Clinical trial NCT06127472: Psychoeducation for Older Adults with Autism
Official title: Support with Psychoeducation for Older Adults with Autism Study
Study type: INTERVENTIONAL
Overall status: RECRUITING
Phase: NA
Conditions: Autism Spectrum Disorder
Keywords: autism
older adults
Lead sponsor: Tilburg University
Sponsor class: OTHER
Collaborators: name: GGZ Breburg
First posted: 2023-11-13
Enrollment: 305
Sex: ALL
Minimum age (years): 55
Standard ages: ADULT
OLDER_ADULT
Accepts healthy volunteers: yes
Allocation: RANDOMIZED
Intervention model: CROSSOVER
Intervention model description: The effects of the adapted PE program will be evaluated in a Stepped Wedge Trial Design (SWTD), with the intervention sequentially rolled-out in ten (specialised) mental healthcare organisations. Furthermore, a pre-post design will be used to compare the situation before the roll-out period with the situation after the roll-out period.

A second intervention, training and education in detection and diagnosis of ASD in older adults, is rolled out in de same SWTD. The effects of this intervention will also be assessed further in pre-post design.
Primary purpose: TREATMENT

Brief summary: Until recently, autism in older adults went unrecognised. Although there has been more attention to autism in older adults in recent years, there is still a lot of unfamiliarity with the phenomenon and underdiagnosis in (mental) health care. Many care providers are reluctant to diagnose autism in later life, due to a lack of knowledge about autism in older adults and because there is still very little scientific knowledge available for this target group. Although several multidisciplinary guidelines for autism in adults prescribe that after the diagnosis psycho-education is the first step in treatment, psycho-education is still only offered in a few places in the Netherlands. Psycho-education is important to help older people gain knowledge about their autism, to help them understand and accept this diagnosis, in order to subsequently make the treatment of the problems, with which they turn to the mental health care, more appropriate and effective.

The aim of this study is to contribute to better recognition and diagnosis of autism among older adults. This research also aims to improve a psycho-education program for older adults and investigate its effects.

The scientific research question is whether training in ASD for health care professionals results in better recognition and detection of ASD in older adults, and whether participation in the psycho-education course for older adults, who have recently been diagnosed with autism, contributes to improvement of mental health and quality of life.

Detailed description: The detection of autism spectrum disorder (ASD) in older adults in Dutch (specialised) mental health care is improving, but underdiagnosis remains. Older adults with ASD experience a low quality of life (QoL) and a high rate of psychopathology across the life span and into old age. Additionally, Dutch and international treatment guidelines advocate psychoeducation (PE) as the first intervention after patients have been diagnosed with ASD. However, as PE for older patients with ASD is hardly available in the Netherlands, access to PE is severely limited for these older adults. Hence, it is important to improve detection and diagnosis of ASD and increase the availability of PE for older adults. The hypotheses of this study are 1) that detection and diagnosis of ASD in older adults will significantly increase following training of professionals and 2) that delivering an adapted and improved PE program for older adults will result in more knowledge and recognition of ASD, a better acceptance of the diagnosis, improved coping with ASD, improved resilience and comorbid general psychological distress, and ultimately in higher quality of life, compared to those patients with ASD that receive no PE.

The aim of this study on the one hand is to gain insight into: 1) the effects of providing training and education to mental health care providers in detection and diagnosis of ASD in older adults, with the expectation that this contributes to an increase in the number and proportion of ASD diagnoses in older adults in the Netherlands; 2) the effects of a PE program for older adults with ASD in terms of knowledge and recognition of ASD and traits, a better acceptance of the diagnosis, improved coping with ASD, improved resilience and comorbid general psychological distress - and ultimately higher quality of life; and 3) the experiences of older adults with ASD following the PE program.

Study design: The effects of training and education in detection and diagnosis of ASD in older adults, and the effects of the PE program will be evaluated in a Stepped Wedge Trial Design (SWTD), with the intervention sequentially rolled-out in ten (specialised) mental healthcare organisations. Furthermore, a pre-post design will be used to compare the situation before the roll-out period with the situation after the roll-out period in terms of diagnosis and individual outcomes such as knowledge regarding ASD. Qualitative measures will be used to assess the experiences of older adults with ASD who participated in the PE program.

Study population: Older adults - aged 60 and over diagnosed with ASD no longer than 12 months before the start of the intervention by a multidisciplinary team according to the Dutch multidisciplinary guidelines, as confirmed by the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders) interview for ASD, or the Netherlands Interview for Diagnosis of ASD in adults (NIDA) as well as a proxy (an individual who provides reports on behalf of, or about, a study participant).

