Evaluation of the Effect of a Social Skills Program for Children and Adolescents With ASD
Condition: Autism Spectrum Disorder
MeSH terms: Autism Spectrum Disorder
Study type: Interventional

Summary: 
      Research evaluating effectiveness of social skills intervention programs for children and
      adolescents with Autism Spectrum Disorder is still limited.

      The main objective of this study was to develop an adaptation of the Social Adjustment
      Enhancement Intervention program form the University of California for a group of children
      and adolescents with autism. Our secondary goal was to evaluate the effect of our program
      through specific indicators. We hypothesized a decrease in comorbid symptomatology, as
      measured by questionnaires. We also expected an increase in social behaviors, measured
      through observational methodology.
    

Detailed description: 
      Participants were recruited by psychologists and psychiatrists from a Multidisciplinary Unit
      for Autism Spectrum Disorder, in accordance the 2000 Helsinki declaration.

      A total sample of 94 participants was divided in two age-groups: children (8 to 12 years old)
      and adolescents (13-17 years old). These groups participated in the study over a three-year
      period (2017, 2018, and 2019). Each year the investigators recruited approximately 30
      participants (children and adolescents). Subjects were paired according to age, gender and
      intelligence quotient; then each pair was randomized between the two groups (experimental
      group and waiting list control group) using R software with a fixed random seed.

      The experimental group of each year received treatment from January to April. The waiting
      list control group received the treatment from April to July, after participating in the
      trial. For both groups, pre-treatment evaluation was performed in January and post-treatment
      evaluation was done in April. The treatment groups were conducted by one psychologist, two
      co-therapists (psychiatrists or mental health nurses), and with the assistance of two
      graduate students in psychology. Fifteen participants were excluded due to missing data.

      Materials and design Diagnostic instruments The Autism Diagnostic Observation Schedule-2 was
      administered to all participants. To be included in the study, participants had to score
      above the cut-off point. Intellectual abilities and verbal comprehension were measured with
      the Wechsler Intelligence Scale for Children and Adolescents.

      Outcome measurement instruments

      Pre- and post-questionnaires for parents were administered to assess comorbid symptomatology:

      Child Behavior Checklist (6-18): This instrument is a questionnaire filled out by parents to
      assess behaviors and emotional problems in subjects aged 1 year 6 months to 5-years old, and
      6 to 18 years old. Both internalizing behaviors (e.g., anxiety, depression, etc.) and
      externalizing behaviors (e.g., aggression, hyperactivity, etc.) are evaluated. The present
      study focused specifically on: Anxious/Depressed, Social Problems and Thought Problems.

      The Spence Children's Anxiety Scale: This instrument is a self-report that measures anxiety
      disorders in childhood and adolescence. It consists of 44 items that assess separation
      anxiety, obsessive-compulsive disorder, panic, social phobia, generalized anxiety, etc. It is
      evaluated from a Likert scale, with a maximum score of 114, average 57, and minimum 0.

      Experimental Coding of Social Behavior: To assess social behaviors, the investigators coded
      14 minutes of free playtime from session #2 and session #10 (last session). Free playtime
      consisted of participants playing with each other in a non-structured format, using different
      games that were offered or remaining alone if they wanted to. Therapists and co-therapists
      did not interact during free playtime. Coded videos were recorded with two different cameras
      located at two different fixed angles. Observational data corresponded to participants that
      attended the specific sessions (i.e., sessions 2 and 10) needed for these analyses and they
      allowed coders (based on audiovisual characteristics) sufficient coding time and angles to
      code the target behaviors. In order to obtain baseline observational data from the control
      group, this group was scheduled for two free playtime sessions (coinciding with sessions 1
      and 2 from the experimental group) the second session was videocoded. To obtain follow-up
      data from the control group, another free playtime session was scheduled three months later.

      Participants were informed about the recording, the research purpose of the videos, and the
      location of the cameras.

