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Research Article                                                                                                                                        Open Access

## Cross-Cultural Adaptation of the KONTAKT Social Skills Group Training Program for Children and Adolescents with high-functioning Autism Spectrum Disorder: A feasibility Study

Nora Choque Olsson 1,2* , Agneta Karlsson 3 , Sofia Andersson 4 , Annie Boström 4 , Mari Ljungström 2 , Sven Bölte 1,2

1 Center of Neurodevelopmental Disorder (KIND), Karolinska Institutet, Stockholm, Sweden 2 Child and Adolescent Psychiatry, Center for Psychiatry Research, Stockholm, Sweden 3 Child and Adolescent Psychiatry Unit Södertalje, Stockholm, Sweden 4 Asperger Center, Habilitation and Health, Stockholm, Sweden

*Corresponding author: nora.choque-olsson@ki.se

## Abstract

Background: Social skills group training is an intervention method that has demonstrated moderate evidence of improvement among children and adolescents with autism spectrum disorder (ASD). KONTAKT is a manualized social skills group training program that was developed in Germany and that has demonstrated preliminary evidence of positive effect. In this study, we describe its adaptation to Scandinavian settings.

Objective: The aim of this study was to evaluate the clinical feasibility of the Swedish version of KONTAKT. The program was piloted in two outpatient departments in Stockholm County.

Method: A convergent mixed-method approach that involved both quantitative (ratings scales for ASD, clinical severity, and adaptive  functioning)  and  qualitative  (semi-structured  interviewing)  evaluation  was  applied.  Twenty-two  children  and adolescents with high-functioning ASD between the ages of 8 and 17 years and their parents were enrolled in a one-group trial and completed assessments before and after KONTAKT training.

Results: The quantitative evaluation showed improvements in social communication and global everyday functioning; the qualitative evaluations yielded general treatment satisfaction. Twenty of the 22 enrolled adolescents (91%) completed the training.

Conclusions: These findings suggest that the Swedish adaptation of KONTAKT is feasible for Scandinavian clinical settings. It is currently being examined for efficacy and effectiveness in the largest multicenter randomized controlled trial of social skills group training in patients with ASD that has ever been undertaken (NCT01854346).

Keywords: intervention; therapy, feasibility; psychiatry; autism spectrum disorder; Asperger syndrome

## Introduction

Autism spectrum disorder (ASD) is a neurodevelopmental  disorder that is characterized by limited social communication and interaction skills in addition  to  restricted,  repetitive,  and  stereotyped interests; it leads to functional impairment (1). ASD is  considered  to  be  incurable,  but  it  is  treatable  to varying  degrees  to  prevent  worse  outcomes  (2). There is general consensus that the ASD diagnoses in the International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10), include Childhood autism (F84.0), Atypical autism (F84.1), Asperger syndrome (F84.5), and Pervasive developmental disorder, unspecified   (F84.9) under the umbrella term of Pervasive developmental disorder (3); a similar classification was used in the Diagnostic  and  Statistical  Manual  of  Mental  Disorders, Fourth  Edition (4).  In  the Diagnostic  and  Statistical Manual  of  Mental  Disorders,  Fifth  Edition (1),  these single  diagnoses  have  been  merged  into  one  ASD concept  under  the  umbrella  concept  of  Neurodevelopmental  disorder.  Although  it  has  not  been formally defined, 'high-functioning ASD' is typically described as ASD  without qualitative intellectual disability (i.e., an intelligence quotient of more than 70); this definition is applied in the current study.

Social skills group training (SSGT) is an increasingly used intervention for patients with ASD (5,  6).  Recent  systematic  reviews  have  indicated moderate  scientific  support  for  SSGT,  despite  the need for large-scale randomized controlled trials to assess  its  effectiveness  (5,  7).  Clinical  guidelines published by the Division of Child and Adolescent Psychiatry  (8)  and  other  clinical  organizations  in Stockholm County include the use of SSGT for the treatment of ASD, but they also point out the partly mixed evidence that supports its use and the apparent shortage of SSGT studies of ASD in clinical settings in Sweden. Indeed, a publication bias exists with  regard  to  the  application  of  SSGT  for  the treatment  of  ASD,  because  the  vast  majority  of published research  has  originated  from  the  United States.  Intercultural  adaptations  of  manual-based SSGT  are few. To the best of the authors' knowledge,  the  PEERS  program  (9),  which  was developed in the United States and adapted to the Korean condition (10), is one of the rare examples for which cross-cultural adaptions exist (11). To date, as far as we are aware, no manualized SSGT for ASD has  been  published  or  evaluated  in  a  Scandinavian clinical setting. Furthermore, in general, few studies of SSGT have applied both quantitative and qualitative  methods  to  explore  its  feasibility  and impact; mixed methods are increasingly recommended to address health care issues (12-14), because  qualitative  research  can  present  a  more complete picture of quantitative findings (15). In the current pilot study, we applied a convergent mixedmethod approach to a pilot manualized SSGT study in Scandinavia.

