personal information shared during group sessions was not to be shared with individuals outside of the group. Other considerations that were given to the adaptation of PST to ASD came from the social skills intervention literature, such as using multiple teaching modalities, incorporating role plays, building on past successes, including visual aids, and increasing structure and predictability during therapy sessions (e.g., White et al. 2010). Given that individuals with ASD display difficulties with attention switching, often fail to pick up on subtle cues, and have problems distinguishing essential from irrelevant details (Klin et al. 2003; O’Hearn et al. 2008), intervention techniques have highlighted the importance of providing immediate and specific constructive feedback (e.g., White et al. 2010). Another challenge for individuals with ASD is generalizing, or transferring, skills from the treatment setting to consistent use in the community (Rao et al. 2008). Delivery of PSS:101 used modeling of new skills, a
J Autism Dev Disord (2014) 44:719–729
technique that is helpful because it demonstrates what should be done in a given situation and increases the likelihood that the individual will learn the skill and use it outside of the therapeutic session (White 2011). Additionally, structured delivery of treatment can reduce anxiety related to unpredictability in the session by helping participants know what to expect and shift between activities (e.g., White et al. 2010) as well as help individuals with ASD stay on task and shift between tasks purposefully (Ozonoff 1997). Finally, White et al. (2010) emphasize the importance of integrating creative and varied teaching strategies by integrating verbal explanation with visual supports and role-play to teach concepts and skills. During the beginning of PSS:101, students selected a problem they wished to work on for the remainder of the program. The purpose of the first session, ‘‘orientation to PSS:101/psychoeducation about ASD’’, was to provide an overview of, and rationale for, PSS:101 and to establish a positive therapeutic relationship. Therapists provided psychoeducation on ASD in relation to problem solving and introduced the acronym ‘‘attitude, define, alternatives, predict, try out’’ (ADAPT) to define the problem solving process (D’Zurilla and Nezu 2007). Sessions two through four focused on the importance of a positive problem orientation (PPO) in relation to problem solving, particularly in viewing problems as challenges rather than threats (D’Zurilla and Nezu 2007). Students were taught how to recognize problems when they occur, how to challenge dysfunctional attitudes toward problem solving, how to regulate negative emotions, and how to use their emotions to facilitate problem solving effectiveness. Sessions five through eight focused on practicing discrete skills of the problem solving process, such as problem definition and formulation (PDF) (e.g., gathering relevant and factual information about the problem to set a realistic goal), using brainstorming techniques to generate alternative solutions to maximize the likelihood of an effective solution, decision making (e.g., screening out ineffective solutions, predicting possible consequences, evaluating solution outcomes, and developing a solution plan), and solution implementation including self-monitoring and self-evaluation of the solution outcome (D’Zurilla and Nezu 2007). In session nine, students evaluated their attempts to implement their chosen solution and re-worked their solution plans, if necessary. Participants Five undergraduate students with ASD diagnoses participated in this study (Table 1). All participants were Caucasian males between 18 and 23 years of age (M = 21.27 years of age) who attended the university for a period of time ranging from 1 month to 5 years
721 Table 1 Participant demographics ID
Age
FSIQ
VCI
PRI
ADOS Tot
Brian
18.25
133
136
131
14
Michael
21.25
123
114
126
19
Daniel
22.83
111
126
107
13
Kevin
20.42
136
141
119
10
Steven
23.58
135
125
137
17
FSIQ full scale intelligence quotient, VCI verbal comprehension index, ADOS Tot ADOS communication scale total ? ADOS reciprocal social interaction scale total
(M = 2.22 years). Each participant had a previous diagnosis of an ASD by a mental health professional and scored in the ASD range on the ADOS (Lord et al. 2000). Four students were previously diagnosed with Asperger’s Disorder and one student with Autistic Disorder. All participants had IQ scores over 100, supported by cognitive testing conducted in the previous 3 years. Measures Feasibility Treatment Integrity Treatment integrity is conceptualized as the delivery of the intervention’s key elements (White et al. 2010) and was assessed via ratings jointly completed by the therapists at the end of each treatment session. Specific components intended for every session included posting of the group agenda, discussing homework assignments, and completing treatment goals during each session. The IE also completed ratings of treatment integrity for each session from video recordings. Treatment Adherence Adherence is composed of a participant’s attendance and engagement during the treatment (Pavuluri et al. 2004). Attendance during the treatment program, engagement ratings of group members during each session (1 = ‘‘uninvolved,’’ 5 = ‘‘very involved’’), the average number of minutes participants were late to group sessions, and the percentage of homework assignments completed or discussed by participants (Smith 2007; White et al. 2010) were assessed. Therapeutic process variables can also be viewed as an index of the participants’ involvement. The therapeutic relationship between the participant and therapists and the group process were rated on a 5-point scale (1 = ‘‘poor,’’ 5 = ‘‘very good’’). The IE completed ratings of treatment integrity for each session from video recordings. Consumer Satisfaction Consumer satisfaction was evaluated after every session via questions on how helpful the session was, how helpful the homework was (0 = ‘‘not at
