Social skills group training for children and adolescents with high-functioning autism spectrum...

Social skills group training for children and adolescents with high-functioning autism spectrum disorders

Nora Choque Olsson

PhD student, Dept. of Women's & Children's Health,

Pediatric Neuropsychiatry Unit, KIND at Karolinska Institutet and

Psychologist at Child and Adolescent Psychiatry Research Clinic,

BUP-KIND

Nora Choque Olsson, September 2014 2

Background Study progress Time plan

Evidence-based interventions for individuals with autism spectrum disorders (ASD) is

lacking (Bölte 2014; SBU 2012; Reichow & Volkmar 2012 ;Choque Olsson et al., 2010).

Prevalence of ASD: ~1% and ~2.6% (Baird, 2006; Gillberg, 2006; Kim, 2011)

Psychiatric comorbidities: anxiety, depression, OCD and ADHD A (Mucaddes et al. 2010)

Societal costs ranges between 10 - 16 million SEK/person with ASD (Knapp et al. 2009)

Some evidence for social skills group training (SSGT) for high-functioning ASD but lack of rigorously conducted studies. (Reichow & Volkmar 2012; SBU 2012; Bölte et al.,2013)


Restrictive Fixated

Interests

Autism spectrum

disorders

Social

Communica-tion



Knowledge gaps


Few interventions for school age children and adolescents with ASD

RCT on social skills group training, more focus on internal validity (efficacy) but the external validity (effectiveness) is

unknown

Methodological flaws

↓ Lak of adapted and validated outcome measures↓ Unclear inclusion and exclusion criteria↓ Small sample size↓ No defined secondary psychiatric comorbidity↓ Lak of evaluated manual-based intervention

Few rigorously evaluated interventions

Mechanisms, moderators and mediators of treatment outcome are still unknown


Review on external validity of RCT on SSGT

Evaluatethe interrater reliability of two tolls: DD-CGAS OSU Autism CGI used in RCT

Examine the effects of SSGT on social skills and adaptive behaviour

Investigate the impact of moderator and mediators

Examine the effects of SSGT as experienced by participants

Our purpose is to:

Novel Clinical based

trial at Child and Adolescent Research Center



Evaluation of two tools Interrater reliability

Examine the effects of SSGT on social skills and adaptive behaviour





Our purpose is to:



Evaluation of two tools, Interrater reliability

Behavioural effects of KONTAKT in comparison with TAU



To examine the

behavioral effects of

SSGT, KONTAKT compared

to TAU



Our purpose is to:





Impact of moderator and mediators


To examine the


SSGT, KONTAKT Compared

to TAU



Our purpose is to:





Impact of moderator and mediators

Qualitative study on effects of SSGT

To examine the


SSGT, KONTAKT Compared

to TAU



Our purpose is to:

Manualized, structured group-based social skills training program for high-functioning ASD.

Focus: social interaction, self-reflection, verbal and non verbal signals in communication, problem solving, and coping strategies.

Children (8-12 y) and adolescent’s (13-17 y) group.

Trainer – children, 2:4-6

Parent involvement is included in the program.



KONTAKT



KONTAKT

The program was developed in Franktfurt, Germany (Herbrecht, Bölte &

Pouska, 2007)

In spring, 2011 a pilot project was conducted at Child and Adolescent

Psychiatry clinic, BUP Södertälje (Bölte & Choque Olsson , 2011)

Objective: to evaluate the feasibility of SSGT, KONTAKT and adapt the program to Swedish conditions.

The result was positive and confirmed prior pilot study in Germany (Herbrecht et al., 2009)


KONTAKT-team



To examine the efficacy and effectiveness of social skills group training for children and adolescents with ASD (KONTAKT), compared to treatment as usual (TAU)

[NCT01854346]

Main aim



STUDY 1 External validity (EV) of Randomized Controlled trial (RCT) studies on social skills group interventions

Objective: Evaluate the reporting of data related to EV from previous RCT on SSGI



STUDY 1External validity (EV) of RCT studies on social skills group interventions

Objective:

Material & Methods:

Systematic review

Published between 1948 and 2013

Ovid MEDLINE, Psych-INFO and PubMed

Swedish Health and Technology Assessment.




Objective:

Material & Methods:

Data Items:

Source population

Included population

Context

Treatment provider

Treatment intervention

Outcome




Objective:

Material & Methods:

Results:


n= 7263

n= 5241

n= 204

n= 5241

n= 11


STUDY 1 External validity (EV) of RCT studies on social skills group interventions

Objective:

Material & Methods:

Results:

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Source popu-lation

Included population

Context

Treatment provider

Treatment in-tervention

Outcome


Figure1: Overall view of reporting data related to external validity of included trials.


STUDY 1 External validity (EV) of RCT studies on social skills group interventions.

