News and Knowledge

Executive functions are the set of thinking skills that allow us to successfully set goals, make plans, wait for what we want, organize information, and be flexible. These skills are critical to doing well in school, at work, and living on our own. People with autism, however, often have difficulty with executive functions, preventing them from contributing their unique perspectives, knowledge, and skills to their communities.

Adolescence is a crucial time to target executive function skills. It is when they are most needed and when young people have gained the language, conceptual, and self-reflective capacities to explore, understand, and apply them. Flexibility, planning, organization, and problem-solving are key executive function skills for treatment because they are common problems that can interfere with school and everyday life but improve when taught directly.

In 2019, Cara Pugliese, Ph.D., and Lauren Kenworthy, Ph.D., completed a two-year OAR-funded research study examining the effectiveness of Unstuck and On Target: Flexible Futures, a school-based executive function intervention for high school students with autism spectrum disorder. Developed with input from autistic youth, parents, teachers, and autistic self-advocates, the program teaches personal executive function, self-advocacy, flexibility, planning, and goal-setting, among other skills. Designed to be taught by non-specialist high school teachers, the program can reach a broad range of autistic teens, including those who cannot access specialized clinical care.

Drs. Pugliese and Kenworthy were interested in answering three questions:

1. Does the Flexible Futures curriculum improve executive function skills and real-world behavior?
2. Can teachers effectively deliver the Flexible Futures program in schools?
3. Do youth and their parents like the Flexible Futures program?

Is The Program Effective?

To answer the first question, they tested the program against services typically given to students with autism, called “treatment as usual.” They predicted that students who received Flexible Futures would show gains in executive function skills as measured by:

• Parent, student, and teacher report
• Direct testing of executive function
• Observations of the students’ executive function skills in the classroom

Forty-nine high school students with autism (eight girls) between the ages of 14 and 20 at eight high schools in the Washington, D.C., area, participated in the study. Four schools were randomly assigned to the Flexible Futures group (29 students) and four to the treatment as usual group (20 students). Students in the treatment as usual group received their IEP accommodations, if applicable, in addition to autism-specific teaching supports and planning/studying supports.

The researchers measured executive function skills and adaptive skills before and after the intervention. Study staff was unaware of which students were in each group so they remained unbiased in their ratings.

Teachers in the Flexible Futures group received a short training along with program materials and were given the freedom to deliver the program in the easiest way possible (for example, as a class or during homeroom or lunch period). Parents received two trainings.

The researchers measured executive function skills in several ways:

• Students completed commonly used problem solving and planning tasks and the Executive Function Challenge Task with evaluators. The Challenge Task consisted of several collaborative activities that challenge the teens to be flexible and plan in a social context.
• Students, parents, and teachers rated students’ executive function skills in their daily lives.
• A member of the evaluation team observed each student during a regular academic class looking for flexibility, planning, organization, negativity, and work completion.
• Adaptive behavior was assessed through parent report.

They found that students in the Flexible Futures group demonstrated medium to large improvements on most of the measures:

• Direct EF testing: They increased their flexibility, problem-solving, and planning skills on both cognitive tests and social problem-solving challenges.
• Classroom EF behaviors: When observed in school, they got better at starting work on their own, staying on task, planning, changing tasks, being flexible, organizing, and showing less negativity.
• Questionnaires: They and their parents noted improved real-world planning and flexibility skills. Parents also said their teens improved in broader daily living skills, including those needed to care for themselves and to successfully interact with others.

In comparison, the treatment as usual group only improved on self-reported flexibility and parent-reported planning/organization skills.

The Flexible Futures group improved more than the treatment as usual group on the social flexibility and planning task, observations of executive function classroom behaviors, and parent-reported daily living skills.

Is It Easy for Teachers to Use?

The researchers found that all of the teachers delivered the correct lesson content and were able to finish teaching the entire curriculum. They were confident, positive, organized, and used the visuals and materials. Students were engaged and participated throughout the observations. All teachers reported that each lesson could be conducted easily and 95 percent noted that each lesson was helpful in the students acquiring new skills.

Do Students and Parents Like It?

Most teens (88%) said they would recommend the program to other teens. All teens (100%) said they were more flexible after participating and 72% said they were better at planning. Teens used skills at home (92%) and school (92%) and with parents (76%) and friends (68%).

Parents were also satisfied with the program. Most (95%) reported that it helped their child and 70% said their child’s flexibility and planning skills got better. All of them said they learned new skills.

Takeaways

These results suggest that autistic teens may be more available to learn in the classroom and have an easier time at school and at home after participating in the program. While the results are promising, this was a small study, and Flexible Futures needs to be tested with more students.

Teachers also noted that the program might be helpful for students with executive function problems who don’t have autism. A future research study could include students with attention deficit hyperactivity disorder and emotional difficulties that interfere with learning. The researchers are currently preparing the research edition of the program for publication so that it can be used more broadly, including in future research studies.