123
722
all helpful,’’ 10 = ‘‘definitely helpful’’), whether they learned anything during the session, and which components of each session were helpful or unhelpful. Efficacy Social Problem Solving Inventory-Revised: Long Form (SPSI-R:L) 52 items comprise the SPSI R:L and are rated on a 5-point scale ranging from 0 (not at all true of me) to 4 (extremely true of me) with higher total scores reflecting greater problem solving ability. Five subscale scores are computed: PPO reflects a constructive problem solving orientation to problems; negative problem orientation (NPO) measures a dysfunctional cognitive-emotional problem solving set; rational problem solving (RPS) is an index of effective problem solving strategies and is further broken down into four specific problem solving areas: PDF, generation of alternative solutions (GAS), decision making (DM), and solution implementation and verification (SIV); impulsivity/carelessness style (ICS) reflects an impulsive problem solving style; avoidance (AS) measures maladaptive strategies (e.g., passivity). The SPSI-R:L has good internal consistency (a = .95 for the total score, a = .75–.95 for subscales) and adequate stability over 3 weeks (r = .72 for the total score, r = .73–.88 for subscales; D’Zurilla et al. 2002). Outcome Questionnaire (OQ 45.2; Lambert et al. 1996; Lambert et al. 2001) A brief self-report instrument designed for repeated assessment of client status through the course of therapy, the 45 items on the OQ 45.2 are rated on a 5-point scale, with anchors of 0 (never) and 4 (almost always). The OQ 45.2 consists of three scales: symptomatic distress (SD), interpersonal relationships (IR), and social role performance (SR). High scores indicate greater distress (e.g., anxiety, depression, somatic problems and stress) as well as interpersonal difficulties in social roles and in quality of life. It has good test–retest reliability over 3 weeks (r = .84) and internal consistency (a = .93) and is sensitive to change (Lambert et al. 2001).
Data Analyses Feasibility data are presented for the group as a whole. Treatment integrity was calculated by both the therapists and the IE as a percentage [(number of objectives met/total number of objectives)* 100] (Pavuluri et al. 2004). To assess treatment adherence, engagement ratings were averaged across sessions to provide a total engagement score. The percentage of sessions participants attended, percentage of assignments completed, and amount of time a participant was late to meetings were averaged across
123
J Autism Dev Disord (2014) 44:719–729
sessions. Treatment satisfaction ratings were averaged across objectives for each participant, as well as across participants to derive an average per session. It was expected that treatment integrity would reach an 80 % benchmark, participant engagement ratings would be moderately high, and participants would attend at least 80 % of the sessions and complete 80 % of their homework assignments. Additionally, it was expected that treatment satisfaction would be moderately high across participants. Reliable changes indices (RCI; Jacobson and Truax 1991) were used to calculate clinical significance of the change in the SPSI-R:L and OQ 45.2. Scores were averaged for the baseline, endpoint, and follow-up period separately, and these scores were used to calculate the RCI.
Results Feasibility Overall, treatment integrity was high. Group leaders adhered to the manual, and agreement between therapist and IE ratings on integrity components was uniformly high, at 100 % agreement (j = 1.00). Two participants attended all nine sessions (Michael and Daniel), two participants attended eight (Brian and Kevin), and one participant (Steven) attended only six. Overall, attendance across sessions averaged 88.89 %. Participants were, on average 2.35 min late per session (SD = 5.04), and were noted to be actively engaged during the session (M = 4.23, SD = 0.83; inter-rater r = 0.89). Participants brought in or discussed their completed assignments in session approximately 83 % of the time during the program (j = 0.88). The therapeutic relationship was rated to be good (M = 4.08, SD = .76; inter-rater r = .93), as was the group process (M = 4.33, SD = .71; inter-rater r = 1.00). Tables 2 and 3 present results from the consumer satisfaction questions. Results indicated that participants generally found the sessions to be helpful (M = 7.40), but rated the homework assignments as only somewhat helpful (M = 4.57). Additionally, participants indicated they had gained new knowledge during all of the sessions except for one person who found the Problem Recognition module uninformative. Examining satisfaction across modules, it
Table 2 Consumer satisfaction for each participant (averaged across session) Brian
Michael
Daniel
Kevin
Steven
Session helpfulness
7.38
7.89
7
7.38
6.33
Homework helpfulness
5.29
4.57
5.63
4.29
4.00
Knowledge gained (%)
100
100
100
88
100
J Autism Dev Disord (2014) 44:719–729
723
Efficacy
Table 3 Consumer satisfaction ratings by session Session
Session helpfulness
Homework helpfulness
Knowledge gained (%)
1: Orientation to PSS:101
6.40
4.25
100
2: Fostering self-efficacy beliefs
6.75
2.75
100
3: Problem recognition 4: Use and control of emotions in problem solving
