1. 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

2. Nora Choque Olsson, September 2014 2 Background Study progress Time plan

3.  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) Nora Choque Olsson, September 2014 3 Restrictive Fixated Interests Autism spectrum disorders Social Communica- tion BackgroundStudy progressTime plan

4. Nora Choque Olsson, September 2014 4 Knowledge gaps BackgroundStudy progressTime plan 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

5. Review on external validity of RCT on SSGT Evaluate the 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 Nora Choque Olsson, September 2014 5 Our purpose is to: Novel Clinical based trial at Child and Adolescent Research Center

6. Review on external validity of RCT on SSGT Evaluation of two tools Interrater reliability 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 Nora Choque Olsson, September 2014 6 Novel Clinical based trial at Child and Adolescent Research Center Our purpose is to:

7. Review on external validity of RCT on SSGT Evaluation of two tools, Interrater reliability Behavioural effects of KONTAKT in comparison with TAU Investigate the impact of moderator and mediators Examine the effects of SSGT as experienced by participants Nora Choque Olsson, September 2014 7 To examine the behavioral effects of SSGT, KONTAKT compared to TAU Novel Clinical based trial at Child and Adolescent Research Center Our purpose is to:

8. Review on external validity of RCT on SSGT Evaluation of two tools, Interrater reliability Behavioural effects of KONTAKT in comparison with TAU Impact of moderator and mediators Examine the effects of SSGT as experienced by participants Nora Choque Olsson, September 2014 8 To examine the behavioral effects of SSGT, KONTAKT Compared to TAU Novel Clinical based trial at Child and Adolescent Research Center Our purpose is to:

9. Review on external validity of RCT on SSGT Evaluation of two tools, Interrater reliability Behavioural effects of KONTAKT in comparison with TAU Impact of moderator and mediators Qualitative study on effects of SSGT Nora Choque Olsson, September 2014 9 To examine the behavioral effects of SSGT, KONTAKT Compared to TAU Novel Clinical based trial at Child and Adolescent Research Center Our purpose is to:

10.  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. Nora Choque Olsson, September 2014 10 BackgroundStudy progressTime plan KONTAKT

11. Nora Choque Olsson, September 2014 11 BackgroundStudy progressTime plan 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)

12. Nora Choque Olsson, September 2014 12 KONTAKT-team BackgroundStudy progressTime plan

13. Nora Choque Olsson, September 2014 13 Background Study progress Time plan

14. Nora Choque Olsson, September 2014 14 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 BackgroundStudy progressTime plan

15. 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 Nora Choque Olsson, September 2014 15 BackgroundStudy progressTime plan

16. STUDY 1 External 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. Nora Choque Olsson, September 2014 16 BackgroundStudy progressTime plan

17. STUDY 1 External validity (EV) of RCT studies on social skills group interventions  Objective:  Material & Methods:  Data Items:  Source population  Included population  Context  Treatment provider  Treatment intervention  Outcome Nora Choque Olsson, September 2014 17 BackgroundStudy progressTime plan

18. STUDY 1 External validity (EV) of RCT studies on social skills group interventions  Objective:  Material & Methods:  Results: Nora Choque Olsson, September 2014 18 BackgroundStudy progressTime plan n= 7263 n= 5241 n= 204 n= 5241 n= 11

19. STUDY 1 External validity (EV) of RCT studies on social skills group interventions  Objective:  Material & Methods:  Results: Nora Choque Olsson, September 2014 19 BackgroundStudy progressTime plan Figure1: Overall view of reporting data related to external validity of included trials.

20. STUDY 1 External validity (EV) of RCT studies on social skills group interventions.  Objective:  Materials & Methods:  Results: Nora Choque Olsson, September 2014 20 High-functioning school-aged children with ASD Eligible population Male and Caucasian Included population Not adequately reported: excluded participants, secondary comorbidities Selection and flow Not sufficient information about treatment provider and settings Treatment intervention

21. STUDY 1 External validity (EV) of RCT studies on social skills group interventions  Objective:  Materials & Methods:  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” Nora Choque Olsson, September 2014 21 BackgroundStudy progressTime plan

22. STUDY 2 Adaptation 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) Nora Choque Olsson, September 2014 22 BackgroundStudy progressTime plan  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).