The  objective  of  this  study  was  to  examine  the feasibility  of  the  Swedish  version  of  KONTAKT. KONTAKT is an SSGT for children and adolescents with high-functioning ASD  that was originally developed for clinical child and adolescent psychiatry in Germany (16) and that has recently been adapted to  the  Swedish  language  and  culture  (17).  More precisely,  we  sought  to  investigate  the  Swedish adaptation  in  terms  of  the  preliminary  quantitative effects of the treatment on everyday functioning and symptom severity with the use of standardized scales and by qualitatively exploring the participants' experiences of the training via semi-structured individual interviews. This convergent mixedmethod  approach  (13,  14)  was  applied  in  two different obligatory clinical care settings.

## Method

## Centers

The intervention was piloted in two different clinical outpatient settings in Stockholm County: the Child and Adolescent Psychiatry Stockholm (Swedish acronym: BUP) outpatient unit of Södertälje (BUPSödertälje) and the Habilitation and Health outpatient  unit  for  children  and  adolescents  with Asperger  syndrome  (Asperger  Center).  The  pilot study  at  BUP-Södertälje  was  conducted  between February and December 2011, and the evaluation at the Asperger Center was conducted between February  and  October  2013.  BUP-Södertälje  is  an obligatory  care  unit  within  BUP  Stockholm,  the largest child and  adolescent  mental  health  care service  provider  in  Sweden.  BUP  Stockholm  has about  1000  employees  and  treats  25,000  patients annually;  it  provides  170,000  annual  visits  at  17 outpatient clinics (four of which offer more intensive treatment), two inpatient clinics, and five specialized units  that  focus  on  certain  groups  of  behavior problems  (e.g.,  self-injury)  and  that  provide  highly specific  care  (e.g.,  neurofeedback).  In  accordance with local health care policies, BUP typically serves complex cases of ASD (i.e., ASD plus a comorbid condition).  The  Asperger  Center  for  children  and adolescents  is  a  unit  that  receives  800  referrals annually  and  that has  a total of  4000  families registered to receive services. It is part of Habilitation and  Health  Stockholm,  which  comprises  15,000 registered patients; it provides 130,000 visits per year and employs 750 individuals. The Asperger Center is obliged to treat patients with ASD, with the aim of increasing adaptive functioning skills independent of any comorbidity.

## Participants

Twenty-two children and adolescents with ASD (i.e., ICD-10 diagnoses F84.0,  F84.1,  F84.5,  and  F84.9) between the ages of 8 and 17 years (M = 12.3 years; SD = 2.4) were enrolled, and n = 20 completed the study. The inclusion and exclusion criteria are given in Table 1. Participants had prior ICD-10 (3) clinical consensus diagnoses of ASD made on the basis of the comprehensive neuropsychiatric assessment procedures outlined in the guidelines of the Division of Child and Adolescent Psychiatry Stockholm (8); they  had  also  been  assessed  with  the  Wechsler Intelligence Scale for Children, Fourth Edition (WISC-IV) (18), and the Autism Diagnostic Observation  Schedule  (19).  All  participants  had intelligence quotients of at least 70.

Participants at BUP-Södertälje were clinically referred outpatients (n = 8) between the ages of 8 and  17  years  (Mean  [M]  =  12.5  years;  standard deviation  [SD]  =  3.1  years)  who  had  at  least  one psychiatric comorbidity, such as attention- deficit/hyperactivity disorder (ICD-10 diagnoses F90.0 and F98.8), an anxiety disorder (F40, F41, and F43), or a mood disorder (F32 and F33). Participants at  the  Asperger  Center (n = 12) were between the ages of 10 and 15 years (M = 12.1 years; SD= 2.2 years) and recruited from the patient population of the Asperger Center (Table 2). Participants recruited from  both  clinical  sites  were  required  to  exhibit fluent Swedish language skills and to express explicit motivation to join the pilot study. One parent of each participant (n = 20) was included in the qualitative evaluation, which involved a semi-structured interview after treatment (20).

