Randomized controlled effectiveness trial of executive function intervention for children on the autism spectrum
Open accessAbstract
Background: Unstuck and On Target ( UOT ) is an executive function ( EF ) intervention for children with autism spectrum disorders ( ASD ) targeting insistence on sameness, flexibility, goal‐setting, and planning through a cognitive‐behavioral program of self‐regulatory scripts, guided/faded practice, and visual/verbal cueing. UOT is contextually‐based because it is implemented in school and at home, the contexts in which a child uses EF skills. Methods: To evaluate the effectiveness of UOT compared with a social skills intervention ( SS ), 3rd–5th graders with ASD (mean IQ = 108; UOT n = 47; SS n = 20) received interventions delivered by school staff in small group sessions. Students were matched for gender, age, race, IQ, ASD symptomotolgy, medication status, and parents' education. Interventions were matched for ‘dose’ of intervention and training. Measures of pre–post change included classroom observations, parent/teacher report, and direct child measures of problem‐solving, EF , and social skills. Schools were randomized and evaluators, but not parents or teachers, were blinded to intervention type. Results: Interventions were administered with high fidelity. Children in both groups improved with intervention, but mean change scores from pre‐ to postintervention indicated significantly greater improvements for UOT than SS groups in: problem‐solving, flexibility, and planning/organizing. Also, classroom observations revealed that participants in UOT made greater improvements than SS participants in their ability to follow rules, make transitions, and be flexible. Children in both groups made equivalent improvements in social skills. Conclusions: These data support the effectiveness of the first contextually‐based EF intervention for children with ASD . UOT improved classroom behavior, flexibility, and problem‐solving in children with ASD . Individuals with variable background/training in ASD successfully implemented UOT in mainstream educational settings.
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Many evidence-based treatments for EF in children with developmental disabilities target specific EF deficit subtypes; for example, central stimulants are evidence-based for inhibition, working memory, and attention deficits, Cogmed improves working memory specifically, and Unstuck and On Target improves flexibility.
“Many evidence-based treatments for EF in children with developmental disabilities target specific “subtypes” of EF deficit, for example central stimulants are evidence-based for inhibition, working memory and attention deficits, while the computer-based treatment Cogmed improves working memory specifically (Diamond & Ling, 2016) and the cognitive-behavioral treatment Unstuck and On Target improves”
From Data‐driven identification of subtypes of executive function across typical development, attention deficit hyperactivity disorder, and autism spectrum disorders (2020) · cites this paper as Kenworthy et al., 2014
Split into 2 atoms — 1 confirmed, 1 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.
Experimental — accuracy not yet measuredDifficulties with habituation and flexibility, associated with disrupted integration between mPFC and limbic regions, can be treated directly with benefits for anxiety and depression.
“Difficulties with habituation and flexibility, associated with disrupted integration between mPFC and limbic regions, can also be treated directly with benefits for anxiety and depression (Kenworthy et al., 2014; Lawson et al., 2015; Wallace et al., 2016).”
From Sensory, emotional and cognitive contributions to anxiety in autism spectrum disorders (2017) · cites this paper as Kenworthy et al., 2014
The Methods describe an intervention that directly teaches flexibility, and the Discussion reports greater improvements in flexibility among children with autism who received it. The paper does not establish benefits for anxiety or depression, or link the treated difficulties to habituation or disrupted mPFC–limbic integration. Page numbers were not available in our copy. (LLM, conf=0.88)
Experimental — accuracy not yet measuredTraining has been shown to be specifically efficacious in ADHD and ASD, improving not only EF, but also symptomatology, such as inattentive symptoms in ADHD and social skills in ASD.
“Training has been shown to be specifically efficacious in ADHD55 and ASD28, improving not only EF, but also symptomatology, such as inattentive symptoms in ADHD and social skills in ASD.”
From Heterogeneity of executive functions among comorbid neurodevelopmental disorders (2016) · cites this paper as [28]
Unstuck and On Target is an executive function intervention designed for children with ASD that targets insistence on sameness, flexibility, goal-setting, and planning through a cognitive-behavioral program involving self-regulatory scripts, guided practice, and cueing.
“Unstuck and On Target (UOT) is an EF intervention designed for children with ASD that can be implemented in school and at home. UOT targets insistence on sameness, flexibility, goal-setting and planning through a cognitive-behavioral program involving self-regulatory scripts, guided practice, and cueing”
From Brain Mechanisms Supporting Flexible Cognition and Behavior in Adolescents With Autism Spectrum Disorder (2021) · cites this paper as [135]
Unstuck and On Target has been shown to be effective for improving classroom behavior, flexibility, and problem-solving in children with ASD.
“and has been shown to be effective for improving classroom behavior, flexibility and problem-solving in children with ASD (135).”
From Brain Mechanisms Supporting Flexible Cognition and Behavior in Adolescents With Autism Spectrum Disorder (2021) · cites this paper as [135]
A randomized controlled trial of the Unstuck and On Target program against a social skills intervention demonstrated that 7- to 11-year-old autistic children in both interventions improved, especially in social skills, but there were greater gains for those who received Unstuck and On Target, including better executive function skills (problem-solving, flexibility, planning) and improved classroom
“A randomized controlled trial that tested the effectiveness of this program against a social skills intervention demonstrated that, while 7-to 11-year-old autistic children in both interventions improved, especially with regard to social skills, there were greater gains for those children who received the Unstuck and On Target program, including better EF skills (problem-solving, flexibility, and”
From Childhood Executive Function Predicts Later Autistic Features and Adaptive Behavior in Young Autistic People: a 12-Year Prospective Study (2019) · cites this paper as Kenworthy et al.'s (2014)
Kenworthy et al.'s Unstuck and On Target program targets autistic executive function difficulties through a cognitive behavioral program that teaches autistic school-age children self-regulatory executive function scripts and how to deploy these scripts across different contexts to guide flexible, goal-directed behavior.
“Kenworthy et al.'s (2014) Unstuck and On Target program targets autistic EF difficulties through a cognitive behavioral program that teaches autistic school-age children self-regulatory EF scripts (e.g., Bstuck on a detail^, Bbig picture^, Bflexible thinking^) and how to deploy these scripts across different contexts in order to guide flexible, goal-directed behavior.”