6.80 7.50
3.75 5.00
80 100
5: Problem definition and formulation
7.25
5.75
100
6: Generation of alternative solutions
7.25
5.75
100
7: Decision making
7.00
6.60
100
8: Solution implementation and verification
8.40
3.60
100
9: Check up and goodbye
7.80
N/A
100
appears that participants found learning the discrete problem solving steps to be most helpful (see Table 3). Overall, participants indicated they liked the PSS:101 program (M = 7.60, range = 5–9), found it to be helpful (M = 7.00, range = 5–9), and were satisfied with the topics of the meetings (M = 8.00, range = 6–10). Using a forced choice response format, four participants identified the group meetings as being the ‘most helpful’ component of the program, whereas one found learning about how to improve problem solving style as being the most helpful. Two participants also identified learning about the actual problem solving process as being helpful. Anecdotally, participants appreciated learning new problem solving skills to promote a systematic approach to problem solving, the potential to apply these strategies outside of sessions, the opportunity to talk with others with ASD, and discussing how attitudes toward problems can affect the problem solving process. Two months after the program, four of the five participants indicated that participating in PSS:101 was a good use of their time (M = 6.20, based on 0–10 scale), and would recommend this program to another student (M = 6.20). Participants indicated that they had continued to work on identified problems after the program ended (M = 6.75, range = 3–10) and felt that they made progress (M = 8.20, range = 5–10) on the problem they chose to work on during PSS:101. Additionally, participants indicated that they continued to apply the skills they learned from the program to other areas of their life (M = 7.00, range = 5–9). Participants also indicated that their problem solving skills changed as a result of PSS:101 (M = 7.20, range = 5–9) and that their problem solving orientation had become more positive (M = 7.60, range = 5–10).
Significant improvement in problem solving on the SPSIR:L was only observed for two participants (Table 4). There was no significant improvement or worsening in problem solving, based on RCI scores, for Michael, Daniel, and Steven from baseline to endpoint and follow-up. On the OQ 45.2 (Table 5), Brian demonstrated reliable improvement on the total score and the SR subscale from baseline to endpoint, indicating significant improvement. Gains on the SD subscale were also significant from baseline to the 2-month follow-up. Kevin demonstrated reliable improvement on the total score and SD subscale at endpoint, but not at follow-up. No significant reliable changes were noted for Michael, Daniel, and Steven on any of the OQ 45.2 subscales.
Discussion Advocates for students with disabilities insist that supports through postsecondary education are essential to improving employment outcomes, achieving financial independence, participating in the community, and gaining social acceptance (Stodden 2003). Without support, graduation rates of college students with disabilities are considerably low and, in turn, prospects for finding meaningful and fulfilling employment are significantly limited; these individuals are more likely to face increased poverty, higher unemployment rates, poor opportunities for job advancement, and discrimination (Stodden 2003). There is clear need to find efficacious interventions to help these individuals lead fulfilling and productive lives. Section 504 of the Vocational Rehabilitation Act of 1973, the Americans with Disabilities Act of 1990, and the Americans with Disabilities Act Amendments of 2008 requires that postsecondary institutions that enroll students with disabilities provide some level of services, supports, or accommodations to assist these students’ access to education (AHEAD 2008; Rao et al. 2008). Once a diagnosis is disclosed to the appropriate university office that serves students with disabilities, the university and its representatives (e.g., faculty) are required to provide the student with accommodations if testing indicates the student is substantially limited in an academic area (Glennon 2001). Although higher education institutions are legally required to ensure access for all students, the needs for students with ASD are unique and they may require specialized support due to their social and communication deficits (Farrell 2004; Hughes 2009; Smith 2007). Based on anecdotal observations made by university personnel, further complications include student noncompliance with support systems like counseling, accommodations, or even registering with the disabilities services office. Extending beyond academic accommodations, it is likely that
123
123
-1.11/-1.64
17.5
1.88/1.37
Avg FU
-0.98/-1.50
10.5
0.46/0.17
Avg FU
-2.41*/-2.22*
1.26/1.66
7.33 8
-0.51/0.34
Avg EP Avg FU
RCI
-1.43/-1.43
17.33 18
24
0.06/-0.12
9.67 10
10.5
1.09/0.79
11.5
12.33
9.33
-1.09/-0.49
8
6.33
9.33
-0.73/0.67
13.67 15.5
15.67
2.75*/1.46
16.5
18.67
12.5
PDF
-0.18/-0.36
10.33 10
11
0.59/0.89
12.5
11.67
10
0.24/-0.24
6
7.33
6.67
-1.66/0.36
11 12
15.67
2.25*/2.31*
18
18.33
11.5
GAS
-0.36/-0.73
11.33 11
13
1.34/0.85
15
16.33
12.67
-0.97/-1.28
4.5
5.33
8
-1.09/-0.49
14.33 13
17.33
2.43*/2.19*
16.5
18.33
10.5
DM
1.35/0.82
12.33 11
9
1.52/1.76
16
15.33
11
-0.12/0.06
7.5
7
7.33
-1.4/0.94
10.33 13
14.33
2.86*/1.76
16.5
18
11.5
SIV
0.30/-0.12
43.67 42
43.5
1.54/1.46
55
55.67
43
-0.65/-0.65
26
26
31.33
-1.66/0.51
49.33 53.5
63
3.32*/2.61*
67.5
73.33
46
RPS
-1.54/-1.00
6 8
12.5
-1.58/-1.51
5
4.67
12
-0.29/-0.79
18
20.33
21.67
0.01/0.57
3.33 6
3.33