TABLE 1. Inclusion and Exclusion Criteria

The  trainers  who  conducted  the  KONTAKT training for the purposes of this study were clinicians with long-standing experience working with children and adolescents with ASD. By profession, they were two clinical psychologists, one social worker, and one occupational therapist. All received regular supervision of four hours per month throughout the pilot evaluation.

| Center          | Inclusion Criteria                                                                                                                                                                                                                                                                         | Exclusion Criteria                                                                                                                                                        |
|-----------------|--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|---------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| BUP-Södertälje  | High-functioning ASD (ICD-10 F84.0, F84.1, F84.5, and F84.9) IQ >85 according to WISC-IV Psychiatric comorbidity: ADHD (ICD-10 F90.0 and F98.8), anxiety syndrome (ICD-10 F40, F41, and F43), or depression (ICD-10 F32 and F33) Fluent in Swedish Motivated to participate in the project | Self-injurious behavior, conduct disorder (ICD- 10 F91), borderline personality disorder (ICD-10 F60.3), and schizophrenia (ICD-10 F20 through F29)                       |
| Asperger Center | ASD (ICD-10 F84.0, F84.1, F84.5, and F84.9) IQ >70 according to WISC-IV                                                                                                                                                                                                                    | Other psychiatric diagnoses, such as ADHD (ICD-10 F90.0 and F98.8), anxiety syndrome (ICD-10 F40, F41, and F43), or depression (ICD- 10 F32 and F33) <10 or >16 years old |

Note. ADHD, Attention-deficit/hyperactivity disorder; ASD, autism spectrum disorder; BUP, Child and Adolescent Psychiatry; ICD-10, International Statistical Classification of Diseases and Related Health Problems, 10th Revision; IQ, intelligence quotient; WISC-IV, Wechsler Intelligence Scale for Children, Fourth Edition.

TABLE 2. Characteristics of the Sample Population

|                                           | BUP-Södertälje                   | Asperger Center                  |
|-------------------------------------------|----------------------------------|----------------------------------|
| Sex                                       | 4 male, 4 female                 | 8 male, 4 female                 |
| Age                                       | Mean, 12.5 years (SD, 3.1 years) | Mean, 12.1 years (SD, 2.2 years) |
| ASD diagnoses                             |                                  |                                  |
| Childhood autism                          | n = 0                            | n = 0                            |
| Atypical autism                           | n = 1                            | n = 0                            |
| Asperger syndrome                         | n = 2                            | n = 8                            |
| Pervasive developmental disorder          | n = 5                            | n = 4                            |
| Comorbidity ADHD (ICD-10 F90.0 and F98.8) | n = 7                            | -                                |
| Anxiety (ICD-10 F40, F41, and F43)        | n = 4                            | -                                |
| Depression (ICD-10 F32 and F33)           | n = 2                            | -                                |

Note. ADHD, Attention-deficit/hyperactivity disorder; ASD, autism spectrum

disorder; BUP, Child and Adolescent Psychiatry; ICD-10, International Statistical Classification of Diseases and Related Health Problems, 10th Revision.

The study was approved by the local ethics committee in Stockholm, Sweden (2011/557-31/5), and  all  participants  and  their  caregivers  provided informed consent before participation began.

## The KONTAKT Program

KONTAKT  is  a  manualized,  structured  SSGT program  for  children  and  adolescents  with  highfunctioning  ASD  that  was  developed  in  Germany (16).  The  original  open  uncontrolled  one-group evaluation study (21) included a total of 17 children and adolescents with high-functioning ASD between the  ages  of  9.3  and  20.3  years.  The  results,  which were based on quantitative measures and statistics, showed moderate to large positive treatment effects on social skills and everyday functioning according to expert,  parent,  and  teacher  ratings  on  standardized scales. The authors concluded that the findings were promising  but  that  larger-sized  controlled  studies were needed to draw firm conclusions about KONTAKT's  utility.  The  KONTAKT  program focuses  on  initiating  social  overtures,  developing conversation  skills,  understanding  social  rules  and relationships, identifying and interpreting verbal and non-verbal  social  signals,  managing  conflicts,  and developing  coping  strategies  in  an  effort  to  help affected individuals to improve their self-confidence. The  teaching  formats  include  conveying  common social  rules  and  norms;  providing  conflict-solving strategies; offering group discussions, social play, and emotion-processing training (22); role-playing; group activities;  homework  assignments;  and  individual behavioral  analysis  (Table  3).  The  KONTAKT program  is  based  on  the  principles  of  cognitive behavioral therapy, observational learning, and behavioral activation; parent involvement and teacher  cooperation  are  also  embedded  into  the KONTAKT program. Participants  are  assigned  to groups  for  either  children  (8  to  12  years  old)  or adolescents  (13  to  17  years  old).  The  groups  meet weekly,  with  60  minutes  of  training  provided  for children and 90 minutes offered for adolescents. The groups  consist  of  four  to  six  participants  and  two trainers.