From Childhood Executive Function Predicts Later Autistic Features and Adaptive Behavior in Young Autistic People: a 12-Year Prospective Study (2019) · cites this paper as Kenworthy et al.'s (2014)
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MethodTHE USE OF CONFIDENCE OR FIDUCIAL LIMITS ILLUSTRATED IN THE CASE OF THE BINOMIAL
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MethodWechsler Abbreviated Scale of Intelligence
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“…this finding is consistent with previous work showing that intervention to improve EF enhances social reasoning (Fisher & Happ e, 2005) and that EF abilities may be precursors to Theory of Mind abilities (Flynn, 2007), or in any case are correlated with them (Pellicano, 2007; Perner & Lang, 1999).”
ResultAdults with Autism Spectrum Disorders
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BackgroundProfiles of everyday executive function in acquired and developmental disorders.
Gioia, G. A., Isquith, P. K., Kenworthy, L., & Barton, R. M. (2002) · Child Neuropsychology · doi:10.1076/chin.8.2.121.8727 · Cited by 498 · see citing works
Self-citationEvidence for a cerebellar role in reduced exploration and stereotyped behavior in autism
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“The interventions were contextuallybased, or occurred in real world school and home settings, to maximize the potential for generalization of skills (Dingfelder & Mandell, 2011; Ylvisaker, Jacobs, & Feeney, 2003).”
BackgroundAdaptive skills and executive function in autism spectrum disorders.
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“…this finding is consistent with previous work showing that intervention to improve EF enhances social reasoning (Fisher & Happ e, 2005) and that EF abilities may be precursors to Theory of Mind abilities (Flynn, 2007), or in any case are correlated with them (Pellicano, 2007; Perner & Lang, 1999).”
ResultTHE RELATIONSHIP OF SELF‐STIMULATION TO LEARNING IN AUTISTIC CHILDREN1
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Repetitive behaviors in autism: relationships with associated clinical features
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“These investigations either had no control (Bauminger, 2002;Stichter et al., 2010,2012)ora waitlist control group (Solomon et al., 2004), and pre-/post-intervention assessment was not conducted by treatment-blind examiners.”
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ResultSelf-citationIncreasing Independence in Autism Spectrum Disorders: A Review of Three Focused Interventions
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“Although not expected, this finding is consistent with previous work showing that intervention to improve EF enhances social reasoning (Fisher & Happ e, 2005) and that EF abilities may be precursors to Theory of Mind abilities (Flynn, 2007), or in any case are correlated with them (Pellicano, 2007;…”
ResultInfluentialKlin, A. J., Danovitch, J. H., Merz, A. B., & Volkmar, F. R. (2007) · Research and Practice for Persons with Severe Disabilities · doi:10.2511/rpsd.32.2.89 · Cited by 222 · see citing works
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“…skills CBT interventions that also briefly address problem-solving skills relatedwithEF (Bauminger, 2002; Solomon, Goodlin-Jones, & Anders, 2004; Stichter et al., 2010, 2012) and find improvements in parent report of EF (Stichter et al., 2010, 2012) and social problem-solving in the laboratory…”
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“The expanding evidence for cognitive-behavioral therapy (CBT) targeting anxiety in ASD (see review Dawson & Burner, 2011) raises the possibility that this treatment modality can be used for other targets as well.”
BackgroundMethodSocial Interaction and Repetitive Motor Behaviors
Loftin, R. L., Odom, S. L., & Lantz, J. F. (2007) · Journal of Autism and Developmental Disorders · doi:10.1007/s10803-007-0499-5 · Cited by 181 · see citing works
Are Executive Control Functions Related to Autism Symptoms in High-Functioning Children?
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Self-citationPositive Supports for People Who Experience Behavioral and Cognitive Disability After Brain Injury
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“…skills CBT interventions that also briefly address problem-solving skills relatedwithEF (Bauminger, 2002; Solomon, Goodlin-Jones, & Anders, 2004; Stichter et al., 2010, 2012) and find improvements in parent report of EF (Stichter et al., 2010, 2012) and social problem-solving in the laboratory…”
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“Some of the scripts taught in UOT were first developed for children with EF deficits stemming from traumatic brain injuries (Feeney, 2010; Feeney & Ylvisaker, 2003; Ylvisaker & Feeney, 2008).”
BackgroundHigh functioning children with autism spectrum disorder: A novel test of multitasking
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The role of inhibitory control in false belief understanding
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“…this finding is consistent with previous work showing that intervention to improve EF enhances social reasoning (Fisher & Happ e, 2005) and that EF abilities may be precursors to Theory of Mind abilities (Flynn, 2007), or in any case are correlated with them (Pellicano, 2007; Perner & Lang, 1999).”
BackgroundResultNew directions in behavioral treatment of autism spectrum disorders
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“Isolation of the active ingredients in the intervention through comparison of outcomes following treatment with specific modules of UOT will allow streamlining this relatively lengthy intervention (Kasari & Lawton, 2010).”
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Self-citationContext-Sensitive Cognitive-Behavioral Supports for Young Children With TBI
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“It is designed to teach new skills and accommodate impairments (Feeney & Ylvisaker, 2008; Ylvisaker & Feeney, 1998) through a CBT program that teaches what flexibility, goal setting and planning are, why they are important, and how to use self-regulatory scripts that guide flexible, goal-directed…”
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ABAS-II Ratings and Correlates of Adaptive Behavior in Children with HFASDs
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“…with impairments in adaptive behavior (Gabriels, Cuccaro, Hill, Ivers, & Goldson, 2005; Gilotty, Ken- worthy, Sirian, Black, & Wagner, 2002; Lopata et al., 2012), learning (Akshoomoff, 2005; Blair & Razza, 2007; Koegel & Covert, 1972; Pierce & Corchesne, 2001), and social adaptation…”
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“Some of the scripts taught in UOT were first developed for children with EF deficits stemming from traumatic brain injuries (Feeney, 2010; Feeney & Ylvisaker, 2003; Ylvisaker & Feeney, 2008).”