-2.47*/-1.08
11.5
5
16.5
ICS
0.42/0.31
16 15
14
-0.15/-0.11
7.5
7.33
8
0.31/0.23
15
15.33
14
0.53/1.26
17 22.5
14.67
-0.19/0.11
5
3.67
4.5
AS
0.46/0.41
11.03 10.96
10.33
2.12*/2.16*
14.13
14.07
10.81
0.24/0.47
9.96
9.61
9.23
-1.24/-0.95
10.27 8.81
12.18
2.75*/1.97*
16.31
17.51
13.28
Total
* Significant change (i.e., [1.96; Jacobson and Truax 1991)
RCI: BL–EP score/FL–FU score
Positive RCI scores on the SPSI-R:L scale and positive problem orientation (PPO), problem definition and formulation (PDF), generation of alternative solutions (GAS), decision making (DM), solution implementation and verification (SIV), rational problem solving (RPS) subscales and negative RCI scores on the negative problem orientation (NPO), impulsivity and carelessness style (ICS), avoidance scale (AS) subscales indicate improvement; baseline averages are based on three administrations, except for Brian, who received four administrations, and Steven, who received two administrations; endpoint averages are based on three administrations
9
Avg BL
Steven
RCI
11.5
10.5
Avg FU
10.67
9.33
Avg EP
21.67
5.67
Avg BL
Kevin
RCI
15
11.33
Avg EP
17.33
10
Avg BL
21.67
0.53/1.77
-1.14/0.29
Daniel
RCI
27.66 35.5
6.67 7.5
Avg EP Avg FU
25.33
10
Avg BL
Michael
RCI
7
19.00
9.33
13.50
Avg EP
14.25
NPO
Avg BL
Brian
PPO
Table 4 Reliable change indices for the SPSI-R:L from baseline to endpoint and baseline to follow-up
724 J Autism Dev Disord (2014) 44:719–729
J Autism Dev Disord (2014) 44:719–729 Table 5 Reliable change indices for the OQ 45.2 from baseline to endpoint and baseline to follow-up
725
OQ SD
OQ IR
OQ SR
OQ Total
Avg BL
23
4.5
8.25
35.75
Avg EP
11.33
0.67
3
15
Avg FU
15.5
1
3.5
20
RCI
-1.68/-1.08
-1.23/-1.11
-2.42*/-2.19*
-2.21*/-1.68
Avg BL
40
9
13.67
62.67
Avg EP
41.33
8.33
14
63.67
Brian
Michael
Negative RCI scores on OQ total scores and symptom distress (SD), interpersonal relations (IR), and social role (SR) subscales indicate improvement; baseline averages are based on three administrations, except for Brian, who received four administrations, and Steven, who received two administrations who received four administrations; endpoint averages are based on three administrations
Avg FU
46.5
5
16
67.5
RCI
0.19/0.94
-0.21/-1.27
0.15/1.07
0.11/0.51
Avg BL
38
11.33
11.67
61.00
Avg EP
37.33
9.67
11.33
58.33
Avg FU
37
9
10
56
-0.10/-0.14
-1.48/-0.74
-0.15/-0.76
-0.28/-0.53
Avg BL
16.33
2
4.47
23
Avg EP
1
0
1.33
2.33
Avg FU
5
0
0.5
5.5
RCI
-2.21*/-1.63
-0.64/-0.64
-1.53/-1.92
-2.20*/-1.86 35
Daniel
RCI Kevin
Steven Avg BL
15.5
7.5
12
RCI: BL–EP score/FL–FU score
Avg EP
10.33
6.67
10.67
27.67
* Significant change (i.e., [1.96; Jacobson and Truax 1991)
Avg FU
12
8
12
32
RCI
-0.74/-.50
-0.27/0.16
-0.61/0
-0.78/-0.32
students will need additional instruction in developmentally appropriate social discourse, such as how to negotiate peer and teacher interactions inside of the classroom as well as how to access extracurricular activities. Students with ASD, as they transition into college, face a new set of social demands in an unfamiliar environment, necessitating the use of flexible problem solving skills. This study serves as an initial attempt to implement and evaluate a group-based program to improve problem solving skills in college students with ASD. As part of the current study, a manual was created to adapt PST (D’Zurilla and Nezu 2007) for college students with ASD. Much of the original concepts and content were kept intact, with the integration of promising strategies from CBT and social skill interventions used with individuals with ASD. Content and examples were driven by the new challenges students with ASD must independently endure at college without the support system, daily routines, or level of structure they previously had in their home environment. As such, PSS:101 was designed to teach students the general problem solving process while emphasizing problems related to social interaction, organization, and time management—challenges associated with impairments in ASD. PSS:101 was conducted in a group format to
encourage the development of a social support network for students with ASD and to provide the opportunity to practice new techniques with same-aged peers in a safe environment. Additionally, out-of-session assignments and ‘‘cheat sheets’’, which summarized session content, were created to reinforce practice of the content outside of session to increase generalization of skills. A secure URL was established to allow participants to access materials (e.g., out-of-session assignments), turn in assignments, and talk to other group members (via an online chat). We were able to implement the new treatment manual as intended, and there is evidence for its feasibility, including treatment integrity, consumer satisfaction, and therapist fidelity. Overall, treatment integrity was high, sessions lasted approximately 90 minutes as planned, and group leaders posted the agenda, reviewed and discussed homework assignments and met all of the treatment goals at every session. Regarding treatment adherence, all of the preestablished minimal benchmarks for attendance, participant engagement, homework completion, therapeutic relationship, group process, and convergence ratings (between therapist and IE) were met. With respect to consumer satisfaction, average helpfulness ratings across sessions were moderately high, though
123
726