Before the current study, the German KONTAKT manual was translated  into  Swedish  by  a  group  of professional  translators  and  experienced  Swedish clinicians who work in child and adolescent psychiatry. One of the authors and developers of the original  German  KONTAKT  program,  who  is bilingual and who has cross-cultural clinical competence for both Swedish and German settings, participated in the process of developing the Swedish adaptation;  this  author  ensured  the  comparability between the original and the adaptation and authorized the final Swedish version. The adaptation accounted for culture-specific traditions, expressions, and clinical concepts, and it sought to maximize practicability for Swedish clinical practice (17).

The overall structure  and  content of the  original KONTAKT  manual  and  program  were  largely maintained. However, some culturally sensitive adaptations  were  made.  For  instance,  the  Swedish version enhanced cognitive behavioral therapy principles as they applied to some of the elements of the KONTAKT program. In particular, the homework assignments were tailored to reflect the participants' own hierarchy of treatment goals; rather than giving similar homework to the participants, as originally conceptualized. Another adaptation concerned the introduction of the Swedish tradition of 'fika' into the middle of each training session; this is a coffee break or snack time that is an integral part of Swedish social culture. For KONTAKT participants,  this  break  offers  a  chance  for  social communication  to  occur  in  a  less  structured  (but relatively sheltered) situation. At the same time, the Swedish  version  reduced  the  number  of  group excursions, which were used by the original KONTAKT  program  to allow participants to practice  social  communication  in  less  structured environments. The original version also made use of response-cost  systems  for  unwanted  behaviors  by using token economies, whereas only positive reinforcement was applied in the Swedish version.

Outcome Assessments and Feasibility Quantitative Measures Before and After Treatment Developmental  Disabilities  Modification  of  the  Children's Global Assessment Scale (DD-CGAS). The DD-CGAS is  an  instrument used by clinicians to rate patients' global adaptive functioning. The scale ranges from 1, which indicates an extremely and consistently reduced  ability,  to  100,  which  indicates  extremely good functioning in all areas of life (e.g., at home, at school, in social relationships). Scores of less than 70 on the DD-CGAS indicate clinically relevant atypical functioning. It is a version of the standard CGAS that has been modified to better fit children and adolescents with ASD. The scale has been translated into Swedish, and it was evaluated in Swedish settings (23). The intraclass correlation coefficient (ICC) for experienced clinicians is .75. In this study, the DDCGAS was scored by the trainers who conducted the KONTAKT training.

The Ohio State University (OSU) Autism Clinical Global Impression -Severity (OSU Aut CGI-S). The OSU Aut CGI-S is a clinician-based rating scale that is used to estimate the current severity of general psychopathology. The global clinical impression of ASD and other symptom severity is rated on  a  7point scale, with 7 indicating extremely severe symptomatology and 1 indicating no sign of clinical symptomatology. The OSU Aut CGI-S is a modified version of the standard CGI scale that was created to better fit the needs of individuals with ASD. It has been translated into Swedish, and it was evaluated in Swedish  settings  (23).  For  this  tool,  the  ICC  for experienced clinicians  is  .72.  The  OSU  Aut  CGI-S was rated by the KONTAKT trainers in this pilot study.