23. STUDY 2 Adaptation and validation of the DD-CGAS and OSU Autism CGI-S  Objective:  Materials & Methods:  Study sample:  Assessment:  DD-CGAS ↑100- 91 ↓10-1  OSU AUTISM GCI ↓7 ↑1 Nora Choque Olsson, September 2014 23 BackgroundStudy progressTime plan

24. STUDY 2 Adaptation and validation of the DD-CGAS and OSU Autism CGI-S  Objective:  Materials & Methods:  Study sample:  16 clinicians from 9 BUP- clinics Experienced (> 2 y) Inexperienced (< 2 y)  8 clinical vignettes Nora Choque Olsson, September 2014 24 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 BackgroundStudy progressTime plan

25. STUDY 2 Adaptation and validation of the DD-CGAS and OSU Autism CGI-S  Objective:  Materials & Methods:  Statistic analysis  Two-way random intraclass correlation coefficients (ICC)  Pearson correlation Nora Choque Olsson, September 2014 25 BackgroundStudy progressTime plan

26. Nora Choque Olsson, September 2014 26 STUDY 2 Adaptation 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:  Materials & Methods:  Results: BackgroundStudy progressTime plan

27. Nora Choque Olsson, September 2014 27 STUDY 2 Adaptation and validation of the DD-CGAS and OSU Autism CGI-S DD CGAS  Objective:  Materials & Methods:  Results: BackgroundStudy progressTime plan ICC was 0.75 for experienced, and 0.58 for inexperienced clinicians. ICC was 0.72 for experienced and 0.59 for inexperienced clinicians.

28. Nora Choque Olsson, September 2014 28 STUDY 2 Adaptation and validation of the DD-CGAS and OSU Autism CGI-S 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:  Materials & Methods:  Results: BackgroundStudy progressTime plan

29. Nora Choque Olsson, September 2014 29 STUDY 2 Adaptation and validation of the DD-CGAS and OSU Autism CGI-S  Objective:  Materials & Methods:  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. BackgroundStudy progressTime plan

30. Nora Choque Olsson, September 2014 30 STUDY 2 Adaptation and validation of the DD-CGAS and OSU Autism CGI-S  Objective:  Materials & Methods:  Results:  Conclusions:  Status: BackgroundStudy progressTime plan

31. 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. Nora Choque Olsson, September 2014 31 BackgroundStudy progressTime plan

32.  Objectives:  Hypotheses:  SSGT ≠ TAU  SSGT ↑ social skills and improved their adaptive behavior ↑ every day functioning ↓ symptom severity ↓ stress in both participants and their parents Nora Choque Olsson, September 2014 32 STUDY 3 [NCT01854346] Behavioral effects of social skills group training, KONTAKT compared to Treatment as usual: an RCT-multicenter study BackgroundStudy progressTime plan

33.  Objectives:  Hypotheses:  Methods:  Design RCT multicenter study  Participants: Large sample size: N= 288 (today n= 230) Nora Choque Olsson, September 2014 33 STUDY 3 [NCT01854346] Behavioral effects of social skills group training, KONTAKT compared to Treatment as usual: an RCT-multicenter study BackgroundStudy progressTime plan

34.  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 Nora Choque Olsson, September 2014 34 STUDY 3 [NCT01854346] Behavioral effects of social skills group training, KONTAKT compared to Treatment as usual: an RCT-multicenter study BackgroundStudy progressTime plan

35.  Objectives:  Hypotheses:  Methods:  Participants: Recruits from 10 child and adolescent psychiatric clinics (BUP) in Stockholm County. Nora Choque Olsson, September 2014 35 STUDY 3 [NCT01854346] Behavioral effects of social skills group training, KONTAKT compared to Treatment as usual: an RCT-multicenter study BackgroundStudy progressTime plan

36.  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) Nora Choque Olsson, September 2014 36 STUDY 3 [NCT01854346] Behavioral effects of social skills group training, KONTAKT compared to Treatment as usual: an RCT-multicenter study BackgroundStudy progressTime plan

37.  Objectives:  Hypotheses:  Methods  Randomization and flowchart  Ethic approbation Nora Choque Olsson, September 2014 37 STUDY 3 [NCT01854346] Behavioral effects of social skills group training, KONTAKT compared to Treatment as usual: an RCT-multicenter study BackgroundStudy progressTime plan