The intervention consists of education in detection and diagnosis of ASD in older adults for mental health professionals and of an adapted PE program for older adults with a recent diagnosis of ASD. The PE program consists of seven, two hour group meetings on a weekly basis.

Primary study parameter concerns clinical outcomes measuring effects of the psycho-education course in terms of quality of life, acceptance of the diagnosis, knowledge of ASD, recognition of ASD traits, coping with ASD, quantitative autistic traits, resilience, and comorbid psychological distress. Quality of life is assessed by the MHQoL-7 (Mental Health Quality of Life Questionnaire). Acceptance of the diagnosis, knowledge and coping with ASD are assessed with use of the Questionnaire Knowledge, Recognition and Acceptance of Autism Diagnosis (VKHAA). Acceptance of ASD (-diagnosis) is further assessed through the Acceptance Questionnaire (AQ). Autistic traits are assessed through the Social Responsiveness Scale-Adults (SRS-A). Comorbid psychological distress is assessed by the Brief Symptom Inventory (BSI). All these assessments are performed (1) at baseline (following diagnosis and informed consent); (2) before the patient starts with PE (on average three months after baseline; participants in the control group will receive this three months after baseline; (3) after the PE (on average two months after the start of the PE program; participants in the control group will receive this measurement 6 months after baseline); (4) at 9-months follow-up (nine months after second measurement). A proxy, chosen by the study participant, will additionally inform on acceptance, knowledge, recognition, coping and ASD traits through measurements on the VKHAA for informants (VKHAA-N) and SRS-A for informants (SRS-A-N) at two moments that overlap with measurements 2 and 3 of study participants.

Secondary study parameters is the number and proportion of ASD diagnoses in the participating centres (collected from the information and registration systems of the mental health care centres) from one year before, during the project, and at one year follow-up.

For patients, benefits will be considerable as they will receive a PE program that is recommended by the Dutch multidisciplinary guideline for ASD in adults, and although being the recommended first intervention by treatment guidelines, is not provided to them momentarily. The benefits account for patients who provide informed consent to participate in the research and patients who do not give their consent, since the same treatment will be available for both. The investigators consider the burden of participating in the research, which consists of filling out questionnaires and inviting a proxy of their choice to fill out two of the same questionnaires, to be limited. Firstly, because this will be done in the context of treatment that fits the recommended first intervention by treatment guidelines and thus does not provide an extra mental burden. Moreover, the time needed to fill out these questionnaires is limited: approximately 40 to 60 minutes per measurement point, and there are no indications that risks are involved with regard to the topics of these questionnaires; specifically in a similar study by the study's research group, no adverse events or risks were observed.

Additional potential benefits exist in the form of increased detection and diagnosis of ASD in older adults across participating organisations, while the burden of participating in the study hardly exceeds time and effort spent in diagnostic efforts as usual, yet lightens efforts spent on informing patients with an ASD diagnosis as this can be done in a group format rather than on an individual basis. The only extra effort is limited to informing patients about the study with verbal and written information.

Eligibility criteria: Inclusion Criteria:

* minimum of 55 years old.
* diagnosed with ASD or an uncertainty diagnosis by a multidisciplinary team according to the Dutch multidisciplinary guideline, as confirmed by the DSM-5 interview for ASD (Spek, n.d.), or the Netherlands Interview for Diagnosis of ASD in adults (NIDA; Vuijk, 2023)

Exclusion Criteria:

* comorbid mental disorder that needs acute treatment and severely interferes with a group treatment (for example psychosis),
* a major neurocognitive disorder (for example dementia or acquired brain injury),
* substance abuse disorder, that requires detoxification, and/or
* an IQ below 70.