TABLE 3. KONTAKT Session Structure and Content

| Structure and Content         | Original German Version                                                                                                                                                                                                                                                                                                                                                                  | Swedish Adaptation                                                                                                                    |
|-------------------------------|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|---------------------------------------------------------------------------------------------------------------------------------------|
| Opening the session           | Warm-up activity; contact initiation; promotion of interaction among group members, such as promoting eye contact (e.g., 'Say hello to each other,' 'Give an account of an experience from the past few days and of one's mood at the beginning of the session,' 'I pass the word to…')                                                                                                  | Same as in the German version                                                                                                         |
| Homework assignment follow up | Homework from the previous session is discussed; the participants will have completed a common homework assignment, and reinforcement and feedback are provided; troubleshooting occurs, if necessary                                                                                                                                                                                    | Same as in the German version, except the homework assignments are individualized according to each participant's own treatment goals |
| Group exercise                | Role-playing: practical solutions and strategies for difficult social situations Social interaction games: basic interaction and communication games, cooperation, recognition of non-verbal signals, eye contact (e.g., 'spin the bottle') Affect recognition: Frankfurt Test of Facial Affect Recognition, recognition and interpretation of facial expressions, emotional thermometer | Same as in the German version                                                                                                         |
| Unstructured activity         | Group activities (e.g., cinema or café visit, baking cookies) to develop group coherence and foster social interaction in less structured situations                                                                                                                                                                                                                                     | Snack time, with same objective as in the German version                                                                              |
| Group discussion              | Exchanging of experiences and practicing social cognition and social relationships; examples of discussion topics include 'What is autism spectrum disorder?' 'How can I tell what somebody else is feeling?' 'How do I initiate a conversation?'                                                                                                                                        | Same as in the German version                                                                                                         |
| Homework assignment           | Generalizing skills to everyday situations, learning to cope with difficult situations, trying out alternative coping behaviors (e.g., 'Make an appointment with a classmate')                                                                                                                                                                                                           | Same as in the German version, except the homework assignments are individualized according to each participant's own treatment goals |
| Closing the session           | Recap of the day; discussion of what has been good or less good; participants give suggestions for improvement and take turns as they did during the session opening; the session is evaluated, and interaction among group members is promoted                                                                                                                                          | Same as in the German version                                                                                                         |

## Social Responsiveness Scale (SRS).

The SRS is a 65-item parent-report questionnaire (24) that assesses autism traits in children and adolescents between the ages of 4 and 18 years. It is rated using a  3-point  Likert  scale,  and  its  items  compose  five subscales:  social  awareness,  social  cognition,  social communication, social motivation, and autistic mannerisms. Total scores range from 0 to 195, with increasing values indicating the increasing severity of autistic traits. The expected scores of individuals with ASD are approximately 100; they are around 25 for those  who  have  experienced  typical  development (25).

## Qualitative  Interviews  with  Participants  and  Parents  after Intervention

Semi-structured  interviews  that  addressed  how  the participants (n = 20) and their caregivers (n = 20) experienced  the  SSGT  KONTAKT  program  were conducted by the KONTAKT trainers after the last session and lasted an average of 45 minutes. Previous to the study an interview guide was developed by the clinicians  who  conducted  the  training  to  explore what it is like to experience the KONTAKT program (20). The interviews inquired about how the patients and  their  parents  valued  KONTAKT,  what  the potential gains and drawbacks of the training were, what the participants  might  have  learned  from  the intervention, what was experienced as good or less good, and whether the participants had any recommendations for treatment improvement.

## Analyses

Feasibility was evaluated by comparing the number of individuals who completed the training with the number  of participants originally enrolled, and reasons  for  dropout  were  explored.  In  addition, verbal data from the semi-structured interviews were analyzed for meaningful comments associated with feasibility  and  outcomes  using  a  thematic  analysis approach  (26).  The  interviews  were  transcribed  by the  trainers,  and  another  researcher  identified  the themes and grouped them into subthemes. Quantitative  treatment  outcome  as  determined  by rating  scales  and  questionnaires  was  analyzed  with the use of non-parametric two-tailed  Wilcoxon Signed  Rank  tests  for  paired  independent  samples after adopting an alpha level of 5%. Analyses were conducted separately for each participating center.

