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Understanding the Gap Between Cognitive Abilities and Daily Living Skills in Adolescents with Autism Spectrum Disorders with A

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Understanding the Gap Between Cognitive Abilities and Daily Living Skills in Adolescents with Autism Spectrum Disorders with A AUT19110.1177/1362361313510068AutismDuncan and Bishop 5100682013 Original Article Autism 2015, Vol. 19(1) 64 –72 Understanding the gap between © The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav cognitive abilities and daily living skills DOI: 10.1177/1362361313510068 in adolescents with autism spectrum aut.sagepub.com disorders with average intelligence Amie W Duncan1 and Somer L Bishop2 Abstract Daily living skills standard scores on the Vineland Adaptive Behavior Scales–2nd edition were examined in 417 adolescents from the Simons Simplex Collection. All participants had at least average intelligence and a diagnosis of autism spectrum disorder. Descriptive statistics and binary logistic regressions were used to examine the prevalence and predictors of a “daily living skills deficit,” defined as below average daily living skills in the context of average intelligence quotient. Approximately half of the adolescents were identified as having a daily living skills deficit. Autism symptomatology, intelligence quotient, maternal education, age, and sex accounted for only 10% of the variance in predicting a daily living skills deficit. Identifying factors associated with better or worse daily living skills may help shed light on the variability in adult outcome in individuals with autism spectrum disorder with average intelligence. Keywords adaptive behavior, adolescence, autism spectrum disorder, cognitive abilities, daily living skills Autism spectrum disorders (ASDs) are considered to be employment, and independent living. Thus, while cognitive lifelong, but the majority of individuals with ASD exhibit ability affects the overall likelihood of a positive adult out- improvements in ASD-related symptoms and behaviors by come for individuals with ASD, having a higher IQ does the time they reach adolescence or young adulthood (Seltzer not necessarily ensure a better outcome. This finding is et al., 2004; Shattuck et al., 2007). Thus, particularly for especially discouraging when considering individuals with some individuals with ASD, such as those with higher intel- ASD with average or above average intelligence because ligence quotient (IQ) and/or milder ASD symptoms, the there is no cognitive impairment impeding their ability to hope is that they will achieve positive adult outcomes, lead independent adult lives. Furthermore, “intellectually including residential independence, postsecondary educa- able” individuals with ASD are often only eligible for a tion, employment, social interaction with peers, and com- limited number of interventions and services after leaving munity participation. Unfortunately, longitudinal high school (Taylor and Seltzer, 2010), which places the investigations have indicated that adult outcomes are gen- responsibility for adult care entirely on their families should erally quite poor for individuals diagnosed with ASD dur- they fail to achieve independence. ing childhood (Eaves and Ho, 2008; Farley et al., 2009; As more and more adolescents with ASD make the tran- Howlin et al., 2004). sition to adulthood, it is critical to identify the factors that Cognitive ability has been found to be the best prognos- promote a more successful adult outcome. Given that IQ is tic indicator of outcome in adulthood (Eaves and Ho, 2008; Farley et al., 2009; Lord and Bailey, 2002). However, even 1Cincinnati Children’s Hospital Medical Center, USA among those with IQs over 70, there is still substantial vari- 2Weill Cornell Medical College, USA ability in rates of adult “success.” For example, Howlin et al. (2004) reported that only 32% of adults with nonver- Corresponding author: Amie W Duncan, Cincinnati Children’s Hospital Medical Center, 3430 bal IQs over 70 had a “Good” or “Very Good” outcome as Burnet Ave, MLC 4002, Cincinnati, OH 45229, USA. measured by their functioning in the areas of friendship, Email: [email protected] Duncan and Bishop 65 clearly not the only determinant of adult success among DLS (e.g. cooking from a recipe, taking a shower, and set- individuals with higher IQs, more research is needed to ting an alarm clock) that are critical to success in the adult understand the observed gap between these individuals’ world do not rely as heavily as other adaptive behavior “potential” for success (e.g. as measured by IQ) and their skills on the social–communication abilities impaired in actual rates of independence in adulthood. individuals with ASD. Poor adaptive behavior is one potential explanation for A deeper understanding of DLS profiles in adolescents the worse than expected outcomes observed in adults with with ASD could lead to the development of supports and ASD with average or above average intelligence. It has interventions that facilitate a more optimal adult outcome. been well established that individuals with ASD demon- Unfortunately, very little is known about what factors are strate impaired adaptive behavior skills relative to their related to DLS