BackgroundThe Neuropsychology of Autistic Spectrum Disorders
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“, 2012), learning (Akshoomoff, 2005; Blair & Razza, 2007; Koegel & Covert, 1972; Pierce & Corchesne, 2001), and social adaptation (e.”
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“Furthermore, gains in social skills and adaptive classroom behaviors were observed in children with HFASD who participated in an EF intervention compared to a social skills intervention during a randomized controlled trial (Kenworthy et al. 2013a, b).”
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“Difficulties with habituation and flexibility, associated with disrupted integration between mPFC and limbic regions, can also be treated directly with benefits for anxiety and depression (Kenworthy et al., 2014; Lawson et al., 2015; Wallace et al., 2016).”
BackgroundWallace, G. L., Kenworthy, L., Pugliese, C. E., Popal, H. S., White, E. I., Brodsky, E., & Martin, A. (2016) · Journal of Autism and Developmental Disorders · doi:10.1007/s10803-015-2655-7 · Cited by 261 · see citing works
“In the case of ASD, one recent example is Unstuck and On Target!, which is a school-based intervention for children and adolescents with ASD (Cannon et al. 2011; Kenworthy et al. 2014a).”
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“Ninety-eight English published case-control studies comparing children and adolescents with HFASD with typically developing controls using well-known neuropsychological measures to assess executive functions were included.”
BackgroundInfluentialThe role of executive functions in social impairment in Autism Spectrum Disorder
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“Moreover, interventions that target metacognitive skills have been shown to improve social abilities in children and adolescents with ASD (Kenworthy et al., 2014) and intellectual disabilities (Rosenthal-Malek & Yoshida, 1994).”
BackgroundPugliese, C. E., Anthony, L. G., Strang, J. F., Dudley, K., Wallace, G. L., Naiman, D. Q., & Kenworthy, L. (2016) · Journal of Autism and Developmental Disorders · doi:10.1007/s10803-015-2584-5 · Cited by 218 · see citing works
“Indeed, gains in social skills were observed in children with ASD who participated in a randomized controlled trial to improve flexibility (Kenworthy et al. 2014) indicating that shifting abilities are important to real world behavioral outcomes.”
Self-citationAnxiety Disorders and Obsessive-Compulsive Disorder in Individuals with Autism Spectrum Disorder
Postorino, V., Kerns, C. M., Vivanti, G., Bradshaw, J., Siracusano, M., & Mazzone, L. (2017) · Current Psychiatry Reports · doi:10.1007/s11920-017-0846-y · Cited by 186 · see citing works
Westwood, H., Stahl, D. R., Mandy, W., & Tchanturia, K. (2016) · Psychological Medicine · doi:10.1017/s0033291716000581 · Cited by 179 · see citing works
“The few studies that have focused on flexibility training in ASD have yielded mixed results, with one study reporting improvements in flexibility (Kenworthy et al. 2014), one showing no improvement (Fisher & Happe, 2005) and one suggesting a trend towards improvement with intention-to-treat…”
ResultBrookman-Frazee, L., Stadnick, N., Chlebowski, C., Baker-Ericzén, M., & Ganger, W. (2018) · Autism · doi:10.1177/1362361317712650 · Cited by 174 · see citing works
“The focus on understanding symptoms aligns with increased focus on developing trans-diagnostic interventions targeting symptoms or underlying mechanisms rather than specific diagnoses (e.g., Kenworthy et al., 2014).”
BackgroundLawson, R. A., Papadakis, A. A., Higginson, C. I., Barnett, J. E., Wills, M. C., Strang, J. F., Wallace, G. L., & Kenworthy, L. (2015) · Neuropsychology · doi:10.1037/neu0000145 · Cited by 169 · see citing works
Self-citationde Vries, M., Prins, P. J. M., Schmand, B. A., & Geurts, H. M. (2014) · Journal of Child Psychology and Psychiatry · doi:10.1111/jcpp.12324 · Cited by 163 · see citing works
Kasari, C., Dean, M., Kretzmann, M., Shih, W., Orlich, F., Whitney, R., Landa, R., Lord, C., & King, B. (2016) · Journal of Child Psychology and Psychiatry · doi:10.1111/jcpp.12460 · Cited by 159 · see citing works
“Two recent effectiveness trials provide some evidence for improvements in social skills when interventions are conducted in schools, although neither study included social network or friendship measures (Beaumont, Rotolone, & Sofronoff, 2015; Kenworthy et al., 2014).”
BackgroundHeterogeneity of executive functions among comorbid neurodevelopmental disorders
Dajani, D. R., Llabre, M. M., Nebel, M. B., Mostofsky, S. H., & Uddin, L. Q. (2016) · Scientific Reports · doi:10.1038/srep36566 · Cited by 126 · see citing works
Vaidya, C. J., You, X., Mostofsky, S., Pereira, F., Berl, M. M., & Kenworthy, L. (2020) · Journal of Child Psychology and Psychiatry · doi:10.1111/jcpp.13114 · Cited by 126 · see citing works
Self-citationZickgraf, H. F., Richard, E., Zucker, N. L., & Wallace, G. L. (2020) · Journal of Clinical Child & Adolescent Psychology · doi:10.1080/15374416.2020.1738236 · Cited by 131 · see citing works
Self-citationOswald, T. M., Winder‐Patel, B., Ruder, S., Xing, G., Stahmer, A. C., & Solomon, M. (2017) · Journal of Autism and Developmental Disorders · doi:10.1007/s10803-017-3421-9 · Cited by 131 · see citing works
“Persistent deficits in social interactions and social communication have been identified as core deficits of ASD (Perry et al. 2009; Kenworthy et al. 2014; Liss et al. 2001, APA 2013).”
BackgroundUddin, L. Q. (2021) · Biological Psychiatry · doi:10.1016/j.biopsych.2020.05.010 · Cited by 116 · see citing works
A Review of Language, Executive Function, and Intervention in Autism Spectrum Disorder
Friedman, L., & Sterling, A. M. (2019) · Seminars in Speech and Language · doi:10.1055/s-0039-1692964 · Cited by 119 · see citing works
“Kenworthy and colleagues 77 conducted a randomized control trial of Unstuck and On Target (UOT), which is an executive function intervention.”