Objective:

Materials & Methods:

Results:

High-functioning school-aged children with ASD

Eligible population

Male and CaucasianIncluded

population

Not adequately reported: excluded participants, secondary comorbidities

Selection and flow

Not sufficient information about treatment provider and settings

Treatment intervention



Objective:


Results:

Conclusions:

Generalizability is limited

EV are often not adequately reported

More attention to external validity is needed

Status: Review to be submitted: Nora Choque Olsson, Ulf Jonsson and Sven Bölte,

"Can findings from RCT studies on social skills training in ASD be

generalized? The neglected dimension of external validity”



STUDY 2Adaptation and validation of the Children's Global Assessment Scale for Developmental Disabilities (DD-CGAS) and OSU Autism Clinical Global Impression Severity (OSU Autism CGI-S)


Objective:

To investigate the clinical utility and inter-rater reliability of the Swedish versions of the DD-CGAS (Choque Olsson& Bölte 2011; Wagner, 2007) and the OSU Autism CGI-S (Choque Olsson & Bölte 2011; RUPP,

2005).


STUDY 2 Adaptation and validation of the DD-CGAS and OSU Autism CGI-S Objective:


Study sample:

Assessment:

DD-CGAS

↑100- 91

↓10-1

OSU AUTISM GCI

↓7

↑1



STUDY 2 Adaptation and validation of the DD-CGAS and OSU Autism CGI-S

Objective:


Study sample:

16 clinicians from

9 BUP- clinics

Experienced (> 2 y)

Inexperienced (< 2 y)

8 clinical vignettes

Nr.

Age

Gender

Diagnosed

Comorbid- diagnosed

Treatment at clinical center

1

15

male

PDD-NOS

ADHD, anxiety, depression

CBT individually at home, cognitive support.

2

11

female

Asperger syndrome

ADHD, anxiety, sleep disorders and aggressive behavior

CBT, pharmacological, family therapy, psychoeducation.

3

16

male

PDD-NOS

DCD, stress.

Psychoeducation, kognitv stöd. School help.

4

8

male

Asperger syndrome

ADHD,

Social skills training, CBT,

5

15

Female

Asperger syndrome,

ADD, depression, stress syndrom, CP.

CBT,

6

8

male

Asperger syndrome

ADHD, depression

KOMET, psychoeducation,

7

15

male

PDD NOS

Anxiety UNS

CBT, psychoeducation,

8

14

female

Asperger syndrome

ADHD

CBT, psychoeducation,Social skills training



STUDY 2 Adaptation and validation of the DD-CGAS and OSU Autism CGI-S Objective:


Statistic analysis

Two-way random intraclass correlation coefficients (ICC)

Pearson correlation



STUDY 2Adaptation and validation of the DD-CGAS and OSU Autism CGI-S

ICC for all raters (experienced and inexperienced) and points in time was 0.63 on the DD-CGAS and 0.60 on the OSU Autism CGI-S.

Objective:


Results:




Experienced Inexperienced0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

ReferralDischarge

Experienced Inexperienced0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

Referral

Discharge

DD CGAS

Objective:


Results:


ICC was 0.75 for experienced, and 0.58 for inexperienced clinicians. ICC was 0.72 for experienced and 0.59 for inexperienced clinicians.



The correlation between DD CGAS and OSU CGI for referral was r= -0.86 (SD=0.69) and

the correlation between those instruments for discharge was r= -0.82 (SD =0.28).

Objective:


Results:




Objective:


Results:

Conclusions:

ICC of all raters for DD-CGAS and the OSU Autism CGI-S indicate good to substantial agreement.

The results is even better the rater have clinical experience.

The correlation between DD-CGAS and OSU Autism CGI-S was high, which indicate that they are equivalent.




Objective:


Results:

Conclusions:

Status:



STUDY 3 [NCT01854346]Behavioral effects of social skills group training, KONTAKT compared to treatment as usual: an RCT- multicenter study

Objective: To examine the effects of SSGT, KONTAKT on social responsiveness and adaptive

behavior among children and adolescents with HFASD and psychiatric comorbidity.



Objectives:

Hypotheses:

SSGT ≠ TAU

SSGT

↑ social skills and improved their adaptive behavior

↑ every day functioning

↓ symptom severity

↓ stress in both participants and their parents

STUDY 3 [NCT01854346]Behavioral effects of social skills group training, KONTAKT compared to Treatment as usual: an RCT-multicenter study



Objectives:

Hypotheses:

Methods:

Design

RCT multicenter study

Participants:

Large sample size: N= 288

(today n= 230)




Objectives:

Hypotheses:

Method:

Participants:

Inclusion criteria:

ASD (ICD-10 and ADOS) aged 8-17 years old.

IQ > 85 (Wechsler scale)

Psychiatric co morbidity: ADHD, Anxiety disorder, Depression (K-SADS).

Exclusion criteria: Conduct disorder

Antisocial personality disorder

Borderline personality disorder

Schizophrenia or related psychotic disorder




Objectives:

Hypotheses:

Methods:

Participants:

Recruits from

10 child and adolescent

psychiatric clinics (BUP) in

Stockholm County.