deficits in individuals with ASD. This infor- cognitive abilities. Previous researchers have described the mation is needed to understand why some individuals with “autism profile” as being characterized by significant defi- ASD with average intelligence exhibit age-appropriate cits in socialization, lesser deficits in communication, and a DLS, and others perform at a level far below age expecta- relative strength in daily living skills (DLS) (Carter et al., tions. A body of research has demonstrated that overall 1998; Klin et al., 2007; Volkmar et al., 1987). Interestingly, adaptive behavior in individuals with ASD is associated deficits in adaptive behavior appear to be more pronounced with age (Kanne et al., 2011; Klin et al., 2007) and IQ in individuals with ASD with higher IQs; those with lower (Charman et al., 2011; Kanne et al., 2011; Klin et al., 2007; IQs are more likely to exhibit adaptive behavior skills that Liss et al., 2001; Perry et al., 2009), but studies on the rela- are commensurate with their cognitive abilities (Kanne tionship between adaptive behavior and autism symptoma- et al., 2011; Klin et al., 2007; Perry et al., 2009). tology have been less conclusive (Charman et al., 2011; Despite the fact that children and adolescents with ASD Kanne et al., 2011; Klin et al., 2007; Liss et al., 2001; Perry exhibit a relative adaptive behavior strength in the area of et al., 2009). For example, in a group of 9- to 14-year-olds DLS, they have poorer DLS than children with other devel- with ASD, IQ, and lifetime social scores (i.e. retrospective opmental disorders or typically developing children parent reports of social symptoms when the child was (Gillham et al., 2000; Kenworthy et al., 2009; Klin et al., between 4 and 5 years old) on the Autism Diagnostic 2007; Liss et al., 2001). As is the case with overall adaptive Interview–Revised (ADI-R; Rutter et al., 2003) were the behavior skills, some research suggests that deficits in DLS only significant predictors of overall adaptive behavior are more pronounced in children with ASD with higher scores (Charman et al., 2011). Kanne et al. (2011) also IQs. Liss et al. (2001) reported that children with higher found strong associations between adaptive behavior and IQs exhibited relatively greater impairments in DLS com- lifetime ADI-R scores in a sample of children and adoles- pared to those with lower IQs. Additionally, Klin et al. cents with ASD from the Simons Simplex Collection (SSC) (2007) found a negative relationship between age and DLS but found weak associations between adaptive behavior in intellectually able individuals with ASD, suggesting that and concurrent clinician-observed symptoms on the Autism deficits in DLS may worsen with age for these individuals Diagnostic Observation Schedule (ADOS; Lord et al., because they are not acquiring skills at the same rate as 1999). Several studies have also found links between adap- their typically developing peers (see also Kanne et al., tive behavior and internalizing and externalizing symp- 2011). toms. For example, Sikora et al. (2012) found that children Together, these studies indicate that adaptive behavior with ASD who had clinically significant attention deficit deficits are highly prevalent in individuals with ASD and hyperactivity disorder (ADHD) symptoms had signifi- may be especially prominent in those with higher cognitive cantly lower DLS as compared to children who had ASD abilities. Impaired adaptive behavior skills likely contribute alone. In another recent study, Drahota et al. (2011) found to overall poor outcomes in adults with ASD and may help that the DLS of children with ASD increased after they par- explain the variability in outcomes among individuals with ticipated in a cognitive behavioral intervention that targeted ASD with higher IQs. For example, difficulties with every- reducing anxiety symptoms. The authors hypothesized that day activities such as bathing, cooking, cleaning, and han- this gain in DLS occurred because parents who participated dling money could drastically reduce an individual’s chance in the intervention gained a new perspective on the skills of achieving independence in adulthood. In fact, Farley their child could obtain and decreased their level of involve- et al. (2009) found that scores in the area of DLS was the ment in their child’s specific self-care skills. variable most highly correlated with a positive outcome in Given the potential association between adaptive behav- 41 adults with ASD who had IQs of at least 70. The finding ior (especially DLS) and adult independence, it is critical to that better DLS may facilitate a positive adult outcome is gain a clearer understanding of which factors are related to very promising because unlike many other skills that are better or worse DLS in children and adolescents with ASD. lacking in individuals with ASD, DLS tend to be relatively The current study examined the prevalence and predictors explicit and concrete and may therefore be more amenable of DLS deficits in a large sample of adolescents with ASD. to intervention (see Hume et al., 2009). Furthermore, many We chose to focus on DLS because they have been linked 66 Autism 19(1) to positive adult outcome, seem to be more amenable to Table 1.
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