InfluentialGardiner, E., & Iarocci, G. (2017) · Autism Research · doi:10.1002/aur.1877 · Cited by 118 · see citing works
Strang, J. F., Anthony, L. G., Song, A. Y., Lai, M., Knauss, M., Sadikova, E., Graham, E. K., Zaks, Z., Wimms, H., Willing, L. M., et al. (2021) · Journal of Clinical Child & Adolescent Psychology · doi:10.1080/15374416.2021.1916940 · Cited by 110 · see citing works
Self-citationGranader, Y., Wallace, G. L., Hardy, K. K., Yerys, B. E., Lawson, R. A., Rosenthal, M., Wills, M. C., Dixon, E., Pandey, J., Penna, R., et al. (2014) · Journal of Autism and Developmental Disorders · doi:10.1007/s10803-014-2169-8 · Cited by 106 · see citing works
“For example, due to the perseverative nature of cognitive flexibility in children with ASD, an intervention that focuses specifically on flexibility training (e.g., Cannon et al. 2011; Kenworthy et al. 2014), may lead to direct improvement in other metacognitive EF domains.”
BackgroundSelf-citationWalters, S., Loades, M., & Russell, A. (2016) · Review Journal of Autism and Developmental Disorders · doi:10.1007/s40489-016-0072-2 · Cited by 99 · see citing works
“…the child intervention (e.g. Reaven et al. 2009, 2012a) and (ii) techniques such as social stories, acronyms and role plays to accommodate features of ASD including literal understanding and theory of mind deficits (e.g. Kenworthy et al. 2014; Rotheram-Fuller and MacMullen 2011; Wood et al. 2014).”
BackgroundInfluentialA meta-analysis of cognitive flexibility in autism spectrum disorder
Lage, C., Smith, E. S., & Lawson, R. P. (2023) · Neuroscience & Biobehavioral Reviews · doi:10.1016/j.neubiorev.2023.105511 · Cited by 112 · see citing works
“…trials on cognitive remediation strategies remains inconsistent (Pugliese et al., 2020), with cognitive enhancement therapy among autistic adults (Eack et al., 2018) and a cognitive behavioural intervention designed for autistic children (Kenworthy et al., 2014) showing some promising results.”
BackgroundPasqualotto, A., Mazzoni, N., Bentenuto, A., Mulè, A., Benso, F., & Venuti, P. (2021) · Brain Sciences · doi:10.3390/brainsci11101280 · Cited by 103 · see citing works
Executive function predicts school readiness in autistic and typical preschool children
Pellicano, E., Kenny, L., Brede, J., Klaric, E., Lichwa, H., & McMillin, R. (2017) · Cognitive Development · doi:10.1016/j.cogdev.2017.02.003 · Cited by 96 · see citing works
“notable exceptions (Fisher & Happé, 2005; Kenworthy et al., 2014) have focused on direct training programmes with school-age autistic children.”
BackgroundKenny, L., Cribb, S. J., & Pellicano, E. (2019) · Journal of Abnormal Child Psychology · doi:10.1007/s10802-018-0493-8 · Cited by 88 · see citing works
Torske, T., Nærland, T., Øie, M. G., Stenberg, N., & Andreassen, O. A. (2018) · Frontiers in Behavioral Neuroscience · doi:10.3389/fnbeh.2017.00258 · Cited by 87 · see citing works
“Interventions that target metacognitive skills have, in earlier studies, shown to improve the social abilities in children and adolescents with ASD (Kenworthy et al., 2014; Leung et al., 2015).”
BackgroundBerenguer, C., Roselló, B., Colomer, C., Baixauli, I., & Miranda, A. (2018) · Research in Developmental Disabilities · doi:10.1016/j.ridd.2018.10.001 · Cited by 85 · see citing works
Bottema‐Beutel, K., Kim, S. Y., & Crowley, S. (2018) · Autism Research · doi:10.1002/aur.2055 · Cited by 81 · see citing works
Ozsivadjian, A., Hollocks, M. J., Magiati, I., Happé, F., Baird, G., & Absoud, M. (2021) · Journal of Child Psychology and Psychiatry · doi:10.1111/jcpp.13295 · Cited by 81 · see citing works
Strang, J. F., Knauss, M., van der Miesen, A. I. R., McGuire, J. K., Kenworthy, L. E., Caplan, R., Freeman, A. J., Sadikova, E., Zaks, Z., Pervez, N., et al. (2020) · Journal of Clinical Child & Adolescent Psychology · doi:10.1080/15374416.2020.1731817 · Cited by 80 · see citing works
“lenges with cognitive and behavioral flexibility (Kenworthy et al., 2014).”
Self-citationKerns, C. M., Roux, A. M., Connell, J. E., & Shattuck, P. T. (2016) · Cognitive and Behavioral Practice · doi:10.1016/j.cbpra.2016.06.002 · Cited by 80 · see citing works
Clinical developmental, neuropsychological, and social–emotional features of Turner syndrome
Hutaff-Lee, C. F., Bennett, E., Howell, S., & Tartaglia, N. R. (2019) · American Journal of Medical Genetics Part C Seminars in Medical Genetics · doi:10.1002/ajmg.c.31687 · Cited by 80 · see citing works
“For all infants with TS, standardized screenings of developmental and social milestones/ASD at well-child care visits are recommended as per American Academy of Pediatrics (AAP) guidelines (American Academy of Pediatrics, Council on Children With Disabilities, Section on Developmental Behavioral Pediatrics, Bright Fut…”
BackgroundInfluentialWeismer, S. E., Kaushanskaya, M., Larson, C., Mathée‐Scott, J., & Bolt, D. M. (2018) · Journal of Speech Language and Hearing Research · doi:10.1044/2018_jslhr-l-rsaut-18-0026 · Cited by 77 · see citing works
Macoun, S. J., Schneider, I., Bedir, B., Sheehan, J. C., & Sung, A. (2020) · Journal of Autism and Developmental Disorders · doi:10.1007/s10803-020-04723-w · Cited by 81 · see citing works
Mallory, C. L., & Keehn, B. (2021) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2021.695825 · Cited by 90 · see citing works
Davids, R. C. D., Groen, Y., Berg, I. J., Tucha, O. M., & van Balkom, I. D. C. (2016) · Journal of Autism and Developmental Disorders · doi:10.1007/s10803-016-2831-4 · Cited by 75 · see citing works
“In children with ASD deficits in executive functioning (EF) have been linked to impairments in social behaviour, and to increasing adaptive behaviour skill deficits, which persist into adolescence (Kenworthy et al. 2008, 2014; Pugliese et al. 2014).”