      In order to quantitatively code social behaviors, an observational instrument was developed
      and administered. This instrument was inspired by a previous observational instrument and by
      the approach of social difficulties of the authors of the Autism Diagnostic Observation-2.
      This instrument allows the observer to quantify the number of occurrences of target behaviors
      according to pre-established categories. The scale includes six defined dimensions and
      category systems that meet the requirements of exhaustively and mutual exclusivity.

      A systematic observation was performed to obtain a code matrix. Two coders analyzed and coded
      the entire set of videos. In order to assure reliability between coders, 20% of videos were
      coded for these propose and coders were blind to the randomized session number (sessions #2
      and #10) that they were assigned to code. Two blinded coders performed a training phase until
      reaching a moderate-to-high (76-89%) Cohen's Kappa agreement rate, prior to coding the videos
      that were then analyzed for this study.

      The observational design was nomothetic (several participants were observed), included
      follow-up (an initial session and the program's last session), and multidimensional (several
      dimensions of the observation instrument were considered suitable)
      (Nomothetic/follow-up/Multidimensional). As the therapeutic process extended to several
      sessions, the groups were considered as a plurality of units. We worked with two levels of
      response: verbal and non-verbal.

      Procedures Parents were invited to attend an informative session in which the study was
      presented. Afterwards, signed consent and informed assent was obtained from each child.
      Sessions took place in a dedicated group-intervention room and had a length of 90 minutes per
      session.

      The social skills intervention program was based on a consented adaptation of the Social
      Adjustment Enhancement Intervention of the University of California. The original design
      contains more than 20 sessions, but in order to be feasible in a Hospital-based service, we
      adapted the program to 10 sessions and eliminated the parent component. According to previous
      community research, evidenced-based intensive intervention programs are challenging to
      implement and they have long waiting lists. Therefore, there is a tendency to limit the
      length of group intervention programs to a fewer number of sessions in order to provide
      higher access to services. For this study, the number of sessions was decreased and the
      program was simplified in order to make it feasible to our hospital setting. Session
      structure was consistent and included initial greeting, free play time, didactic, joke
      telling, and closing activities. Topics of didactic sessions were related to social
      competence, such as empathy, talking about feelings, and solving social problems. Each
      session had the purpose of practicing different social competence skills that are typically
      affected in a young population with Autism Spectrum Disorder.

      Data analysis The Statistical Package for the Social Sciences (SPSS v23.0) was used for
      statistical analyses. Descriptive analyses were conducted to characterize the sample. To test
      hypotheses, 2x2 ANOVA analyses were conducted, comparing differences between groups
      (experimental vs control) and time (baseline vs follow up). The amount of social behaviors
      and psychological symptoms were compared.

      All statistical tests were performed with a bilateral contrast and the level of significance
      was set at 0.05, while marginally significant was understood to be below 0.10 and above 0.05,
      so as to better understand our results and potential discussion. Based on the previous
      literature, the analyses described above were replicated stratifying by verbal IQ and age.
    

Intervention name(s): Adaptation of the Social Adjustment Enhancement Intervention of the UC Davis MIND Institute (Solomon, 2004).
Intervention type(s): Behavioral
Intervention description(s): The social skills intervention program was based on a consented adaptation of the Social Adjustment Enhancement Intervention of the UC Davis MIND Institute (Solomon, 2004). In order to be feasible in a hospital-based service, we adapted the program to 10 sessions. Session structure included initial greeting, free play time, didactic, joke telling, and closing activities. Topics of didactic sessions were related to social competence, such as empathy, talking about feelings, and solving social problems. We also adapted the content of the sessions, including activities proposed by Solomon (2004) but also from other experts in social cognition, such as García-Winner (2000). Each group was comprised by 7-10 participants. Children groups were conducted by a clinical psychologist, a mental health nurse and the support of two master degree students. Adolescent groups were conducted by a psychologist, a psychiatrist and the support of two master degree students.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Outcomes Assessor)
Primary purpose: Treatment