A preliminary randomized, controlled trial of executive function training for children with autism spectrum disorder

Abstract

This randomized, controlled study examined the initial efficacy of an executive function training program for children with autism spectrum disorder. Seventy 7- to 11 year-olds with autism spectrum disorder and intelligence quotients ⩾80 were randomly assigned to receive a web-based set of executive function training games combined with in-person metacognition coaching or to a waitlist. Primary outcomes were evaluated for neural responses related to executive function, lab-based executive function behavior, and generalization of executive function skills. Secondary outcomes included measures of social function. Post-testing and analyses were conducted by staff naïve to group assignment. Children exhibited a change in neural response following training relative to the waitlist group [Formula: see text]. Training effects were not detected via lab-based tasks [Formula: see text] or generalized to caregiver-reported executive function skills outside the lab [Formula: see text]. However, the training group demonstrated reduced symptoms of repetitive behavior [Formula: see text] following training. There were no adverse events or attrition from the training group. Findings suggest that brief, targeted computer-based training program accompanied by coaching is feasible and may improve neural responses and repetitive behaviors of school-aged children with autism spectrum disorder. Lay abstract Executive function, which is a set of thinking skills that includes stopping unwanted responses, being flexible, and remembering information needed to solve problems, is a challenge for many children on the autism spectrum. This study tested whether executive function could be improved with a computerized executive function training program under the guidance of a coach who reinforced the use of executive function skills. Seventy children with autism spectrum disorder from age 7 to 11 years of age participated in the study. They were randomly assigned to receive training or to a waiting group. The tests most likely to determine whether the training may be effective were chosen from a larger battery before the study started and included one task measuring brain responses, two measures of executive function in the lab, and a parent questionnaire. Changes in social functioning and repetitive behaviors were also explored. All children assigned to training completed the program and families generally reported the experience was positive. Brain responses of the training group changed following training, but not within the waiting group during a similar time period. Children who received training did not exhibit behavioral changes during the two the lab-based tasks. Parent report on questionnaires indicated that neither group showed a significant change in their broad use of executive function in other settings. Yet, children who received training were reported to have fewer restricted and repetitive behaviors following training. These initial findings suggest that short executive function training activities are feasible and may improve some functioning of school-aged children on the autism spectrum.

Beyond group differences: Exploring the preliminary signals of target engagement of an executive function training for autistic children

“…The parent RCT, including the selection of outcome measures, was pre‐registered on http://clinicaltrials.gov (NCT02361762). See Faja et al, 2022 for the CONSORT diagram as well as full information on study design, training content, fidelity, and acceptability, and EEG acquisition and processing procedures.…”

“…Two of the games targeted inhibition (interference suppression and reactive inhibition), two targeted visual working memory, and all required set‐shifting. These specific EF skills were selected as training content because of prior evidence of ASD‐specific EF dysfunction in these areas (Faja et al, 2022). The number of consecutive correct responses and overall accuracy determined participants' progress between levels of each game.…”

“…Coaching supported the generalization of skills and information learned during training. Specific examples of coaching strategies can be found in the Supplemental Materials of the parent RCT report (Faja et al, 2022). The full manual is available from the senior author.…”

“…The parent RCT found that the EF training improved EF skills only at the neural level—the level of target engagement. At the more distal, clinical outcomes level, there were treatment effects for restricted and repetitive behaviors, but no effects related to EF behavior (Faja et al, 2022). This raised the possibilities that (1) the EF training was simply not delivered at the intensity needed to improve behavioral in addition to brain‐based EF outcomes, or that (2) the EF training improved EF at the behavioral level only for a subgroup of participants.…”

“…The parent RCT found that the EF training, compared to waitlist, improved performance on the hypothesized neural target: children's ability to monitor and differentiate conflicting information during a flanker task as measured by EEG (e.g., N2 incongruent amplitude) (Faja et al, 2022). It is not known whether the pre‐to‐post training change in this “neural target” is related to change in the behaviorally measured clinical outcomes of interest, including parent‐reported EF and repetitive behaviors (Figure 1).…”