BackgroundUljarević, M., Richdale, A. L., Evans, D. W., Cai, R. Y., & Leekam, S. (2017) · Molecular Autism · doi:10.1186/s13229-017-0158-4 · Cited by 76 · see citing works
“In addition, Unstuck on Target [59], a behavioural approach to develop flexibility and compensatory strategies for impairments in EF, has been shown to increase problem-solving, flexibility, and planning/organizing aspects of executive functioning based on experimental assessments and parental reports, as well as enab…”
BackgroundContribution of Rating Scales to Intervention for Executive Dysfunction
Isquith, P. Κ., Roth, R. M., Kenworthy, L. E., & Gioia, G. A. (2014) · Applied Neuropsychology Child · doi:10.1080/21622965.2013.870014 · Cited by 73 · see citing works
Self-citationVogan, V. M., Leung, R. C., Safar, K., Martinussen, R., Smith, M. L., & Taylor, M. J. (2018) · Frontiers in Psychology · doi:10.3389/fpsyg.2018.01774 · Cited by 72 · see citing works
Autism Symptoms, Executive Functioning and Academic Progress in Higher Education Students
Dijkhuis, R., de Sonneville, L. M. J., Ziermans, T. B., Staal, W., & Swaab, H. (2020) · Journal of Autism and Developmental Disorders · doi:10.1007/s10803-019-04267-8 · Cited by 75 · see citing works
Neural correlates of set-shifting in children with autism
Yerys, B. E., Antezana, L., Weinblatt, R., Jankowski, K. F., Strang, J., Vaidya, C. J., Schultz, R. T., Gaillard, W. D., & Kenworthy, L. (2015) · Autism Research · doi:10.1002/aur.1454 · Cited by 71 · see citing works
“Inflexibility is an important target for treatment in ASD [Kenworthy et al., 2013].”
BackgroundSelf-citationBrookman-Frazee, L., Roesch, S., Chlebowski, C., Baker-Ericzen, M., & Ganger, W. (2019) · JAMA Psychiatry · doi:10.1001/jamapsychiatry.2019.0011 · Cited by 71 · see citing works
Strang, J. F., Anthony, L. G., Yerys, B. E., Hardy, K. K., Wallace, G. L., Armour, A. C., Dudley, K., & Kenworthy, L. (2017) · Journal of Autism and Developmental Disorders · doi:10.1007/s10803-017-3152-y · Cited by 70 · see citing works
“Of particular significance, based on the most parsimonious factor solution of the FS, is the emergence of a factor linking cognitive flexibility and social functioning (“Social Flexibility”), a linkage which has been foreshadowed in previous studies (Fisher and Happé 2005; Kenworthy et al. 2014; Pugliese et al. 2016;…”
BackgroundSelf-citationMcLean, R. L., Harrison, A. J., Zimak, E. H., Joseph, R. M., & Morrow, E. M. (2014) · Journal of the American Academy of Child & Adolescent Psychiatry · doi:10.1016/j.jaac.2014.05.019 · Cited by 69 · see citing works
“Indeed, a recent study has shown that a relatively new EF intervention led to improvements in EF, social skills, and classroom behavior.(42) Furthermore, given research showing that EF, as assessed by questionnaire, relates to neuroimaging findings,(43,44) EF, combined with neuroimaging measurements, may help shed lig…”
BackgroundPhung, J. N., & Goldberg, W. A. (2019) · Journal of Autism and Developmental Disorders · doi:10.1007/s10803-019-04072-3 · Cited by 83 · see citing works
“To date, numerous clinical trials and treatment studies have used the BRIEF-2, including one testing the effectiveness of an executive functioning intervention for children with ASD (Kenworthy et al. 2014).”
Freitag, C. M., Jensen, K., Elsuni, L., Sachse, M., Herpertz‐Dahlmann, B., Schulte‐Rüther, M., Hänig, S., von Gontard, A., Poustka, L., Schad‐Hansjosten, T., et al. (2015) · Journal of Child Psychology and Psychiatry · doi:10.1111/jcpp.12509 · Cited by 68 · see citing works
Facial affect recognition in autism, ADHD and typical development
Berggren, S., Engström, A.-C., & Bölte, S. (2016) · Cognitive Neuropsychiatry · doi:10.1080/13546805.2016.1171205 · Cited by 65 · see citing works
Tse, A. C. Y., Anderson, D. I., LIU, V. H. L., & TSUI, S. S. L. (2021) · Medicine & Science in Sports & Exercise · doi:10.1249/mss.0000000000002609 · Cited by 59 · see citing works
Adaptive behavior in youth with autism spectrum disorder: The role of flexibility
Bertollo, J. R., Strang, J. F., Anthony, L. G., Kenworthy, L., Wallace, G. L., & Yerys, B. E. (2020) · Journal of Autism and Developmental Disorders · doi:10.1007/s10803-019-04220-9 · Cited by 58 · see citing works
Self-citationKlinger, L. G., Cook, M. L., & Dudley, K. M. (2020) · Journal of Clinical Child & Adolescent Psychology · doi:10.1080/15374416.2020.1833735 · Cited by 57 · see citing works
“Unstuck and On Target, for example, is an executive function intervention which aims to increase flexibility with a cognitive behavioral framework and has demonstrated promising positive treatment outcomes for children with ASD in RCTs (Kenworthy et al., 2013).”
