DEPARTMENT OF DEFENSE - CONGRESSIONALLY DIRECTED MEDICAL RESEARCH PROGRAMS

Cognitive Enhancement Therapy: A Promising Approach for Adults with Autism Spectrum Disorder

Posted April 18, 2018

Nancy J. Minshew, M.D., Shaun M. Eack, Ph.D., University of Pittsburgh

Dr. Nancy Minshew
Dr. Nancy J. Minshew

Dr. Shaun M. Eack
Dr. Shaun M. Eack

Autism Spectrum Disorder (ASD) is characterized by the development of neurobiological impairments in social and non-social information processing. Individuals living with this neurodevelopmental disorder are known to experience substantial deficits in cognitive function and social interaction, as well as verbal and non-verbal communication. ASD-related neurocognitive impairments typically result in significant functional disability that persists throughout the lifetimes of those affected. Such deficits present significant challenges to individuals in adulthood, affecting employability, relationship development, and diminishing overall quality of life. While several treatment options have been made available for children with ASD, such efforts are fairly limited for adults. Only a few interventions currently exist for the adult population, none of which have been proven to effectively target both social and non-social cognitive impairments in information processing in a manner that can influence major domains of functioning, including employment.

With support from a Fiscal Year 2010 Clinical Trial Award, Dr. Nancy Minshew and Dr. Shaun Eack sought to conduct the first randomized, controlled clinical trial evaluating the efficacy of Cognitive Enhancement Therapy (CET) on cognitive and behavioral deficits in verbal adults with ASD, with an 18-month comprehensive cognitive rehabilitation intervention that was originally developed for schizophrenia. CET was compared to Enriched Supportive Therapy (EST), an active comparison condition focused on psychoeducation and stress management, in a total of 54 verbal adult outpatients with ASD. The CET treatment utilizes a combination of computer-based exercises and group therapy sessions to improve thinking and to facilitate the achievement of adult social milestones, particularly perspective-taking. Computer exercises draw from a range of existing programs that focus on improving processing speed, memory, and flexibility, while group sessions center on enhancing social cognition, or the ability to understand and effectively interact with others. EST utilizes individual therapy to provide psychoeducation on autism and to improve skills related to condition and stress management.

The first results of the clinical trial have been recently published in the journal Autism Research. After 18 months of treatment, both therapies demonstrate gains, although CET produces more substantial improvements in social and non-social cognition (see Figure 1) (Eack et al., 2017). In particular, CET has proven to be highly efficacious in enhancing neurocognitive function, specifically attention and processing speed. These neurocognitive improvements demonstrated a positive and substantial effect on employability in adults with ASD (see Figure 2), such that participants who received CET were more likely to be employed at the end of treatment compared to EST (Eack et al., 2017). Individuals treated with EST also achieved noticeable enhancements in social ability, although they took longer to emerge and were not as large as the benefits from CET. Nonetheless, CET and EST address different challenges and are both expected to be beneficial treatments for adults with ASD. Further results from this trial are in preparation and expected to be published in the near future, including neuroimaging evidence of the potential brain mechanisms that underlie improved outcomes associated with these treatments.

As the first empirically validated treatment to address some of the core deficits in adult autism, this work will lay the first stone for upcoming efforts in third party reimbursement and broad dissemination of the results. Dr. Eack stated that the Substance Abuse and Mental Health Services Administration, which operates the Centers for Medicare and Medicaid Services, has already accepted CET for the treatment of schizophrenia and insurers have expressed interest in its use in ASD. However, approval to utilize CET as a standardized therapy requires confirmation of these results in a second, larger clinical trial in adults with ASD. This trial is funded by the National Institute of Mental Health (MH106450, Eack, PI), is currently in progress, and is due for completion in 2020. In preparation for disseminating their results, Dr. Minshew and Dr. Eack are in the process of developing training modules of the CET program to help facilitate other providers in learning and adopting the intervention. They intend to demonstrate that other sites and providers can be taught to deliver CET and EST to patients and implement both properly.

Dr. Minshew and Dr. Eack are hopeful that there can be combined centers delivering CET and EST for adults suffering from autism, schizophrenia, and other neurodevelopmental conditions for which these interventions are indicated. Presenting community providers with the ability to support verbal adults with ASD will alleviate several other challenges, such as the common misdiagnosis of high functioning ASD individuals as having schizophrenia and the later development of schizophrenia in about 9% of adults with ASD. Centers with the capabilities to deliver CET and EST would facilitate the development and maintenance of the expertise and cross talk needed to help address these diagnostic difficulties, and provide an opportunity for reducing social and cognitive impairments in adults with ASD through effective evidence-based treatments.


Figure 1
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Figure 2
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Publication:

Eack SM, Hogarty SS, Greenwald DP, Litschge MY, Porton SA, Mazefsky CA, and Minshew NJ. 2017. Cognitive enhancement therapy for adult autism spectrum disorder: Results of an 18-month randomized clinical trial. Autism Research.

 

Link:

Public and Technical Abstracts: A Randomized Clinical Trial of Cognitive Enhancement Therapy for Adults with Autism Spectrum Disorders

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Last updated Wednesday, April 18, 2018