Posted April 2, 2015
Nancy Minshew, M.D., and Shaun M. Eack, Ph.D., University of Pittsburgh
Autism spectrum disorder (ASD) are a range of neurodevelopmental disorders that are characterized by impairments in social interaction, verbal and nonverbal communication deficits, and repetitive interests and behaviors. Adults with ASD experience significant impairments in social and nonsocial information processing, which often results in unemployment or underemployment, poor academic performance, limited social functioning, and poor quality of life. Despite advances in early detection and intervention approaches to limit the impact of ASD, few efforts have focused on interventions for adults with ASD. In fact, no interventions currently exist for adults that effectively remediate the broad range of information processing impairments characteristic of ASD. Drs. Nancy Minshew and Shaun Eack of the University of Pittsburgh sought to address this research gap and test new intervention strategies for the adult ASD population.
With support from a Fiscal Year 2010 Autism Research Program Clinical Trial Award, Drs. Minshew and Eack initiated a pilot trial in which they randomized 54 adults with ASD to either Cognitive Enhancement Therapy (CET) or Enriched Supportive Therapy (EST). Both of these interventions have been shown to be effective in improving adaptive function in schizophrenia patients but have never before been tested in individuals with ASD. CET integrates computer-based training focusing on attention, memory, and problem solving, with a small group-based curriculum to facilitate the development of adult social-cognitive milestones. EST, an emotion management intervention that provides psychoeducation about ASD and condition management skills, was used as a control to account for the non-specific effects of CET.
To assess cognitive and behavioral outcomes, the research team used a battery of standardized neuropsychological tests and clinical interviews before and after implementation of either intervention strategy. Preliminary analysis of 42 participants in the study indicates that after 18 months of either CET or EST, adults with ASD had significant increases in neurocognition, social cognition, and social adjustment compared to baseline measures, although increases were highest in the CET group (see Figure 1). "CET, a cognitive approach, is more effective at addressing core cognitive impairments, and as a result, is improving functioning to a greater degree than EST," says Dr. Minshew. Furthermore, although CET is not an employment-based treatment, it resulted in significant gains in employment in the adult ASD population that was not observed with EST treatment.
Dr. Minshew and Dr. Eack next used functional magnetic resonance imaging (fMRI) to analyze brain images of the individuals undergoing either CET or EST while completing established perspective-taking and emotion regulation tasks. In the CET treatment group, they found significant differential increases in prefrontal brain function, signifying improvements in perspective-taking, and front-medial temporal connectivity, suggesting an increase in emotion regulation.
The results of the trial thus far show that both CET and EST are effective at improving cognition and adaptive function in adults with ASD compared with baseline measures. Additional advantages have been seen with CET intervention, including greatly improved neurocognitive and social-cognitive measures, increased employment, and increased prefrontal brain plasticity in the fMRI studies. Dr. Minshew adds, "The conclusion of the trial, which is near, is expected to establish the evidence base for not one, but two novel interventions for the treatment of adult ASD, for whom no empirically supported interventions targeting core deficits exist."
Eack SM, Bahorik AL, McKnight SA, et al. 2013. Commonalities in social and non-social cognitive impairments in adults with autism spectrum disorder and schizophrenia. Schizophr Res 148:24-28.
Eack SM, Greenwald DP, Hogarty SS, et al. 2013. Cognitive enhancement therapy for adults with autism spectrum disorder: Results of an 18-month feasibility study. J Autism Dev Disord 43:2866-2877.
Eack SM, Bahorik AL, Hogarty SS, et al. 2013. Brief report: Is cognitive rehabilitation needed in verbal adults with autism? Insights from initial enrollment in a trial of cognitive enhancement therapy. J Autism Dev Disord 43:2233-2237.
Bishop-Fitzpatrick L, Minshew NJ and Eack SM. 2013. A systematic review of psychosocial interventions for adults with autism spectrum disorders. J Autism Dev Disord 43:687-694.
Eack SM, Mazefsky CA, and Minshew NJ. 2014. Misinterpretation of facial expressions of emotion in verbal adults with autism spectrum disorder. Autism (Epub ahead of print).
Bishop-Fitzpatrick L, Mazefsky CA, Minshew NJ, et al. 2014. The relationship between stress and social functioning in adults with autism spectrum disorder and without intellectual disability. Autism Research (Epub ahead of print])