BackgroundInfluentialFong, V. C., & Iarocci, G. (2020) · Autism Research · doi:10.1002/aur.2350 · Cited by 57 · see citing works
Bertollo, J. R., & Yerys, B. E. (2019) · American Journal on Intellectual and Developmental Disabilities · doi:10.1352/1944-7558-124.3.191 · Cited by 55 · see citing works
Ratto, A. B., Anthony, B. J., Pugliese, C. E., Méndez, R., Safer‐Lichtenstein, J., Dudley, K. M., Kahn, N. F., Kenworthy, L. E., Biel, M. G., Martucci, J. L., et al. (2016) · Autism · doi:10.1177/1362361316650394 · Cited by 54 · see citing works
“For many of the families in this study, this research trial represented the first time that they had met other families of children with ASD or ADHD.”
BackgroundInfluentialSelf-citationMoon, J., Ke, F., & Sokolikj, Z. (2020) · British Journal of Educational Technology · doi:10.1111/bjet.13005 · Cited by 53 · see citing works
“Kenworthy et al. (2014)”
School-based social skills training for young people with autism spectrum disorders
Einfeld, S., Beaumont, R. B., Clark, T., Clarke, K. S., Costley, D., Gray, K. M., Horstead, S. K., Hodge, M. A., Roberts, J., Sofronoff, K., et al. (2017) · Journal of Intellectual & Developmental Disability · doi:10.3109/13668250.2017.1326587 · Cited by 53 · see citing works
“These have included strategies to improve executive functions (Kenworthy et al., 2014), social engagement with peers (Kasari et al., 2012, 2016; Laugeson, Ellingsen, Sanderson, Tucci, & Bates, 2014; Wood, Fujii, Renno, & Van Dyke, 2014); emotional development (Ratcliffe, Wong, Dossetor, & Hayes,…”
BackgroundMethodSpaniol, M. M., Shalev, L., Kossyvaki, L., & Mevorach, C. (2017) · Journal of Autism and Developmental Disorders · doi:10.1007/s10803-017-3371-2 · Cited by 53 · see citing works
“One attempt to train cognitive flexibility and executive function in a school setting was carried out by Kenworthy et al. (2014) using the "Unstuck and On Target" (UOT) intervention.”
MethodHollocks, M. J., Charman, T., Baird, G., Lord, C., Pickles, A. R., & Simonoff, E. A. (2021) · Autism · doi:10.1177/13623613211046160 · Cited by 51 · see citing works
“There is already some evidence that a group-based educational intervention targeting executive functioning can lead to improvements in cognitive flexibility in autistic young people (Kenworthy et al., 2014).”
BackgroundMethodInfluentialAssistive Technology for Cognition to Support Executive Functions in Autism: a Scoping Review
Desideri, L., Santantonio, A. D., Varrucciu, N., Bonsi, I. I., & Sarro, R. D. (2020) · Advances in Neurodevelopmental Disorders · doi:10.1007/s41252-020-00163-w · Cited by 50 · see citing works
Zajączkowska, M., & Abbot‐Smith, K. (2020) · Journal of Experimental Child Psychology · doi:10.1016/j.jecp.2020.104942 · Cited by 47 · see citing works
What does it take to be rigid? Reflections on the notion of rigidity in autism
Petrolini, V., Jorba, M., & Vicente, A. (2023) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2023.1072362 · Cited by 49 · see citing works
“Alternatively, the idea that treating circumscribed interests has a direct impact on externalizing behavior (2) could be reinforced, or that intervention on cognitive flexibility and planning can contribute to improving social skills (53).”
BackgroundAlbein‐Urios, N., Youssef, G. J., Kirkovski, M., & Enticott, P. G. (2018) · Journal of Autism and Developmental Disorders · doi:10.1007/s10803-018-3503-3 · Cited by 45 · see citing works
Characteristic Executive Dysfunction for High‐Functioning Autism Sustained to Adulthood
Xie, R., Sun, X., Yang, L., & Guo, Y. (2020) · Autism Research · doi:10.1002/aur.2304 · Cited by 45 · see citing works
“On the one hand, an increasing body of studies have proved that interventions like cognitive enhancement therapy [Hogarty & Greenwald, 2006], unstuck and on target [Kenworthy et al., 2014], and social adjustment enhancement intervention [Solomon, Goodlin-Jones, & Anders, 2004] for HFA could either improve EF, alleviat…”
BackgroundAssessment and Treatment of Executive Function Impairments in Autism Spectrum Disorder
Wallace, G. L., Yerys, B. E., Peng, C. S., Dlugi, E., Anthony, L. G., & Kenworthy, L. E. (2016) · International review of research in developmental disabilities · doi:10.1016/bs.irrdd.2016.07.004 · Cited by 45 · see citing works
Self-citationBremer, E., Graham, J. D., Heisz, J. J., & Cairney, J. (2020) · Frontiers in Behavioral Neuroscience · doi:10.3389/fnbeh.2020.00084 · Cited by 41 · see citing works
Bombonato, C., Lucchese, B. D., Ruffini, C., Lieto, M., Brovedani, P., Sgandurra, G., Cioni, G., & Pecini, C. (2023) · Neuropsychology Review · doi:10.1007/s11065-022-09574-z · Cited by 48 · see citing works
“…Egeland et al., 2013; Kirk et al., 2016; Klingberg et al., 2005; Leins et al., 2007; Smith et al., 2020; Strehl et al., 2017), autism symptoms ( Kenworthy et al., 2014), mood (Weiss et al., 2018) referred by parents and teachers or by the clinician (Smith et al., 2020; Strehl et al., 2017;…”
BackgroundResultInfluentialEmotion regulation and executive function: Associations with depression and anxiety in autism
Conner, C. M., Elias, R., Smith, I. C., & White, S. W. (2023) · Research in Autism Spectrum Disorders · doi:10.1016/j.rasd.2023.102103 · Cited by 43 · see citing works
Lynch, C. J., Breeden, A. L., You, X., Ludlum, R. S., Gaillard, W. D., Kenworthy, L. E., & Vaidya, C. J. (2017) · Biological Psychiatry Cognitive Neuroscience and Neuroimaging · doi:10.1016/j.bpsc.2017.03.008 · Cited by 40 · see citing works
Self-citationEylen, L. V., Boets, B., Cosemans, N., Peeters, H., Steyaert, J. G., Wagemans, J. P., & Noens, I. L. J. (2016) · Journal of Child Psychology and Psychiatry · doi:10.1111/jcpp.12637 · Cited by 40 · see citing works
Foss‐Feig, J. H., McPartland, J. C., Anticevic, A., & Wolf, J. M. (2015) · Journal of Autism and Developmental Disorders · doi:10.1007/s10803-015-2539-x · Cited by 41 · see citing works
“Finally, executive functioning interventions (Kenworthy et al. 2014) may be best suited to target underlying cognitive impairments in ASD.”