TABLE 4. Qualitative Interview Results: Themes and Examples Related to the Participants

| Themes                                             | Children and Adolescents at BUP-Södertälje                                              | Parents of Children and Adolescents at BUP- Södertälje                                                                                                                                                                                                                                                                                    | Children and Adolescents at Asperger Center                                                                                                           | Parents of Children and Adolescents at Asperger Center                         |
|----------------------------------------------------|-----------------------------------------------------------------------------------------|-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-------------------------------------------------------------------------------------------------------------------------------------------------------|--------------------------------------------------------------------------------|
| Better self- awareness and obtaining new abilities | 'I have more information about [my] diagnosis' (A) 'Emotional thermometer was good' (A) | 'She has become better to ask when she doesn't understand sarcasm and irony' (P)                                                                                                                                                                                                                                                          | 'I learned some interesting things about myself' (C)                                                                                                  | 'He is less anxious when something changes' (P)                                |
| Better social skills                               | 'I'm more confident, I ask when I didn't understand what the others mean' (C)           | 'It has been an experience for him to go to KONTAKT, he is more positive to go to a new school and to meet new people now' (P) 'She has become more expressive and can explain why she feels sad or angry' (P) 'He is more positive and can express his thoughts and feelings more than he could before' (P) 'Now, she tells us about how | 'It has become much easier to get in touch now' (A) 'I thought it was fun to be here! It made sense because I have learned to talk to more people'(C) | 'She has become more positive and talks about when things go wrong' (P)        |
| Self-confidence                                    | 'I have managed to call a relative' (A)                                                 | 'He is less worried regarding new events and uncertainty' (P) 'She does not get angry or explosive as before' (P)                                                                                                                                                                                                                         | 'It made me feel better about myself, and I'm a bit more confident' (A) 'It has helped me to avoid fights better and I feel more confident' (A)       | 'He has become more secure when he meets new people'(P)                        |
| Sense of connection and cohesion                   | 'Being in a group where others have the same diagnosis has helped him much' (A)         | 'She does not feel alone anymore' (P) 'He is now motivated to make contact with other people'(P)                                                                                                                                                                                                                                          | 'It was great to go in this group and meet others with [autism spectrum disorder] and know that they have the same problem' (A)                       | 'He now dares to get in touch with new people and he feels more confident' (P) |
| Positive effects in everyday life                  | 'I can control my anger even though I often get angry and feel anger' (A)               | 'He is able to take the bus alone from the school to the therapy sessions' (P) 'He helps me more now at home' (P) 'Telephone contact with [my child] works better now' (P)                                                                                                                                                                | 'I constantly used to think about how I am as a person, and after KONTAKT, it has opened many new doors for me' (A)                                   | 'I think it has become less trouble' (P)                                       |

Note. (A), Adolescent; BUP, Child and Adolescent Psychiatry; (C), child; (P), parent.

## Results

## Feasibility and Qualitative Findings

With regard to feasibility, 20 of 22 enrolled participants (91%) completed the study. Two adolescents dropped out of the project. The first one did not show up for the training, even though the proband had accepted the invitation to participate. No reason could be ascertained for this individual's dropping out. The second one dropped out during training because the proband's clinical symptomatology turned out to be too severe to allow this patient to function within the context of SSGT.

## Findings Related to Participants

The  semi-structured interviews  revealed  that  the majority of the participants from both  BUP- Södertälje and the Asperger Center expressed satisfaction after participating in the group training. The  themes  identified  in  the  verbal  data  from  the interviews with participants and their parents included  'Better  self-awareness  and  obtaining  new abilities,'  'Better  social  skills,'  'Self-confidence,' 'Sense of connection and cohesion,' and 'Positive effects in everyday life.' Most participants stated that they had learned new skills and gained new insights related to social communication and that their selfconfidence had improved. Several participants expressed  that  they  had  become  better  at  making social  overtures,  which  was  consistent  with  their individual treatment goals. Two participants noticed positive effects in everyday life and found it rewarding to meet other people with ASD during the KONTAKT program. One participant said that she had become better at describing her emotions both at  home  and  at  school  by  using  the  'emotional thermometer' device discussed in the KONTAKT training. Parents stated that they had received helpful support and novel knowledge from the trainers that helped  them  to  better  help  and  interact  with  their children. Several parents felt that the treatment had enhanced their awareness of the difficulties that their children face and helped them to better understand how their children are perceived in different environments.  See  Table  4  for  an  overview  of  the verbal results.

