The Effect of Dyadic Metacognitive Strategy Training in Autistic Youth or Young Adults and a Primary Caregiver

The U.S. healthcare and educations systems are failing autistic adolescents and young adults (AYAs) through inadequate or inaccessible services that hinder the development of independent living skills for long-term participation, health, and the transition to adulthood. In fact, only 19% of autistic AYAs who received special education services live independently and just over half were employed by their early 20s. These trends negatively impact autistic people's health and well-being and result in substantial familial and societal costs ranging from $1.4 to $2.4 million per person. Existing rehabilitation interventions for autistic AYAs primarily target isolated skills and overlook caregiver influences on AYA outcomes, so intervention gains do not translate to improvements in long-term participation or transition outcomes.

Pathways and Resources for Engagement and Participation (PREP), an MCST intervention for AYAs with physical disabilities and their families, may improve participation, health, and transition outcomes in autistic youths. PREP is a problem-solving approach to family-chosen goals that focuses on activity or environmental modifications over skill development. PREP improves activity performance and participation in AYAs with physical disabilities and autistic children ages 6-12. However, PREP has not been rigorously tested with autistic AYAs and caregivers. The critical next step is to test whether PREP improves participation, health and well-being, and transition outcomes in autistic AYAs. The overall study hypothesis is that PREP will be feasible for autistic AYAs and caregivers.

We will conduct a randomized controlled trial with waitlist crossover in autistic AYAs and their caregivers (e.g., youth-caregiver dyads). Youth-caregiver dyads will include one autistic AYA and one primary caregiver that meet other study inclusion criteria and provide electronic informed consent and assent. AYA-caregiver dyads will complete a baseline assessment (T1) of AYA activity performance, participation, and mental health. Then, they will be randomly assigned to intervention or waitlist control groups. The intervention group will complete remote PREP immediately (one hour/week x 12 weeks), and the waitlist control group will wait 12 weeks without intervention and then complete remote PREP (one hour/week x 12 weeks). The intervention group will complete post-intervention (T2) and follow-up (T3) assessments. The waitlist control group will complete second baseline (T2) and post-intervention (T3) assessments. AYA-caregiver dyads will complete one in-depth, semi-structured interview post-intervention to determine intervention acceptability.

We aim to test the feasibility of remote PREP for autistic AYAs and their caregivers. We hypothesize that feasibility data (e.g., recruitment, retention, and intervention adherence) will indicate that the study protocol and intervention can be implemented with autistic AYAs and a primary caregiver. We also hypothesize that acceptability data will indicate adequate intervention acceptability and inform optimization for future trials. Our second aim is to conduct limited efficacy testing to identify the preliminary effect of remote PREP on AYA outcomes. We hypothesize that effect size estimations will indicate the remote PREP has a greater positive effect, compared to waitlist control, on AYA activity performance, participation, health, and transition outcomes.