homework assignments were rated as only somewhat helpful. Some participants had difficulty completing their homework thoroughly given competing time demands. Homework assignments are an integral part of CBT (Helbig and Fehm 2004; Kazantzis et al. 2000). It is possible that lack of perceived importance or an inability to complete homework negatively impacted the acquisition and implementation of targeted problem solving skills outside of the session. Participants also indicated they gained new knowledge in most of the sessions, with some evidence to suggest that they preferred learning the discrete problem solving steps. Perhaps most important, nearly all of the participants indicated that they liked the PSS:101 program and found it to be moderately helpful, and most were satisfied with the topics of the meetings. Additionally, participants indicated that they have continued to apply the skills they learned from the program to other areas of their life. Most group members also indicated that they found group meetings to be the most helpful component of PSS:101. Every participant indicated that they had a positive experience meeting others with ASD on the endpoint consumer satisfaction questionnaire. Specifically, they stated that it was helpful to meet other students with ASD to have people in similar situations to talk with, to see that many of the group members share the same problems, and to learn how others with ASD solve their problems. The group setting may have helped ‘normalize’ their problems in college. Although there are some pragmatic considerations (i.e., scheduling around classes and other commitments), for various reasons it is felt that a group modality offers some benefits relative to individual (i.e., therapist-client) intervention. Despite diverse symptomatology of ASD, many individuals in the group had similar problems in the college environment and group therapy created a forum for participants to offer advice, strategies, and insight to other group members. Whereas an individual with ASD may feel like an outsider in a group of typically developing peers, the group therapy modality provides the opportunity to feel accepted and understood by a group of peers who struggle with the same disorder and offers the chance to practice problem solving skills in a relatively naturalistic, but safe and supportive environment. By the time they have reached college, many students are likely to have experienced substantial social failure, rejection, and exclusion by peers (e.g., Glennon 2001). Group members may be more likely to be sympathetic and understanding of behaviors (e.g., poor social skills, self stimulatory behavior, bluntness) associated with ASD, which typically developing individuals may find off-putting. In the current study, group therapy afforded the opportunity for roleplaying, where observers provided constructive feedback on other individual’s problem solving processes.
123
J Autism Dev Disord (2014) 44:719–729
An exploratory aim of the current study was to assess treatment efficacy through measures of problem solving ability and symptom distress. Overall, results from the SPSI-R and OQ 45.2 are inconclusive. Three participants did not significantly improve on their social problem solving from pre-treatment to post-treatment, while two participants significantly improved on several specific areas related to problem solving, with this pattern holding true for the majority of subscales from baseline to followup. Of the participants who did not demonstrate reliable improvement, two exhibited trends in the expected direction on approximately half of the subscales, including the total SPSI-R:L, from baseline to endpoint and follow-up. Another participant experienced subthreshold change in the opposite of the predicted direction (i.e., worsening) from baseline to endpoint. From baseline to follow-up, however, approximately half of that participant’s observed change across the problem solving subscales was in the expected direction. Similar patterns were found for the OQ 45.2; two participants significantly improved from baseline to endpoint on several subscales with subthreshold change in the expected direction on all others, two participants exhibited subthreshold change in the expected direction for all subscales of the OQ 45.2, and one participant worsened across most subscales. At follow-up, only one participant was rated as having significant improvement on one subscale, though three participants reported scores in the expected direction on the total score and all subscales. These results suggest that, despite considerable variability in observed change during the intervention, most participants experienced positive change in problem solving and general distress, at either a clinical or subthreshold level. A noted concern of using self-report questionnaires rests on the ability of individuals with ASD to introspect (Johnson et al. 2009). Anecdotally, though, it was noted on several occasions during the treatment sessions that participants had difficulty recognizing and reporting on their own emotions, consistent with an emerging body of research suggesting caution in use and interpretation of self-report data with higher functioning adolescents with ASD (Lerner et al. 2012; Mazefsky et al. 2011; White et al. 2011). Another factor that may have accounted for the differences observed in treatment outcome is comorbidity. The participants who exhibited the least improvement both had co-occurring symptoms of anxiety and depression. As individuals with ASD gain more insight into their difficulties, they may initially report worsening symptoms (White et al. 2010). Additionally, it is also possible that the treatment was too short to lead to clinically significant improvement. Many CBT treatments utilize at least 12 sessions to find an effect (e.g., Sofronoff et al. 2007), with some incorporating individual treatment along with group treatment (e.g., White et al. 2010).
