Interventions for Adolescents and Young Adults With Autism Spectrum Disorders

374 Pages·2012·2.93 MB·English

Comparative Effectiveness Review
Number 65
Interventions for
Adolescents and Young
Adults With Autism
Spectrum Disorders
Comparative Effectiveness Review
Number 65

Interventions for Adolescents and Young Adults With
Autism Spectrum Disorders

Prepared for:
Agency for Healthcare Research and Quality
U.S. Department of Health and Human Services
540 Gaither Road
Rockville, MD 20850
www.ahrq.gov

Contract No. 290-2007-10065-I

Prepared by:
Vanderbilt Evidence-based Practice Center
Nashville, TN

Investigators:
Julie Lounds Taylor, Ph.D.
Dwayne Dove, M.D.
Jeremy Veenstra-VanderWeele, M.D.
Nila A. Sathe, M.A., M.L.I.S.
Melissa L. McPheeters, Ph.D., M.P.H.
Rebecca N. Jerome, M.L.I.S., M.P.H.
Zachary Warren, Ph.D.

AHRQ Publication No. 12-EHC063-EF
August 2012
This report is based on research conducted by the Vanderbilt Evidence-based Practice Center
under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD
(Contract No. 290-2007-10065-I). The findings and conclusions in this document are those of the
author(s), who are responsible for its content, and do not necessarily represent the views of
AHRQ. No statement in this report should be construed as an official position of AHRQ or of the
U.S. Department of Health and Human Services.

The information in this report is intended to help health care decisionmakers—patients and
clinicians, health system leaders, and policymakers, among others—make well-informed
decisions and thereby improve the quality of health care services. This report is not intended to
be a substitute for the application of clinical judgment. Anyone who makes decisions concerning
the provision of clinical care should consider this report in the same way as any medical
reference and in conjunction with all other pertinent information, i.e., in the context of available
resources and circumstances presented by individual patients.

This report may be used, in whole or in part, as the basis for the development of clinical practice
guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage
policies. AHRQ or U.S. Department of Health and Human Services endorsement of such
derivative products or actions may not be stated or implied.

This document is in the public domain and may be used and reprinted without permission except
those copyrighted materials that are clearly noted in the document. Further reproduction of those
copyrighted materials is prohibited without the specific permission of copyright holders.

Persons using assistive technology may not be able to fully access information in this report. For
assistance contact [email protected].

None of the investigators has any affiliations or financial involvement that conflicts with the
material presented in this report.

Suggested citation: Lounds Taylor J, Dove D, Veenstra-VanderWeele J, Sathe NA, McPheeters
ML, Jerome RN, Warren Z. Interventions for Adolescents and Young Adults With Autism
Spectrum Disorders. Comparative Effectiveness Review No. 65. (Prepared by the Vanderbilt
Evidence-based Practice Center under Contract No. 290-2007-10065-I.) AHRQ Publication No.
12-EHC063-EF. Rockville, MD: Agency for Healthcare Research and Quality. August 2012.
www.effectivehealthcare.ahrq.gov/reports/final.cfm.

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Preface
The Agency for Healthcare Research and Quality (AHRQ) conducts the Effective Health
Care Program as part of its mission to organize knowledge and make it available to inform
decisions about health care. As part of the Medicare Prescription Drug, Improvement, and
Modernization Act of 2003, Congress directed AHRQ to conduct and support research on the
comparative outcomes, clinical effectiveness, and appropriateness of pharmaceuticals, devices
and health care services to meet the needs of Medicare, Medicaid, and the Children’s Health
Insurance Program (CHIP).
AHRQ has an established network of Evidence-based Practice Centers (EPCs) that produce
Evidence Reports/Technology Assessments to assist public- and private-sector organizations in
their efforts to improve the quality of health care. The EPCs now lend their expertise to the
Effective Health Care Program by conducting comparative effectiveness reviews (CERs) of
medications, devices, and other relevant interventions, including strategies for how these items
and services can best be organized, managed, and delivered.
Systematic reviews are the building blocks underlying evidence-based practice; they focus
attention on the strength and limits of evidence from research studies about the effectiveness and
safety of a clinical intervention. In the context of developing recommendations for practice,
systematic reviews are useful because they define the strengths and limits of the evidence,
clarifying whether assertions about the value of the intervention are based on strong evidence
from clinical studies. For more information about systematic reviews, see
www.effectivehealthcare.ahrq.gov/reference/purpose.cfm
AHRQ expects that CERs will be helpful to health plans, providers, purchasers, government
programs, and the health care system as a whole. In addition, AHRQ is committed to presenting
information in different formats so that consumers who make decisions about their own and their
family’s health can benefit from the evidence.
Transparency and stakeholder input from are essential to the Effective Health Care Program.
Please visit the Web site (www.effectivehealthcare.ahrq.gov) to see draft research questions and
reports or to join an email list to learn about new program products and opportunities for input.
Comparative Effectiveness Reviews will be updated regularly.
We welcome comments on this CER. They may be sent by mail to the Task Order Officer
named below at: Agency for Healthcare Research and Quality, 540 Gaither Road, Rockville, MD
20850, or by email to [email protected].

