Wilson, K. P., Steinbrenner, J. R., Kalandadze, T., & Handler, L. (2019). Interventions targeting expressive communication systems in adults with autism spectrum disorders: A systematic review. Journal of Speech, Language, and Hearing Research, 62(4), 1959-1978.
Reviewed by: Kristen Singagliese, MS Ed, SPEd and David Celiberti, PhD, BCBA-D
Association for Science in Autism Treatment
Why study this topic?
The prevalence of autism has led to a greater need for research and interventions to better support individuals throughout their lifespan. This growing body of literature surrounding interventions highlights the need for increased attention to interventions for adults with autism, a group who demonstrate a continued capacity for learning and skill development throughout the lifespan. In their review, Wilson and colleagues acknowledge the relative lack of research in this area but suggest there is a body of work that can be used to build an evidence base going forward.
Vocational, residential, and community experiences associated with adulthood can provide diverse opportunities for the use of expressive communication, including social skills (Magiati et al., 2014). Unfortunately, current research does show that expressive language challenges persist throughout an individual’s lifespan and outcomes for adults with autism often include limitations in community participation, steady employment, and social relationships (e.g., Eaves & Ho, 2008; Gray et al., 2014). Therefore, continued intervention is needed. In particular, expressive communication remains an important target because it increases the likelihood of an individual conveying their wants and needs, and such skills may be incompatible with challenging behavior.
What did the researchers do?
To assess the state of the existing published literature researchers conducted a systematic review with three goals: (1) Synthesize available research on interventions designed to improve the expressive communication in adults with ASD; (2) Analyze current research results, indicating the effect of each intervention on the expressive communication targets; and (3) Examine the effects of the interventions across sets of studies that use comparable research designs, interventions, and outcome measures.
The following inclusion criteria for research studies were used: (1) Included at least one participant diagnosed with ASD who was at least 18 years of age; (2) The research study examined an intervention, treatment, or model of care, such as behavioral, clinical, or educational; (3) The study provided outcome data in at least one area related to expressive communication and reported results separately for the adult participants with ASD; (4) The study design was experimental, quasi-experimental, case study, or pre-post; and (5) The review article was published in English.
Previously published research reviewed for this study was found using MEDLINE/PubMed, Psych Info, and CINAHL; a screening procedure which included the Covidence web-based systematic review software was also used. In an effort to capture any newly published research, a follow-up search was completed in 2018 using relevant journals (e.g., key ASD and speech-language pathology journals). Researchers linked medical subject headings, specific vocabulary, and keywords relating to ASD, communication, interventions, and programs to make the search more precise. Bibliographies, unpublished studies such as dissertations and conference abstracts of meta-analyses (a procedure for combining data from multiple studies), systematic reviews, and book chapters were cross-referenced to identify already existing completed research. After abstract screening, full-text review, and quality review, 20 studies out of the original 8,809 recorded through the database search were included in the final systematic review. This included 13 single-case design studies (SCD) and seven group design studies. After the follow-up review in 2018, two additional studies were included, one SCD and one group design, and both SCD and group design studies were included as to best represent the available evidence.
What did the researchers find?
Although evidence guiding the treatment of expressive communication challenges for adults with autism is expanding slowly, there are some interventions which were developed to target the expressive communication needs of adults with autism as will be highlighted below. Researchers found limited literature focused on expressive communication needs of adults with ASD. They also noted that barriers to the collection of the literature included differences in interventions and strategies, the duration of implementation, participant characteristics, and outcome measurements. Researchers determined that change would be more likely observed in studies in which the skills measured were taught through direct instruction and then measured in the intervention context.
The authors categorized the SCD studies based on general characteristics and ranged in intervention sessions from three to 33 sessions, with a majority of sessions between five to 10 sessions. The studies were then grouped into the following: (1) Five studies utilizing traditional applied behavior analytical techniques, including interventions such as tact training, task analysis, and reinforcement schedules; (2) Five studies which included a integration of video modeling, video feedback, and/or self-management strategies; (3) Two studies which measured outcomes of peer-mediated strategies; (4) Two studies which reviewed communication book training and writing strategy training.