J Autism Dev Disord (2014) 44:719–729
We found no evidence of observer bias based on interrater reliability with an assessor independent from the therapists, and we endeavored to control variability in behavior by establishing a stable, three-point baseline. Nevertheless, any single subject design is limited with respect to generalizability of findings. This sample only consisted of five Caucasian males. It is possible that females or individuals of other races and ethnicities may respond differently to PSS:101. Additionally, while singlecase designs can provide initial evidence for the efficacy of an intervention, the inclusion of a control group in randomized controlled trials could provide stronger evidence for causal clarity of PSS:101, while simultaneously allowing for the examination of mediator and moderator variables, such as participant characteristics or environmental features through cross-site studies (e.g., Lord et al. 2005). Additionally, it will be important to obtain feedback from stakeholders (e.g., individuals with ASD, university personnel, parents) in an iterative manner to further ensure viability outside of a research study. Preliminary findings indicate that PSS:101 could be delivered as intended and was acceptable to the students. Future studies should identify sensitive, objective measures of problem solving skills to be used in conjunction with self-report measures to more accurately detect treatment change. Given the chronic nature of ASD, it is likely that more intensive treatment for adults is necessary to produce consistent and pronounced treatment effects. Future research may also consider augmenting the procedure by incorporating the use of more frequent assessments to derive stable baseline and endpoint measures of symptom and skill levels. Given that the structure of support services afforded to students with ASD differs across college campuses in the United States, it will be important to continue dialogue regarding best practice for supporting students in an empirically supported manner. The timelimited group-based nature of the current intervention may be a cost effective way to increase skills in multiple students simultaneously in order to reduce psychological distress. Additionally, a fundamental purpose of the current intervention was to teach individuals to develop the skills necessary to make their own decisions, allowing them to gradually reduce the amount of support required from others and build their self-efficacy. In this respect, targeting processes underlying the problems faced by students with ASD in higher education may enhance generalizability and reduce the need for continued treatment across the lifespan. Improved problem solving may be one such process worth further pursuing for this population. Acknowledgments This study was prepared from the first author’s doctoral dissertation and was partially funded by the Graduate Research Development Program Dissertation Award at Virginia Tech.
727 We are grateful to the support received from others, such as Nicole Kreiser, M.S., who participated as a co-therapist, and Nuri Reyes, M.S., who served as an assessor. We are also appreciative of the involvement of the Services for Students with Disabilities Office at Virginia Tech under the guidance of Susan Angle, Ph.D., and the students who gave their time and energy to participate in this study. Finally, I would like to extend a thank you to my dissertation committee members, George Clum, Ph.D., and Bethany Bray, Ph.D., for their guidance along the way.
References Adreon, D., & Durocher, J. S. (2007). Evaluating the college transition needs of individuals with high-functioning autism spectrum disorders. Intervention in School and Clinic, 42, 271–279. doi:10.1177/10534512070420050201. Association on Higher Education and Disability. (2008). ADA recommendations act of 2008. Policy implications for accommodating students with disabilities. Retrieved from http://ahead. org/resources/government/relations. Bannan, N. (2010). Group-based problem-solving therapy in selfpoisoning females: A pilot study. Counselling and Psychotherapy Research, 10, 201–213. doi:10.1080/14733140903337292. Bauminger, N. (2002). The facilitation of social-emotional understanding and social interaction in high functioning children with autism: Intervention outcomes. Journal of Autism and Developmental Disorders, 32, 283–298. doi:10.1023/A:1016378718278. Bloom, M., Fischer, J., & Orne, J. G. (2006). Evaluating practice: Guidelines for the accountable professional (5th ed.). Boston: Pearson. D’Zurilla, T. J., & Nezu, A. M. (2007). Problem-solving therapy: A positive approach to clinical intervention (3rd ed.). New York: Springer. D’Zurilla, T. J., Nezu, A. M., & Maydeu-Olivares, A. (2002). Manual for the social problem-solving inventory-revised. North Tonawanda, NY: Multi-Health Systems. Dunlop, A., Knott, F., & MacKay, T. (2008). Developing social interaction and understanding high-functioning individuals with autism spectrum disorder. In E. McGregor, M. Nunez, K. Cebula, & J. C. Gomez (Eds.), Autism: An integrated view from neurocognitive, clinical, and intervention research. Oxford: Blackwell. Farrell, E. (2004). Asperger confounds colleges. Chronicle of Higher Education, 51(7), A35–A36. Gaus, V. L. (2011). Adult asperger syndrome and the utility of cognitive-behavioral therapy. Journal of Contemporary Psychotherapy, 41, 47–56. doi:10.1007/s10879-010-9159-8. Glennon, T. J. (2001). The stress of the university experience for students with asperger syndrome. Work: A Journal of Prevention, Assessment and Rehabilitation, 17(3), 183–190. Graetz, J. E., & Spampinato, K. (2008). Asperger’s syndrome and the voyage through high school: Not the final frontier. Journal of College Admission, 198, 19–24. Harpur, J., Lawlor, M., & Fitzgerald, M. (2004). Succeeding in college with asperger syndrome. London: Jessica Kingsley Publishers. Helbig, S., & Fehm, L. (2004). Problems with homework in CBT: Rare exception or rather frequent? Behavioural and Cognitive Psychotherapy, 32, 291–301. doi:10.1017/S1352465804001365. Hill, E. L. (2008). Executive functioning in autism spectrum disorder. In E. McGregor, M. Nunez, K. Cebula, & J. C. Gomez (Eds.), Autism: An integrated view from neurocognitive, clinical, and intervention research (pp. 145–165). Oxford: Blackwell.