Strang, J. F., Chen, D., Nelson, E. E., Leibowitz, S. F., Nahata, L., Anthony, L. G., Song, A. Y., Grannis, C., Graham, E. K., Henise, S. B., et al. (2021) · Child Psychiatry & Human Development · doi:10.1007/s10578-021-01195-6 · Cited by 42 · see citing works
Self-citationKenworthy, L. E., Verbalis, A. D., Bascom, J., daVanport, S., Strang, J. F., Pugliese, C. E., Freeman, A. J., Jeppsen, C., Armour, A. C., Jost, G. M., et al. (2021) · Autism · doi:10.1177/13623613211029117 · Cited by 40 · see citing works
“Impairment in EF is common in autistic people (Hill, 2004; Kenworthy et al., 2008), related to key outcomes (Hume et al., 2009), and responsive to external supports (Schopler et al., 1995) and skill building (Kenworthy et al., 2014).”
BackgroundSelf-citationLei, J., Charman, T., Leigh, E., Russell, A., Mohamed, Z., & Hollocks, M. J. (2022) · Autism Research · doi:10.1002/aur.2826 · Cited by 35 · see citing works
Peristeri, E., Vogelzang, M., & Tsimpli, I. M. (2021) · Neurobiology of Language · doi:10.1162/nol_a_00055 · Cited by 36 · see citing works
“Based on previous findings that autistic traits, autism symptomatology, and stereotyped and rigid behaviors affect cognitive flexibility (Albein-Urios et al., 2018; Gökçen et al., 2014; Kenworthy et al., 2014; Ridley et al., 2011), we expected autistic children’s performance in the dual-tasks to be modulated by indivi…”
BackgroundInfluentialTakara, K., & Kondo, T. (2015) · Mental Health in Family Medicine · doi:10.25149/1756-8358.1102011 · Cited by 35 · see citing works
“Figure 2 shows a schematic diagram of the goals of mental health and social life and the necessary approaches to support individuals on the autism spectrum, which is based on previous reports [142-146].”
BackgroundLester, J. N. (2014) · Qualitative Psychology · doi:10.1037/qup0000013 · Cited by 35 · see citing works
Verbal Thinking and Inner Speech Use in Autism Spectrum Disorder
Williams, D. M., Peng, C. S., & Wallace, G. L. (2016) · Neuropsychology Review · doi:10.1007/s11065-016-9328-y · Cited by 35 · see citing works
“For example, a recently developed intervention that targets executive function deficits in ASD, BUnstuck and On Target!^, makes critical use of verbal labelling and verbal scripts throughout its curriculum (Cannon et al. 2011; Kenworthy et al. 2014).”
Self-citationWagle, S., Ghosh, A., Karthic, P., Ghosh, A., Pervaiz, T., Kapoor, R., Patil, K., & Gupta, N. (2021) · Scientific Reports · doi:10.1038/s41598-021-93258-w · Cited by 35 · see citing works
Greco, G., & Ronzi, R. D. (2020) · Journal of Physical Education and Sport · doi:10.7752/jpes.2020.04223 · Cited by 35 · see citing works
Williams, R. M., & Park, C. (2023) · Proceedings of the 2023 CHI Conference on Human Factors in Computing Systems · doi:10.1145/3544548.3581556 · Cited by 35 · see citing works
Ameis, S. H., Haltigan, J. D., Lyon, R. E., Sawyer, A., Mirenda, P., Kerns, C. M., Smith, I. M., Vaillancourt, T., Volden, J., Waddell, C., et al. (2021) · Journal of Child Psychology and Psychiatry · doi:10.1111/jcpp.13493 · Cited by 37 · see citing works
“, 2017) or childhood EF training in ASD (Kenworthy et al., 2014) could mitigate developmental risk for impairment across a variety of priority outcomes later in life.”
BackgroundFaja, S., Clarkson, T., Gilbert, R. K., Vaidyanathan, A., Greco, G., Rueda, M. R., Cómbita, L. M., & Driscoll, K. (2021) · Autism · doi:10.1177/13623613211014990 · Cited by 36 · see citing works
“Unsurprisingly, we found no evidence of significant transfer to social cognition or function or to untrained EF subdomains (verbal working memory, decision-making), which was consistent with other studies that reported non-significant transfer in lab-based social (Kenworthy et al., 2014) or untrained EF tasks (de Vrie…”
BackgroundResultInfluentialKuschner, E. S., Morton, H. E., Maddox, B. B., de Marchena, A. B., Anthony, L. G., & Reaven, J. (2017) · Clinical Child and Family Psychology Review · doi:10.1007/s10567-017-0236-3 · Cited by 33 · see citing works
“For individuals with ASD, research with CBT programs has generally targeted a verbal IQ above 70 (Reaven et al. 2012; White et al. 2009; Wood et al. 2009a) or a verbal mental age of at least eight years (Kenworthy et al. 2014).”
BackgroundMethodInfluentialSelf-citationReal-world executive functioning for autistic children in school and home settings
Tschida, J. E., & Yerys, B. E. (2021) · Autism · doi:10.1177/13623613211041189 · Cited by 32 · see citing works
“, 2018), and school is a setting where evaluations and executive function interventions are already being successfully implemented (Kenworthy et al., 2014; Tamm et al., 2020).”