Objectives:

Hypotheses:

Methods

Outcome measures

Primary outcome measures

Social Responsiveness Scale, SRS (parent and teacher),

Secondary outcome measures

Adaptive Behavior Assessment System II, ABAS II (parents and teachers),

Children Under Stress, BUS (children and adolescent),

Perceived Stress Scale, PSS (parents),

OSU Autism CGI-S (expert)

DD-CGAS (expert)




Objectives:

Hypotheses:

Methods

Randomization and flowchart

Ethic approbation





Objectives:

Hypotheses:

Method:

Statistical analysis

To test the demographic variables.

t-test and X2 tests

To evaluate the treatment effect

Mixed-model MANOVA pre-, post and follow-up to compare KONTAKT and TAU

Intention to treat (ITT) principle.

STUDY 3 [NCT01854346]Behavioral effects of social skills group training, KONTAKT compared to Treatment as usual: A RCT-multicenter study



Objectives:

Hypotheses:

Method:


Status:

n= 230 Children and adolescents with HFASD have participated in the study




STUDY 4Moderators and mediators of treatment outcome in a SSGT for children with HFASD and psychiatric comorbidity

Objectives:

To investigate whether the moderators and mediators are crucial for the effect of the treatment




Objectives:

Hypotheses:

Moderators as: age, gender, IQ, verbal ability, psychiatric comorbidity and stress have significant impact on intervention effects.

SSGT is superior in HFASD with comorbid anxiety/depression compared with ADHD.

Short (three months) treatment is less effective than and long (six months) intervention.




Objectives:

Hypotheses:

Method:

Sample: based on data from the STUDY 3

Baseline data on IQ, age, gender, symptom severity and psychiatric comorbidity

Long and short SSGT training of 3 months (12 sessions) and another group for 6 months (24 sessions) is contrasted.

Outcome measures are: SRS (parent and teacher), ABAS II (parents and teachers), CGI (expert) and DD-CGAS, (expert).




Objectives:

Hypotheses:

Method:

Statistical analysis:

Mixed-model MANOVA




Objectives:

Hypotheses:

Method:

Status:

Analyses will begin after completed data collection from STUDY 3 (i.e. spring 2015) and an article drafted in fall 2015.



STUDY 5Qualitative evaluation of social skills training, KONTAKT: a responder analysis

Objective:

This qualitative study aims to evaluate KONTAKT based on responders and non-responders.




Objective:

Method:

Study Sample:

Based on STUDY 3 from a total N= 169 participants

Based on Social Responsiveness Scale (SRS) = responders and no responders

n =12 (6 responders and 6 non-responders) who participated in KONTAKT

n =12 parents

Deep interview

Data analysis

Thematic analysis




Objective:.

Method:

Results:

Improved social skills

Higher self-confidence

Increased independence and a new way of thinking about consequences of their behavior

Increased awareness of own impairments




Objective:.

Method:

Results:

Conclusions: Differences between responders and non-responders were few

Suggesting that even non-responders benefited from the treatment

Good group cohesion is important

Status: Study completed and the article is in preparation – Nora Choque-Olsson, Daniel Rautio, Jenny Asztalos, Ulrich Stötzer & Sven Bölte, Social skills training in ASD: A qualitative responder and non-responder analysis.



Background

Study progress

Time plan

Time plan

Activity 2011-2012

Spring 2012

Autumn 2012

Spring 2013

Autumn 2013

Spring 2014

Autumn 2014

Spring 2015

Autumn 2015

Spring 2016

Mars- Jun

August-Dec.

Jan - Jun

Aug – Dec Jan - Jun

Aug - Dec Jan - Jun Aug - Dec

Jan - Jun

Adapt. Manual & pilot

Recruitment and education: group trainers

Group training Supervising support to group trainersCollectionAnalysis

Article

ProgressStudy1Publised

Study 2Manus-cript

Study 5 in prepara-tion

Study 3Data collection

Study 4Data collection



Thanks for your attention!

52Nora Choque Olsson, September 2014


Objectives:

Hypotheses:

Method:


Status: 230 participants have

participated in the study.

STUDY 3Behavioral effects of social skills group training, KONTAKT compared to Treatment as usual: A RCT-multicenter study


Activities

Obligatory

Intermittent

Flexible

Warm-up activity, contact initiation Evaluation of the session

Group rulesHomework

Affect recognitionGroup discussionsInteraction and communication gamesRole playGroup activities

•Recognition and interpretation of facial expressions•FEFA•CAT-kit •basic and complex emotions•social stories•pantomime


CAT-KIT


Activities

Obligatory

Intermittent

Flexible

Contact initiation Of interaction between group members

Group rulesHomework


• Resolving a conflict•Access to a new group and make contact• Apologize in a good way• Collaborate• Understand the irony, jokes• Interpret non-verbal cues• Tolerance


Activities

Obligatory

Intermittent

Flexible

Contact initiation Of interaction between group members

Group rulesHomework


• Eye- contact• Focussing on cooperation• Watching each other closely•Recognition of non verbal signals•“What has changed?”,“Fruit basket overturning”.



Preliminary support for KONTAKT in a open trial in Germany (Herbrecht, Bölte & Pouska, 2009).

Social skills group training for children and adolescents with high-functioning autism spectrum...

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