Carolyn M. Clancy, M.D. Jean Slutsky, P.A., M.S.P.H.
Director Director, Center for Outcomes and Evidence
Agency for Healthcare Research and Quality Agency for Healthcare Research and Quality

Stephanie Chang, M.D., M.P.H. Shilpa Amin, M.D., MBsc, FAAFP
Director Task Order Officer
Evidence-based Practice Program Center for Outcomes and Evidence
Center for Outcomes and Evidence Agency for Healthcare Research and Quality
Agency for Healthcare Research and Quality

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Acknowledgments
The authors gratefully acknowledge the following individuals for their contributions to this
project:
Dr. Adeola Davis assisted with reviewing abstracts and full-text articles and data extraction.
We appreciate her willingness to take on whatever was asked of her.
Dr. Shanthi Krishnaswami lent her keen eye for detail to data extraction and reviews of
abstracts and full text articles. We also appreciate her thoughtful input into methodological
discussions.
Ms. Kathy Lee provided helpful assistance in locating articles and preparing materials for
meetings.
Ms. Sanura Latham and Ms. Leah Vance assisted with formatting tables and appendices and
lent their support to logistical elements of the review.
Key Informants
Somer L. Bishop, Ph.D. Marcia Mailick Seltzer, Ph.D.
Cincinnati Children’s Hospital Waisman Center
Cincinnati, OH Madison, WI

Edwin H. Cook, Jr., M.D. Fred R. Volkmar, M.D.
University of Illinois, Chicago Yale Child Study Center
Chicago, IL New Haven, CT

Jim Perrin, M.D.
Massachusetts General Hospital
Boston, MA
Technical Expert Panel
Somer L. Bishop, Ph.D. Patricia Howlin, Ph.D.
Cincinnati Children’s Hospital Institute of Psychiatry
Cincinnati, OH London, United Kingdom

Daniel Coury, M.D. Jim Perrin, M.D.
Ohio State University Massachusetts General Hospital
Columbus, OH Boston, MA

Edwin H. Cook, Jr., M.D. Peter Szatmari, M.D., M.Sc.
University of Illinois, Chicago McMaster University
Chicago, IL Hamilton, Ontario, Canada

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Peer Reviewers
Somer L. Bishop, Ph.D. Jim Perrin, M.D.
Cincinnati Children’s Hospital Massachusetts General Hospital
Cincinnati, OH Boston, MA

Edwin H. Cook, Jr., M.D. Lawrence Scahill, Ph.D.
University of Illinois, Chicago Yale University
Chicago, IL New Haven, CT

Patricia Howlin, Ph.D. Tristram Smith, Ph.D.
Institute of Psychiatry University of Rochester
London, United Kingdom Rochester, NY

Doris Lotz, M.D. Peter Szatmari, M.D., M.Sc.
New Hampshire Department of Health and McMaster University
Human Services Hamilton, Ontario, Canada
Concord, NH

Gary Mesibov, Ph.D.
University of North Carolina
Chapel Hill, NC

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Interventions for Adolescents and Young Adults With
Autism Spectrum Disorders
Structured Abstract
Objectives. We systematically reviewed evidence on therapies for adolescents and young adults
(ages 13 to 30) with autism spectrum disorders (ASD). We focused on the outcomes, including
harms and adverse effects, of interventions addressing the core symptoms of ASD; common
medical and mental health comorbidities occurring with ASD; the attainment of goals toward
functional/adult independence; educational and occupational/vocational attainment; quality of
life; access to health and other services; and the transitioning process (i.e., process of
transitioning to greater independent functioning). We also addressed the effects of interventions
on family outcomes including parent distress and satisfaction with interventions.

Data sources. We searched MEDLINE® via PubMed, PsycINFO®, the Educational Resources
Information Clearinghouse, and the Cumulative Index of Nursing and Allied Health Literature
databases as well as the reference lists of included studies.

Review Methods. We included studies published in English from January 1980 to December
2011. We excluded intervention studies with fewer than 20 adolescents or young adults with
ASD or fewer than 20 parents or family members of such individuals and studies lacking
relevance to ASD treatment.

Results. We identified 32 unique studies, most of which were poor quality. Five studies, mostly
of medical interventions, were fair quality, and none were good. In the behavioral literature,
studies of group- and computer-based interventions reported short-term gains in social skills.
Two poor-quality studies of educational interventions reported some gains in vocabulary and
reading. Four small studies investigated disparate interventions addressing highly specific
adaptive/life skills with some positive results in studies typically of short duration. Studies of
vocational interventions, all of poor quality, reported that on-the job supports may promote
employment in the community. Little evidence supports the use of medical interventions in
adolescents and young adults with ASD; however, antipsychotic medications and serotonin
reuptake inhibitors were associated with improvements in specific challenging behaviors.
Similarly, little evidence supports the use of allied health interventions including facilitated
communication.