InfluentialRockhold, M. N., Krueger, A. M., de Water, E., Lindgren, C. W., Sandness, K. E., Eckerle, J. K., Schumacher, M. J., Fink, B. A., Boys, C. J., Carlson, S. M., et al. (2020) · Alcoholism Clinical and Experimental Research · doi:10.1111/acer.14538 · Cited by 33 · see citing works
“Similar results were found with EF interventions in children with Autism Spectrum Disorders (ASDs); the Unstuck and On Target (UOT) program is an EF training intervention that has been shown to improve social skills in children ages eight to eleven with an ASD diagnosis (Kenworthy et al., 2014).”
ResultCavalli, G., Galeoto, G., Sogos, C., Berardi, A., & Tofani, M. (2021) · Expert Review of Neurotherapeutics · doi:10.1080/14737175.2022.2011215 · Cited by 35 · see citing works
“Positive effects were found in working memory task [22], classroom behavior, flexibility, and problemsolving [24].”
BackgroundHocking, D. R., Reeve, J. L., & Porter, M. A. (2015) · PLoS ONE · doi:10.1371/journal.pone.0137628 · Cited by 31 · see citing works
“ability to follow rules, make transitions and be flexible) when behavioural flexibility is directly targeted in contextually-based EF interventions [18].”
BackgroundCroydon, A., Remington, A., Kenny, L., & Pellicano, E. (2019) · Autism & Developmental Language Impairments · doi:10.1177/2396941519886475 · Cited by 32 · see citing works
Hawco, C. S., Yoganathan, L., Voineskos, A. N., Lyon, R. E., Tan, T., Daskalakis, Z. J., Blumberger, D. M., Croarkin, P. E., Lai, M., Szatmári, P., et al. (2020) · NeuroImage Clinical · doi:10.1016/j.nicl.2020.102260 · Cited by 30 · see citing works
Dickson, K. S., Lind, T., Jobin, A., Kinnear, M., Lok, H., & Brookman-Frazee, L. I. (2021) · Administration and Policy in Mental Health and Mental Health Services Research · doi:10.1007/s10488-021-01144-4 · Cited by 31 · see citing works
Bednarz, H. M., Trapani, J. A., & Kana, R. K. (2020) · Child Neuropsychology · doi:10.1080/09297049.2020.1745166 · Cited by 30 · see citing works
Kenworthy, L. E., Childress, D., Armour, A. C., Verbalis, A. D., Zhang, A., Troxel, M., Handsman, R., Kocher, K., Myrick, Y., Werner, M. A., et al. (2022) · Autism · doi:10.1177/13623613221111212 · Cited by 30 · see citing works
Self-citationWergeland, G. J., Posserud, M.-B. R., Fjermestad, K. W., Njarðvík, U., & Öst, L. (2022) · Clinical Psychology Science and Practice · doi:10.1037/cps0000106 · Cited by 30 · see citing works
Dickson, K. S., Lind, T., Jobin, A., Kinnear, M., Lok, H., & Brookman-Frazee, L. I. (2021) · Administration and Policy in Mental Health and Mental Health Services Research · doi:10.1007/s10488-021-01133-7 · Cited by 31 · see citing works
Maddox, B. B., Cleary, P., Kuschner, E. S., Miller, J. S., Armour, A. C., Guy, L., Kenworthy, L. E., Schultz, R. T., & Yerys, B. E. (2017) · Autism · doi:10.1177/1362361317712651 · Cited by 30 · see citing works
“This could be accomplished in a number of ways, including cognitive–behavioral therapy targeting emotion dysregulation, cognitive training therapy for executive function (e.g. Unstuck and On Target) (Kenworthy et al., 2014), or CPS. CPS would target these skills in situations where there is an incompatibility between…”
BackgroundMethodInfluentialSelf-citation
- Authors
- Kenworthy, L., Anthony, L. G., Naiman, D. Q., Cannon, L., Wills, M. C., Luong‐Tran, C., Werner, M. A., Alexander, K. C., Strang, J., Bal, E., Sokoloff, J. L., & Wallace, G. L.
- Affiliations
- Children's National (US)
- Johns Hopkins University (US)
- The Ivymount School Rockville MD USA
- National Institutes of Health (US)
- Corresponding author
- Kenworthy, Lauren
- Anthony, Laura Gutermuth
- Venue
- Journal of Child Psychology and Psychiatry
- Publisher
- Wiley
- Published
- 2013-11-21
- Volume
- 55
- Issue
- 4
- Pages
- 374-383
- ISSN
- 0021-9630 (ISSN-L)
- 1469-7610
- PMC
- PMC4532389
- OpenAlex
- W2051323717
- Cited by
- 323
- References
- 48
- Citations by year
- 2026: 30 · 2025: 19 · 2024: 24 · 2023: 28 · 2022: 26 · 2021: 44 · 2020: 34 · 2019: 27 · 2018: 27 · 2017: 25 · 2016: 17 · 2015: 13 · 2014: 9
- FWCI
- 7.10
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Journal of Child Psychology and Psychiatry (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- Funders
- National Institute of Mental Health (R34MH083053)
- Organization for Autism Research
- Isadore and Bertha Gudelsky Family Foundation
- Topics
- Life Sciences › Neuroscience › Cognitive Neuroscience › Autism Spectrum Disorder Research
- Social Sciences › Psychology › Developmental and Educational Psychology › Behavioral and Psychological Studies
- Health Sciences › Medicine › Psychiatry and Mental health › Child Nutrition and Feeding Issues
- Keywords
- autism spectrum disorder, executive function interventions, insistence on sameness, cognitive flexibility, problem solving, planning and organization, self-regulation, social skills intervention, school-based intervention, classroom behavior, transition skills, rule-following, children
- MeSH terms
- Child, Child Development Disorders, Pervasive, Female, Humans, Male, Neuropsychological Tests, Problem Solving, Schools, Wechsler Scales, Cognitive Behavioral Therapy, Treatment Outcome, Executive Function, Social Skills
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