TABLE 5. Qualitative Interview Results Related to Parents

With regard to the KONTAKT homework assignments, the majority of the parents stated that their children had problems grasping the objectives. The parents reported that some homework assignments had been difficult to implement, whereas the child and adolescent patients themselves said  that  it  had  been  difficult  to  set  their  own treatment goals. Many  of  the  enrolled patients decided  to  complete  their  homework  assignments while they were at school, which made it difficult for trainers and parents to evaluate the assignments or support their implementation. The majority of parents mentioned that they had difficulty motivating their  children  to  practice  social  skills  in  situations outside of the KONTAKT training environment.

| Themes                               | Parents of Children and Adolescents at BUP- Södertälje           | Parents of Children and Adolescents at Asperger Center                     |
|--------------------------------------|------------------------------------------------------------------|----------------------------------------------------------------------------|
| Share experiences with other parents | 'It was very important to meet other parents'                    | 'To hear other parents in the same situation was good'                     |
| Tool to help the child               | 'We parents have been given some tools to help him better'       | 'They taught us how we can support and help her when she locks herself up' |
| Better understanding                 | 'We are now more able to understand better difficult situations' | 'We have learned to see her needs'                                         |

Note. BUP , Child and Adolescent Psychiatry

TABLE 6. Means and Standard Deviations With Repeated Measurements and the Results of Nonparametric Wilcoxon Signed-Rank Tests

|                    | BUP-Södertälje (n = 8) †   | BUP-Södertälje (n = 8) †   | BUP-Södertälje (n = 8) †   | BUP-Södertälje (n = 8) †   | Asperger Center (n = 12)   | Asperger Center (n = 12)   | Asperger Center (n = 12)   | Asperger Center (n = 12)   |
|--------------------|----------------------------|----------------------------|----------------------------|----------------------------|----------------------------|----------------------------|----------------------------|----------------------------|
|                    | Mean                       | SD                         | z                          | p value                    | Mean                       | SD                         | z                          | p value                    |
| DD-CGAS Pre        | 61.7                       | 3.8                        | 2.5                        | .01*                       | 65.5                       | 5.2                        | 2.8                        | .004*                      |
| DD-CGAS Post       | 67.70                      | 5.6                        |                            |                            | 71.3                       | 5.2                        |                            |                            |
| OSU Aut CGI-S Pre  | 4.5                        | 0.5                        | 2.5                        | .01*                       | 4.0                        | 0.8                        | 2.7                        | .008*                      |
| OSU Aut CGI-S Post | 2.8                        | 0.6                        |                            |                            | 2.3                        | 0.5                        |                            |                            |
| SRS Pre            | 60.9                       | 28.4                       | 1.2                        | .24                        | 94.5                       | 19.1                       | .00                        | 1.00                       |
| SRS Post           | 58.1                       | 24.7                       |                            |                            | 94.6                       | 19.3                       |                            |                            |

Note. † Autism spectrum disorder plus psychiatric comorbidity.

*Significant results.

BUP, Child and Adolescent Psychiatry; DD-CGAS, Developmental Disabilities Modification of the Children's Global Assessment Scale; OSU Aut CGI-S, Autism Clinical Global Impression - Severity; SD, standard deviation; SRS, Social Responsiveness Scale.

## Findings Related to Parents

With regard to the themes derived from the semistructured  interviews  related  to  the  parents'  issues, this study identified the following: 'Share experiences with other parents,' 'Tool to help the child,' and 'Better understanding.' Parents felt that it was valuable to share experiences with each other at  the  parent  meetings,  but  they  also  wanted  more hands-on  advice  from  the  trainers  about  how  to respond  to  their  children's  behaviors.  One  parent explicitly  requested  more  KONTAKT  training  for the child beyond the regular duration of the program as well as additional parent sessions (Table 5).

## Quantitative Findings

The outcomes of the DD-CGAS showed increased adaptive functional skills post training in the groups held at both BUP-Södertälje (z = 2.5; p = .01) and the  Asperger  Center  (z  =  2.8; p =  .004).  Before treatment, the average DD-CGAS scores were 61.7

(SD, 3.8) at BUP-Södertälje and 65.5 (SD, 5.2) at the Asperger Center; after treatment, they were 67.7 (SD, 5.6) and 71.3 (SD, 5.2), respectively. The OSU Aut CGI-S results showed a decrease in clinical symptomatology post training at both BUPSödertälje (z = 2.5; p = .01) and the Asperger Center (z  =  2.7; p =  .008).  At  BUP-Södertälje, the CGI-S values  dropped from M= 4.5 (SD, 0.5) to M= 2.8 (SD, 0.6); they dropped from a mean of 4.0 (SD, 0.8) to M = 2.3 (SD, 0.5) at the Asperger Center. Pre-post treatment values on the SRS did not change at either BUP-Södertälje (z = 1.2; p =  .24)  or  the  Asperger Center (z = .00; p =  1.00)  indicating no significant changes  in  social  communication  skills  following training (Table 6).