123
728 Hughes, J. L. (2009). Higher education and asperger’s syndrome. Chronicle of Higher Education, 55(40), 21. Jacobson, N. S., & Truax, P. (1991). Clinical significance: A statistical approach to defining meaningful change in psychotherapy research. Journal of Consulting and Clinical Psychology, 59, 12–19. doi:10.1037/0022-006X.59.1.12. Johnson, S. A., Filliter, J. H., & Murphy, R. R. (2009). Discrepancies between self- and parent- perceptions of autistic traits and empathy in high functioning children and adolescents on the autism spectrum. Journal of Autism and Developmental Disorders, 39, 1706–1714. doi:10.1007/s10803-009-0809-1. Kazantzis, N., Deane, F. P., & Ronan, K. R. (2000). Homework assignments in cognitive and behavioral therapy: A metaanalysis. Clinical Psychology: Science and Practice, 7, 189–202. doi:10.1093/clipsy.7.2.189. Klin, A., Jones, W., Schultz, R. T., & Volkmar, F. R. (2003). The enactive mind-from actions to cognition: Lessons from autism. Philosophical Transactions of the Royal Society, Biological Sciences, 358, 345–360. doi:10.1098/rstb.2002.1202. Lambert, M. J., Hansen, N. B., & Finch, A. E. (2001). Patient-focused research: Using patient outcome data to enhance treatment effects. Journal of Consulting and Clinical Psychology, 69, 159–172. doi:10.1037/0022-006X.69.2.159. Lambert, M. J., Hansen, N. B., Umphress, V., Lunnen, K., Okiishi, J., Burlingame, G. M., et al. (1996). Administration and scoring manual for the OQ-45. Stevenson, MD: Professional Credentialing Services. Leon, A. C., Davis, L. L., & Kraemer, H. C. (2011). The role and interpretation of pilot studies in clinical research. Journal of Psychiatric Research, 45, 626–629. doi:10.1016/j.jpsychires. 2010.10.008. Lerner, M. D., Calhoun, C. D., Mikami, A. Y., & De Los Reyes, A. (2012). Understanding parent–child social informant discrepancy in youth with high functioning autism spectrum disorders. Journal of Autism and Developmental Disorders, 42, 2680–2692. doi:10.1007/s10803-012-1525-9. Lord, C., Risi, S., Lambrecht, L., Cook, E. H., Leventhal, B. L., & Rutter, M. (2000). The autism diagnostic observation schedule– generic: A standard measure of social and communication deficits associated with the spectrum of autism. Journal of Autism and Developmental Disorders, 30, 205–223. doi:10.1023/ A:1005592401947. Lord, C., Rutter, M., DiLavore, P. C., & Risi, S. (1999). Autism diagnostic observation schedule-WPS (ADOS-WPS). Los Angeles, CA: Western Psychological Services. Lord, C., Wagner, A., Rogers, S., Szatmari, P., Aman, M., Charman, T., et al. (2005). Challenges in evaluating psychosocial interventions for autistic spectrum disorders. Journal of Autism and Developmental Disorders, 35, 695–708. doi:10.1007/s10803005-0017-6. Mazefsky, C. A., Kao, J., & Oswald, D. P. (2011). Preliminary evidence suggesting caution in the use of psychiatric self-report measures with adolescents with high-functioning autism spectrum disorders. Research in Autism Spectrum Disorders, 5, 164–174. doi:10.1016/j.rasd.2010.03.006. Moree, B. N., & Davis, T. E. (2010). Cognitive-behavioral therapy for anxiety in children diagnosed with autism spectrum disorders: Modification trends. Research in Autism Spectrum Disorders, 4(3), 346–354. O’Hearn, K., Asato, M., Ordaz, S., & Luna, B. (2008). Neurodevelopment and executive function in autism. Development and Psychopathology, 20, 1103–1132. doi:10.1017/S0954579408 000527. Ozonoff, S. (1997). Causal mechanisms of autism: Unifying perspectives from an information-processing framework. In D. J. Cohen & F. R. Volkmar (Eds.), Handbook of autism and pervasive
123
