Do Researchers Evaluate Psychosocial Interventions

Authors: Nick Chown

Publish Date: 2015/05/09

Volume: 2, Issue: 3, Pages: 243-261

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Abstract

Despite the increasing sophistication of research in autism some authors refer to a researchtopractice gap in this field There are large bodies of theoretical work in autism and of work on psychosocial interventions for autism In this article we investigate the extent to which researchers evaluate psychosocial interventions for autism from the perspective of the three dominant cognitive autism theories theory of mind executive dysfunctioning and central coherence We believe that we have identified a theorytoresearchtopractice gap and propose consideration of theory as a standard part of research practice in connection with autism interventions to bridge this gap and enhance the efficacy and effectiveness of interventionsIt has been written that despite the increasing sophistication of research in autism the gap between pure and applied research in this field is increasing ie that a disconnect between the knowledge built up by researchers and its applicability in the real world has developed Reichow et al 2008 Other authors refer to a researchtopractice gap in autism intervention and of growing evidence that this contributes to a situation where it is rare for effective autism interventions to be implemented successfully in public mental health and education contexts Dingfelder and Mandell 2011 There is a recognition that integration is crucial to making progress in autism research but that integrated research frameworks invariably overlook the intervention aspect McGregor et al 2008 For interventions in autism to be as successful as they should be it would seem unarguable that these disconnects need to be addressed Increasing use of evidencebased practice EBP is clearly crucial in this respect Reichow et al 2008 Wilczynski and Christian 2008 EBP involves using currently best available evidence explicitly and prudently in determining how to intervene with an individual Sackett et al 1996 There must be evidence for both the efficacy whether an intervention works and effectiveness whether it has benefits for the individual of an intervention two concepts that are considered by some to fall on a continuum Silverman and Hinshaw 2008An intervention is psychosocial if it is ‘aimed at improving people’s wellbeing and uses cognitive cognitivebehavioural behavioural and supportive interventions’ Zimmermann et al 2009 p 97 It has been pointed out that psychosocial autism interventions have generally been founded either in theory or empirical evidence of effectiveness or both Jones and Jordan 2008 This suggests that such interventions would be more likely to be efficacious and effective if founded in both empirical evidence and theory Whilst theory capable of explaining the cognitive differences in autism would be of obvious importance in connection with cognitively based interventions it could be argued that all psychosocial interventions in autism should be considered in the light of the cognitive differences that are generally accepted to characterise autism or ‘the autisms’ to borrow Gillberg’s term Doan and Fenton 2012 Frith and Happé 1999 Gillberg 2013 Happé and Frith 2006 Kunda and Goel 2008 Mottron et al 2006 and to reflect those differences as necessary Later we describe the three cognitive autism theories that are generally accepted to characterise many of the aspects of cognition in autism have a substantial evidence base and assume a pivotal role in autism education and training the theory of mind ToM executive dysfunctioning EDF and central coherence CC However we suspected that theory—whether autism theory or theory of general application applied to autism eg behavioural theory and social learning theory—would play a lesser role than empirical evidence in support of the majority of psychosocial interventions in autism Although the primary focus in our study was on the three cognitive theories that have assumed such a prominent position in autism education and training and have therefore had a major influence on those working in the context of autism in education healthcare social care and elsewhere we sought references to any theory in the studies we reviewed as we believe that all autism support should have a sound theoretical baseDespite extensive research there is still no established theoretical framework for autism or an account that captures the definitive nature of autism although in recent times the ToM EDF and CC theories of autism have assumed a dominant position in the psychological domain of autism research Rajendran and Mitchell 2007 These three theories have ‘been hugely influential in understanding different aspects of autism’ Rajendran 2013 with leading experts in the field acknowledging that they explain many characteristics associated with autism and predict many areas of difficulty experienced in autism Bowler 2006 Hill and Frith 2003 Rozga et al 2011 They are supported by extensive empirical evidence Bowler 2006 Happé 1995 Rutter et al 2011 Although not a definitive framework these three theories of autism have assumed a special position in the canon of autism theory featuring in most if not all autism education and training and