Conclusions. Few studies have been conducted to assess treatment approaches for adolescents
and young adults with ASD, and as such there is very little evidence available for specific
treatment approaches in this population; this is especially the case for evidence-based approaches
to support the transition of youth with autism to adulthood. Of the small number of studies
available, most were of poor quality, which may reflect the relative recency of the field. Five
studies, primarily of medical interventions, had fair quality. Behavioral, educational, and
adaptive/life skills studies were typically small and short term and suggested some potential
improvements in social skills and functional behavior. Small studies suggested that vocational
programs may increase employment success for some individuals. Few data are available to
support the use of medical or allied health interventions in the adolescent and young adult
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population. The medical studies that have been conducted focused on the use of medications to
address specific challenging behaviors, including irritability and aggression, for which
effectiveness in this age group is largely unknown and inferred from studies including mostly
younger children.
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Contents
Executive Summary .................................................................................................................ES-1
Introduction ....................................................................................................................................1
Need for Evidence Regading Treatment of Autism Spectrum Disorders in Adolescents
and Young Adults ................................................................................................................1
Interventions Used To Treat ASD .............................................................................................2
Behavioral Interventions ......................................................................................................2
Educational Interventions ....................................................................................................3
Vocational Interventions ......................................................................................................3
Adaptive/Life Skills Interventions .......................................................................................3
Medical and Related Interventions ......................................................................................4
Allied Health Interventions ..................................................................................................4
Importance of this Review .........................................................................................................5
Scope and Key Questions ..........................................................................................................5
Scope of This Report ...........................................................................................................5
Key Questions ......................................................................................................................5
Organization of This Evidence Report ......................................................................................6
Uses of This Report ...................................................................................................................6
Methods ...........................................................................................................................................8
Topic Development and Refinement .........................................................................................8
Role of the AHRQ Task Order Officer ................................................................................8
Analytic Framework ..................................................................................................................8
Literature Search Strategy........................................................................................................10
Databases ...........................................................................................................................10
Regulatory Information ......................................................................................................10
Search Terms .....................................................................................................................10
Process for Study Selection .....................................................................................................11
Inclusion and Exclusion Criteria ........................................................................................11
Screening of Studies ................................................................................................................13
Categorization of Interventions................................................................................................13
Data Extraction and Data Management ...................................................................................14
Individual Study Quality Assessment ......................................................................................14
Determining Quality Levels ...............................................................................................15
Data Synthesis ..........................................................................................................................15
Grading the Body of Evidence for Each Key Question ...........................................................15
Applicability ............................................................................................................................17
Peer Review and Public Commentary .....................................................................................17
Results ...........................................................................................................................................18
Article Selection.......................................................................................................................18
Organization of Results............................................................................................................19
Overview of the Literature .......................................................................................................19
Studies of Behavioral Interventions .........................................................................................20
Key Points ..........................................................................................................................20
Overview of the Literature .................................................................................................21
Detailed Analysis ...............................................................................................................21
Studies of Educational Interventions .......................................................................................26
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Key Points ..........................................................................................................................26
Overview of the Literature .................................................................................................26
Detailed Analysis ...............................................................................................................26
Studies of Adaptive/Life Skills Interventions ..........................................................................28
Key Points ..........................................................................................................................28
Overview of the Literature .................................................................................................28
Detailed Analysis ...............................................................................................................29
Studies of Vocational Interventions .........................................................................................32
Key Points ..........................................................................................................................32
Overview of the Literature .................................................................................................32
Detailed Analysis ...............................................................................................................32
Studies of Medical Interventions .............................................................................................37
Key Points ..........................................................................................................................37
Overview of the Literature .................................................................................................37
Detailed Analysis ...............................................................................................................38
Studies of Allied Health Interventions .....................................................................................49
Key Points ..........................................................................................................................49
Overview of the Literature .................................................................................................49
Detailed Analysis ...............................................................................................................49
Discussion......................................................................................................................................54
State of the Literature...............................................................................................................54
Summary of Outcomes ............................................................................................................54
Studies of Behavioral Interventions ...................................................................................54
Studies of Educational Interventions .................................................................................54
Studies of Adaptive/Life Skills Interventions ....................................................................55
Studies of Vocational Interventions ...................................................................................55
Studies of Medical Interventions .......................................................................................55
Studies of Allied Health Interventions ...............................................................................57
Strength of the Evidence for Effectiveness of Therapies .........................................................57
Overview ............................................................................................................................57
Applicability ............................................................................................................................61
Applicability of the Evidence ............................................................................................61
Gaps in the Evidence ...............................................................................................................64
Methodologic Considerations ............................................................................................64
Future Research .................................................................................................................65
Conclusions ..............................................................................................................................67
References .....................................................................................................................................68
Acronyms and Abbreviations .....................................................................................................73

Tables
Table A. Description of Study Quality Levels...........................................................................ES-6
Table B. Summary of Strength of Evidence and Key Outcomes of Studies ...........................ES-11
Table 1. Inclusion and Exclusion Criteria ......................................................................................11
Table 2. Description of Study Quality Levels ...............................................................................15
Table 3. Domains Used To Assess Strength of Evidence ..............................................................16
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