Addressing Disparities: A Pragmatic Comparative Effectiveness Trial of School-Based Executive Functioning Interventions

Background Executive functioning challenges, including difficulties with flexible thinking, goal setting and planning, are common among neurodivergent children, especially those identified with autism and/or attention-deficit/hyperactivity disorder. Executive functioning problems are linked to poorer academic achievement and are exacerbated by poverty. Importantly, executive functioning is responsive to intervention.Objective This pragmatic study compared the effectiveness of two school-based executive functioning interventions for children with autism and/or attention-deficit/hyperactivity disorder in Title 1 (low-income-serving) school settings to improve accessibility of effective interventions.Methods 148 children (82% male) in 3rd–5th grades were cluster-randomized by school (N = 24) to receive Unstuck and On Target (Unstuck), a cognitive-behavioral program, or Parents and Teachers Supporting Students, a behavior-management program considered best practice for children with attention-deficit/hyperactivity disorder. Both programs targeted executive functioning, were matched for dosage, and were delivered in small groups by school staff, with parent and teacher training to support generalization. The sample (attention-deficit/hyperactivity disorder N = 98; autism N = 50) was ethnically and socioeconomically diverse. The primary outcome was executive functioning behaviors assessed through masked classroom observations. Secondary outcomes were masked executive functioning tasks, and a parent report measure. Treatment fidelity, acceptability, potential moderation of family income, age, and cognitive functioning were assessed.Results Both interventions were implemented with high fidelity and were well-liked by children and parents, with Unstuck receiving higher acceptability ratings. Child executive functioning improved across both interventions and on all outcomes. There was limited moderation by income, and outcomes improved following intervention, even after accounting for income.Conclusions School staff can effectively deliver both Unstuck and Parents and Teachers Supporting Students in low-income community schools to improve executive functioning. These accessible, low-cost options address income-based health disparities by providing an alternative to clinic-based care. The interventions show promise for broader applications in schools.Clinical Trials registry Community Based Intervention for Children with ADHD and ASD; clinicaltrials.gov (NCT03003286) 9/13/2014.