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Psychosocial Interventions For Executive Function in ADHD and ASD

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Psychosocial Interventions For Executive Function in ADHD and ASD

 

November 29, 2010

Latha Soorya, PhD

 

Assistant Professor of Psychiatry, Mount Sinai School of Medicine

First published in Psychiatry Weekly, Volume 5, Issue 29, on November 29, 2010.

 

Introduction

Autism spectrum disorders (ASDs) and attention-deficit/hyperactivity disorder (ADHD) are among the most commonly diagnosed psychiatric syndromes in childhood. Both syndromes have unambiguous distinctions, but ADHD and ASD share several common cognitive and behavioral disturbances, including deficits in behavior regulation, deficits associated with executive function impairments (planning, inattention, behavioral regulation), motor coordination problems, and impairments in peer relationships and socialization.

Executive Functions

Executive functions are among the most well-studied neurocognitive deficits in the ASD and ADHD literature. Across disorders, executive function is a broad construct consisting of several higher-order cognitive abilities (eg, working memory, response inhibition, set-shifting, planning, and monitoring skills) that govern one’s ability to perform adaptive responses to complex or novel situations. Executive function deficits are at the core of the neurocognitive profile in ADHD, with deficits in inattention, inhibition, and working memory. Less conclusive evidence is available for deficits in other executive function domains such as fluency, perseveration, and self-regulation/monitoring.

The nature of the executive function problems in ASD is not well described. For example, questions remain about the profile of executive function deficits, specificity of executive function deficits to ASD, and presence across the lifespan. Ozonoff and colleagues provide a comprehensive review of executive function research in ASD and suggest that when evaluating components of executive function in ASD, a consistent pattern of abilities and disabilities appear. Generally, the literature suggests that sustained attention and response inhibition are two components of executive function that are relatively preserved in ASD. In contrast, set-shifting/flexibility and planning are commonly found deficits. Deficits in other executive functions are more mixed, particularly in the area of working memory. Some studies have found no deficits in working memory, with others suggesting verbal or spatial working memory deficits.

Targeted Treatments for Executive Functions

Functional impairments associated with the executive function domains of attention and inhibition are cardinal features of ADHD and are commonly associated with ASD.

In ADHD, a large pool of studies support the efficacy of behavioral parent training and behavioral classroom management for the core symptoms of inattention and behavioral regulation (see Pelham and Fabiano, 2008 for review), although the additive value of behavioral interventions to the standard of care (ie, medication treatment) remains a contentious debate in the field. The behavioral interventions involve parent or teacher training in the use of effective reinforcement and punishment procedures (eg, time-out) for target behaviors (eg, following directions, completing homework). The rationale for these behavioral interventions is to provide compensatory systems for the executive functioning deficits found in ADHD (eg, behavioral regulation, working memory, and internalized/self-directed speech). Research in ADHD also includes cognitive remediation programs targeting a broad range of functional deficits associated with executive function and computerized attention training programs.

Behavioral interventions for inattention and impulsivity in ASD generally utilize similar contingency management approaches, in combination with antecedent-based (or preventative) interventions. Interventions that create scheduled access to a child’s intense interests (eg, through picture activity schedules) may also be helpful. Stevenson and colleagues conducted a randomized controlled trial of targeted executive function interventions in ASD utilizing an 8–12-week psychosocial program targeting time management, organization, and planning skills in adults. Findings suggest clinically significant improvements in ADHD symptomology and organization skills, with maintenance seen 12 months post-intervention. Studies of computerized attention training have shown promise in clinic settings and untrained tasks, but have failed to show generalization outside of the lab (eg, academic settings, teacher/parent ratings). Interventions directly targeting organization and planning skills in ASD have not been published to date.

Disclosure: Disclosure: Dr. Soorya reports no affiliations with, or financial interests in, any organization that may pose a conflict of interest.