## Discussion

The  purpose  of  this  study  was  to  describe  the adaptation,  feasibility,  and  preliminary  evidence  of the Swedish version of KONTAKT, an SSGT that originated in Germany for children and adolescents with  higher-functioning  ASD.  Several  minor  but important  adaptations  were  made  when  translating the manual and adapting the program procedures to a Scandinavian clinical setting. Culture-specific preferences  in  addition  to  clinical  expertise  and vocabulary  were  taken  into  account  to  form  a meaningful  and  culturally  sensitive  version  of  a psychological intervention method originating outside of Sweden. We applied a convergent mixedmethod  approach  to  explore  both  the  quantitative and qualitative effects of the Swedish adaptation of SSGT, KONTAKT. This methodological approach endorsed  the  applicability  and  usefulness  of  the training method as indicated by, among other things, a  low  dropout  rate  (<10%)  and  a  high  level  of treatment satisfaction in two different clinical settings  in  Stockholm  for  children  and  adolescents with ASD either with or without psychiatric comorbidity. During verbal exploration, participants reported newly acquired social communication skills, and their parents reported improved knowledge of ASD and better problem awareness. Moreover, on standardized scales, global clinical severity decreased, and  the  overall  functional  level  of  adaptive  skills increased in the eyes of the trainers. However, the severity of the patients' autism traits did not reduce according to what was observed by their parents.

Despite  the  mainly  positive  current  findings,  it must be noted that this is a pilot study, with many limitations as far as the generalizability of the evidence  presented  here.  The  uncontrolled  onegroup design and the small sample size without blind ratings warrant humble interpretation as a result of the multiple associated risks for bias. Furthermore, the stability of the achieved changes is not known, because  this  study  did  not  include  any  long-term follow-up assessments. However, our data is in line with  evaluation  data  from  the  original  German version  of  KONTAKT  (16),  and  it  provides  the initial evidence needed to conclude that the intercultural  adaptation  of  KONTAKT  was  rather successful:  enough  of  the  basic  prerequisites  were fulfilled to determine that it is worthwhile to continue applying and evaluating the Swedish version of KONTAKT. With this in mind, we are currently conducting the largest ever multicenter randomized controlled  trial  of  SSGT  using  the  KONTAKT program in Stockholm and Örebro County in 288 children and adolescents with ASD at 14 outpatient units (NCT01854346).

In conclusion, the results of the current pilot study provide  preliminary  evidence  in  support  of  the Swedish  adaptation  of  KONTAKT,  and  they  also yield suggestions for improvement that are important to consider for the future use of this program and its implementation  in  clinical  practice.  For  example, additional  information  about  the  objectives  of  the homework  assignments was requested by both participants and their parents. Moreover, participants may require more explicit incentives to complete the homework assignments.

## Clinical Significance

There  is  still  a  lack  of  sufficiently  evidence  based intervention methods for patients with ASD (5, 7). SSGT programs are popular for these patients, but there are limitations to their generalizability (27). In Sweden and Scandinavia, no manualized and evaluated SSGT programs for ASD have previously been available. The present study is the first to test the  feasibility  of  such  a  program  in  Scandinavian clinical settings for the treatment of both pure ASD and  more  complex  variants  of  ASD  with  multiple coexisting  psychopathologies.  Our  results  yielded promising preliminary evidence, which may stimulate more research in this field in Northern Europe and potentially  lead  to  improved  access  to  evidencebased  services  for  children  and  adolescents  with ASD in Sweden and elsewhere.

## Conflicts of Interest

Sven  Bölte  receives  royalties  for  the  German  and Swedish versions of the KONTAKT manual from Hogrefe Publishers. The other authors declare that they  have  no  conflicts  of  interest  regarding  the publication of this paper.

## Acknowledgements

The authors  thank  all  of  the  children,  adolescents, and parents who participated for their contributions to this study. They also thank Peter Ericson, Head of Child  and  Adolescent  Psychiatry,  South  Region, Stockholm County Council; Karin Sigward, Head of the Department of Child and Adolescent Psychiatry in Södertälje; and Gunilla Keith Bodros, Head of the Asperger Center, Stockholm County Council.

Sven Bölte was supported by the Swedish Research Council (523-2009-7054).

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