being written about extensively in many books on autismTheory of mind is the ability to know that others have different thoughts and feelings to one’s own and to be able to understand and predict the feelings of others When originally applied to autism it was hypothesised that the social difficulties associated with autism result from an absent or impaired theory of mind BaronCohen et al 1985 Nowadays it is unlikely that many people still believe that absence or impairment in theory of mind is the sole cause of autism it is generally considered to be one of the three ‘key’ theories able to explain some of the cognitive differences between those with autism and those without BaronCohen and Swettenham 1997 Frith and Happé 1994 Ozonoff et al 1991 Pellicano 2010 The second of the two dominant cognitive theories of autism is known as executive dysfunctioning Executive function has been defined as the cognitive functions necessary to enable the selfcontrol necessary to facilitate problemsolving for the attainment of a future goal and includes planning impulse control/inhibition set maintenance search organisation working memory and flexibility of thought and action The executive dysfunctioning hypothesis in autism hypothesises that autism involves difficulties with certain executive functions including planning cognitive flexibility and working memory Ozonoff et al 1991 Verté et al 2006 The other dominant cognitive theory of autism is central coherence which refers to the view that a characteristic of information processing in typically developing people is the tendency to draw together diverse information to understand the whole known as global processing The original formulation of the central coherence theory of autism held that in autism there is a lack of central coherence resulting in a focus on the detail rather than the whole local processing which was classified as weak central coherence Frith and Happé 1994 But in their later formulation Happé and Frith 2006 now regard the focus on detail in autism to be a cognitive style or preference not a weakness There is a substantial evidence base for the efficacy of these three theories Bowler 2006 Happé 1995 Rutter et al 2011It would seem reasonable to conclude that evidencebased interventions based on efficacious and effective autism theory would stand a better chance of proving successful in practice than those with no explicit foundation in autism theory and thus at best an unclear grounding in cognition characteristic of autism or ‘the autisms’ Gray explains that human beings interpret the behaviour of others by making a variety of assumptions based on a common social understanding but that these assumptions will be wrong if an individual thinks differently Attwood and Gray 1999 p 2 write that these ‘assumptions…may not be applicable to children with an ASD autism spectrum disorder who have significant problems with Theory of Mind Skills Affected Relatedness Central Coherence and Executive Function’ Gray explains that this makes it difficult for a person with autism and a nonautistic peer to understand each other and interact effectively because the two people are ‘responding with equally valid but different perceptions of the same event’ Gray 1998 p 168 The interventions Gray is most closely associated with and which are widely used as an intervention tool to assist people with autism to understand nonautistic behaviour—social stories and comic strip conversations—are specifically designed to take account of the differences in cognition in autism described by the ToM EDF and CC theories‘challenges thinking patterns and includes the use of metacognitive strategies selfmonitoring and selfregulation and exposure and response situations…to address…idiosyncratic ways of perceiving and understanding emotions deficits in theory of mind and challenges to executive functioning that inhibit socially competent interactions with others’ Stichter et al 2010 p 1069This intervention provided 29 students with a diagnosis and test score criteria consistent with either high functioning autism HFA or Asperger syndrome AS in seven groups of a maximum of six individuals per group over five semesters with 20 h of group activity undertaken twice weekly for a period of 10 weeks in an afterschool clinical setting The results for two of the students were excluded from the analysis as they had missed more than a quarter of the sessions The mean age at enrolment was 1257 years SD = 128 range 1083–1475 All the students were male as no female students diagnosed with HFA or AS were enrolled The authors’ preliminary report indicated that the SCI intervention was effective in increasing social competence in these students with HFA and AS although the ToM results were mixed1 Parents reported that measures of both social abilities and executive functioning improved as well as in the ability to recognise emotions in facial expressions The authors consider that their work demonstrates the importance of developing interventions to improve social competence in autism that are specifically designed to reflect the cognitive characteristics of autism Stichter et al 2010 Importantly they call for an increase in interdisciplinary working as a means to develop better autism interventions

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