Primary outcomes:
measure: Quality of life (MHQoL-7)
timeFrame: minimum of 9 to maximum of 15 months with four measurements over this period.
measure: Acceptance of the diagnosis
timeFrame: minimum of 9 to maximum of 15 months with four measurements over this period.
measure: Acceptance of the diagnosis from proxy perspective
timeFrame: 8 weeks with two measurements over this period.
measure: Knowledge of ASD
timeFrame: minimum of 9 to maximum of 15 months with four measurements over this period.
measure: Knowledge of ASD from proxy perspective
timeFrame: 8 weeks with two measurements over this period.
measure: Recognition of ASD traits
timeFrame: minimum of 9 to maximum of 15 months with four measurements over this period.
measure: Recognition of ASD traits from proxy perspective
timeFrame: 8 weeks with two measurements over this period.
measure: Coping with ASD
timeFrame: minimum of 9 to maximum of 15 months with four measurements over this period.
measure: Coping with ASD from proxy perspective
timeFrame: 8 weeks with two measurements over this period.
measure: Quantitative autistic traits
timeFrame: minimum of 9 to maximum of 15 months with four measurements over this period.
measure: Quantitative autistic traits from proxy perspective
timeFrame: 8 weeks with two measurements over this period.
measure: Resilience
timeFrame: minimum of 9 to maximum of 15 months with four measurements over this period.
measure: Comorbid psychological distress
timeFrame: minimum of 9 to maximum of 15 months with four measurements over this period.
Secondary outcomes:
measure: Number of ASD diagnoses
timeFrame: Collection of data concerns numbers per month, starting from one year before, during the expected 18 months of the roll out of the ASD training intervention, and at one year follow-up following roll out of this training in the last cluster of the SWTD.
measure: Proportion of ASD diagnoses
timeFrame: Collection of data concerns numbers per month, starting from one year before, during the expected 18 months of the roll out of the ASD training intervention, and at one year follow-up following roll out of this training in the last cluster of the SWTD.
Other outcomes:
measure: Descriptives
timeFrame: At informed consent (zip code) and the baseline measurement (gender, age, education level), which averages the first two weeks of participants' inclusion in the study.
Locations:
city: Apeldoorn
country: Netherlands
facility: GGNet Ouderen (Elderly)
state: Gelderland
city: Heerlen
country: Netherlands
facility: Mondriaan Ouderen (Elderly)
state: Limburg
city: Venray
country: Netherlands
facility: Vincent van Gogh Ouderen (Elderly)
state: Limburg
city: Den Bosch
country: Netherlands
facility: Reinier van Arkel
state: Noord-Brabant
city: Eindhoven
country: Netherlands
facility: GGzE Nestor
state: Noord-Brabant
city: Eindhoven
country: Netherlands
facility: SeneVita GGZ
state: Noord-Brabant
city: Halsteren
country: Netherlands
facility: GGz WNB Ouderen (Elderly)
state: Noord-Brabant
city: Tilburg
country: Netherlands
facility: GGz Breburg PersonaCura
state: Noord-Brabant
city: Hoorn
country: Netherlands
facility: GGz NHN Frailty
state: Noord-Holland
city: Enschede
country: Netherlands
facility: GGz Mediant
state: Overijssel
Study officials:
affiliation: Tilburg University, GGz Breburg
name: Arjan Videler, Dr.
role: PRINCIPAL_INVESTIGATOR
References:
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citation: de Beurs, E. (2011). Brief Symptom Inventory-BSI. Handleiding herziene editie 2011. Leiden: PITS BV.
citation: Cage E, Di Monaco J, Newell V. Experiences of Autism Acceptance and Mental Health in Autistic Adults. J Autism Dev Disord. 2018 Feb;48(2):473-484. doi: 10.1007/s10803-017-3342-7.
citation: van Krugten FCW, Busschbach JJV, Versteegh MM, Hakkaart-van Roijen L, Brouwer WBF. The Mental Health Quality of Life Questionnaire (MHQoL): development and first psychometric evaluation of a new measure to assess quality of life in people with mental health problems. Qual Life Res. 2022 Feb;31(2):633-643. doi: 10.1007/s11136-021-02935-w. Epub 2021 Jul 9.
citation: Verbeek, I.C., Wedjelek, J., Elfeddali, I., & Videler, A.C. (2023). Acceptance Questionnaire Dutch translation. In development.
citation: Verbeek, I.C., Lenders, M.A.C.., van Alphen, S.P.J., Elfeddali, I., & Videler, A.C., (2023a). Questionnaire Knowledge, Recognition and Acceptance of Autism Diagnosis. In development.
citation: Verbeek, I.C., Lenders, M.A.C, van Alphen, S.P.J., Elfeddali, I., & Videler, A.C., (2023b). Questionnaire Knowledge, Recognition and Acceptance of Autism Diagnosis for Proxies. In development.
citation: Constantino, J.N., & Gruber, C.P. (2016). SRS-A Screeningslijst voor autismespectrumstoornissen: Handleiding. Hogrefe. [Dutch Handbook for the Social Responsiveness Scale for Adults]