In the SCD studies reviewed, all but one exhibited a functional relationship between the intervention and the targeted outcome(s) although many had limited data points per participant. More specifically, in the SCD studies, which used conventional applied behavior analytic strategies; two of these studies reported medium effects while three reported large effects. Six of the SCD studies included data directly related to an individual’s generalization of skills taught to additional interactions with different partners and settings. Eight of the SCD studies included data referencing the maintenance of the skills gained for targeted outcomes. In the two studies which reported on maintenance data, the authors noted that participants generalized skills taught into new interactions with people, and these effects were maintained for one to two months. SCD studies on video modeling/feedback and self-management interventions demonstrated functional relationships between the interventions and the outcome variables; three of these video modeling/feedback and self-management reported that skills were generalized to new peers and/or settings with five studies reporting maintenance at six weeks to one year. SCD studies which focused on peer-mediated interventions demonstrated a functional relationship between intervention and outcome variables. The communication book training intervention also reported a functional relationship between the intervention and the individual participant’s interaction skills. Writing training is the only SCD study that did not demonstrate a functional relationship between the intervention and the outcome variable.
The group design studies targeted social and pragmatic skills but utilized standardized tools to assess the outcomes of the interventions. These particular studies investigated a smaller range of available interventions which included two interventions focused on executive functioning and the third being the PEERS for Young Adults caregiver-assisted social skills intervention. The remaining three group design studies examined other interventions including the ACCESS Program, virtual reality job interview training, and oxytocin hormone therapy. The job interview skill intervention program used a rubric developed by the programs authors to assess progress. The number of intervention sessions for the group design studies ranged from 14 to 200 sessions, with most lasting 14 to 20 sessions; the hormone therapy lasted for six weeks. The group design studies reported on outcome variables that were generalized; a wide range of effects was noted.
What were the strengths and limitations of the study?
Strengths of this study included encouraging results regarding communication interventions overall and the beneficial impact they can have on expressive communication skills across the lifespan of individuals with autism. The potential for continued learning throughout adulthood is supported. Furthermore, the methods used to identify the exiting literature were comprehensive. This review provides detailed tables on interventions which have been effective for individual needs and characteristics of individual adults with autism. Although beyond the scope of this brief synopsis, our readers should spend time perusing the chart of interventions for more information and consider incorporating this information into their work.
Limitations were also noted. Studies indicated differences in settings, intervention lengths, and measurements. The study also lacks identification of a commonality in the characteristics of the participants included. Results across single and group design studies were not comparable and obstructed direct comparison. Visual analysis of graphs was used to make determinations as to the size of the studies’ effects; however, interrater agreements across decisions related to the size of these effects was only moderate. Steps were taken to avoid publication of only successful intervention reviews; however, publication bias may still exist and is therefore considered a limitation.
What do the results mean?
The results identify the gap that currently exists in the adult research and the continued need for expanded attention to interventions targeting expressive communication skills in adults with autism. It cannot be overstated that adults have the capacity to learn important skills throughout their lifespan. Future research should continue to adhere to quality standards and incorporate replication of previous research whenever possible. Clinicians and professionals can adapt interventions and create outcome measures specific to the adult population. Interventions considered evidence-based should continue to be adapted by professionals for the individual learner. The information and skill acquisition obtained should be used to assist in identifying areas most critical to address throughout an individual’s lifespan.
References
Eaves, L. C., & Ho, H. H. (2008). Young adult outcome of autism spectrum disorders. Journal of Autism and Developmental Disorders, 38(4), 739-747.
Gray, K. M., Keating, C. M., Taffe, J. R., Brereton, A. V., Einfeld, S. L., Reardon, T. C., & Tonge, B. J. (2014). Adult outcomes in autism: Community inclusion and living skills. Journal of Autism and Developmental Disorders, 44(1), 37-45.
Magiati, I., Tay, X. W., & Howlin, P. (2014). Cognitive, language, social and behavioural outcomes in adults with autism spectrum disorders: A systematic review of longitudinal follow-up studies in adulthood. Clinical Psychology Review, 34(1), 73-86.
Citation for this article:
Singagliese, K., & Celiberti, D. (2020). Research synopsis: Interventions targeting expressive communication systems in adults with autism spectrum disorders. Science in Autism Treatment, 17(1).