J Autism Dev Disord (2014) 44:719–729 developmental disorders (2nd ed., pp. 868–879). New York: Wiley. Ozonoff, S., Coon, H., Dawson, G., Joseph, R., Klin, A., & McMahon, W. M. (2004). Performance on CANTAB subtests sensitive to frontal lobe function in people with autistic disorder: Evidence from the CPEA network. Journal of Autism and Developmental Disorders, 34, 139–150. doi:10.1023/B:JADD. 0000022605.81989.cc. Ozonoff, S., South, M., & Provencal, S. (2005). Executive functions. In F. R. Volkmar, A. Klin, R. Paul, & D. Cohen (Eds.), Handbook of autism and developmental disorders (3rd ed., pp. 606–627). New York: Wiley. Pavuluri, M. N., Graczyk, P. A., Henry, D. B., Carbray, J. A., Heidenreich, J., & Miklowitz, D. J. (2004). Child- and familyfocused cognitive-behavioral therapy for pediatric bipolar disorder: Development and preliminary results. Journal of American Academy of Child and Adolescent Psychiatry, 43, 528–537. doi:10.1097/01.chi.0000116743.71662.f8. Rao, P. A., Beidel, D. C., & Murray, M. J. (2008). Social skills interventions for children with asperger’s syndrome or highfunctioning autism: A review and recommendations. Journal of Autism and Developmental Disorders, 38, 353–361. doi:10.1007/ s10803-007-0402-4. Reaven, J., Blakeley-Smith, A., Nichols, S., Dasari, M., Flanigan, E., & Hepburn, S. (2009). Cognitive-behavioral group treatment for anxiety symptoms in children with high-functioning autism spectrum disorders. Focus on Autism and Other Developmental Disabilities, 24, 27–37. doi:10.1177/1088357608327666. Rinehart, N. J., Bradshaw, J. L., Moss, S. A., Brereton, A. V., & Tonge, B. J. (2001). A deficit in shifting attention present in high-functioning autism but not asperger’s disorder. Journal of Research and Practice, 5, 67–80. doi:10.1177/136236130100 5001007. Smith, C. P. (2007). Support services for students with asperger’s syndrome in higher education. College Student Journal, 41(3), 515–531. Sofronoff, K., Attwood, T., Hinton, S., & Levin, I. (2007). A randomized controlled trial of cognitive behavioural intervention for anger management in children diagnosed with asperger syndrome. Journal of Autism and Developmental Disorders, 46, 1152–1160. doi:10.1007/s10803-006-0262-3. Solomon, M., Goodlin-Jones, B. L., & Anders, T. F. (2004). A social adjustment enhancement intervention for high functioning autism, asperger’s syndrome, and pervasive developmental disorder NOS. Journal of Autism and Developmental Disorders, 34, 649–668. doi:10.1007/s10803-004-5286-y. Stichter, J. P., Herzog, M. J., Visovsky, K., Schmidt, C., Randolph, J., Schultz, T., et al. (2010). Social competence intervention for youth with asperger syndrome and high-functioning autism: An initial investigation. Journal of Autism and Developmental Disorders, 40, 1067–1079. doi:10.1007/s10803-010-0959-1. Stodden, R. A. (2003, September 15). People with disabilities and postsecondary education: Position paper. Retrieved February 28, 2011 from www.ncd.gov. United States Centers for Disease Control and Prevention. (2012). Prevalence of autism spectrum disorders-autism and developmental disabilities monitoring network, 14 sites, United States, 2008. Surveillance Summaries, MMWR 2012; 61 (No. SS-3). United States Government Accountability Office. (2009). Higher education and disability: Education needs a coordinated approach to improve its assistance to schools in supporting students. Washington, DC: United States Government Accountability Office. White, S. W. (2011). Practitioner’s guide to social skills training in children with asperger’s syndrome and high functioning autism. New York: Guilford Publications.
J Autism Dev Disord (2014) 44:719–729 White, S. W., Albano, A. M., Johnson, C. R., Kasari, C., Ollendick, T., Klin, A., et al. (2010). Development of a cognitive-behavioral intervention program to treat anxiety and social deficits in teens with high functioning autism. Clinical Child and Family Psychological Review, 13, 77–90. doi:10.1007/s10567-009-0062-3. White, S. W., Ollendick, T. H., & Bray, B. C. (2011). College students on the autism spectrum. Autism, 15, 683–701. doi:10. 1177/1362361310393363.
729 Wood, J. J., Drahota, A., Sze, K., Har, K., Chiu, A., & Langer, D. A. (2009). Cognitive behavioral therapy for anxiety in children with autism spectrum disorders: A randomized, controlled trial. Journal of Child Psychology and Psychiatry, 50, 224–234. doi:10.1111/j.1469-7610.2008.01948.x.
123