38.  Objectives:  Hypotheses:  Method:  Statistical analysis To test the demographic variables.  t-test and X 2 tests To evaluate the treatment effect  Mixed-model MANOVA pre-, post and follow-up to compare KONTAKT and TAU  Intention to treat (ITT) principle. Nora Choque Olsson, September 2014 38 STUDY 3 [NCT01854346] Behavioral effects of social skills group training, KONTAKT compared to Treatment as usual: A RCT-multicenter study BackgroundStudy progressTime plan

39.  Objectives:  Hypotheses:  Method:  Statistical analysis  Status:  n= 230 Children and adolescents with HFASD have participated in the study Nora Choque Olsson, September 2014 39 STUDY 3 [NCT01854346] Behavioral effects of social skills group training, KONTAKT compared to Treatment as usual: an RCT-multicenter study BackgroundStudy progressTime plan

40. STUDY 4 Moderators 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 Nora Choque Olsson, September 2014 40 BackgroundStudy progressTime plan

41. STUDY 4 Moderators and mediators of treatment outcome in a SSGT for children with HFASD and psychiatric comorbidity  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. Nora Choque Olsson, September 2014 41 BackgroundStudy progressTime plan

42. STUDY 4 Moderators and mediators of treatment outcome in a SSGT for children with HFASD and psychiatric comorbidity  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). Nora Choque Olsson, September 2014 42 BackgroundStudy progressTime plan

43. STUDY 4 Moderators and mediators of treatment outcome in a SSGT for children with HFASD and psychiatric comorbidity  Objectives:  Hypotheses:  Method:  Statistical analysis: Mixed-model MANOVA Nora Choque Olsson, September 2014 43 BackgroundStudy progressTime plan

44. STUDY 4 Moderators and mediators of treatment outcome in a SSGT for children with HFASD and psychiatric comorbidity  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. Nora Choque Olsson, September 2014 44 BackgroundStudy progressTime plan

45. STUDY 5 Qualitative evaluation of social skills training, KONTAKT: a responder analysis  Objective: This qualitative study aims to evaluate KONTAKT based on responders and non- responders. Nora Choque Olsson, September 2014 45 BackgroundStudy progressTime plan

46. STUDY 5 Qualitative evaluation of social skills training, KONTAKT: a responder analysis  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 Nora Choque Olsson, September 2014 46 BackgroundStudy progressTime plan

47. STUDY 5 Qualitative evaluation of social skills training, KONTAKT: a responder 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 Nora Choque Olsson, September 2014 47 BackgroundStudy progressTime plan

48. STUDY 5 Qualitative evaluation of social skills training, KONTAKT: a responder analysis  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. Nora Choque Olsson, September 2014 48 BackgroundStudy progressTime plan

49. Nora Choque Olsson, September 2014 49 Background Study progress Time plan

50. Activity2011- 2012 Spring 2012 Autumn 2012 Spring 2013 Autumn 2013 Sprin g 2014 Autumn 2014 Spring 2015 Autum n 2015 Spri ng 2016 Mars- Jun August- Dec. Jan - Jun Aug – DecJan - Jun Aug - DecJan - JunAug - Dec Jan - Jun Adapt. Manual & pilot Recruitment and education: group trainers Group training Supervising support to group trainers Collection Analysis Article Progress Study1 Publised Study 2 Manus- cript Study 5 in prepara- tion Study 3 Data collection Study 4 Data collection Nora Choque Olsson, September 2014 50

51. Thanks for your attention! Nora Choque Olsson, September 2014 51

52. 52 Nora Choque Olsson, September 2014

53.  Objectives:  Hypotheses:  Method:  Statistical analysis  Status:  230 participants have participated in the study. Nora Choque Olsson, September 2014 53 STUDY 3 Behavioral effects of social skills group training, KONTAKT compared to Treatment as usual: A RCT-multicenter study BackgroundStudy progressTime plan

54. Activities Obligatory Intermittent Flexible  Warm-up activity, contact initiation  Evaluation of the session  Group rules  Homework  Affect recognition  Group discussions  Interaction and communication games  Role play  Group activities Recognition and interpretation of facial expressions FEFA CAT-kit basic and complex emotions social stories pantomime 54 Nora Choque Olsson, September 2014

55. CAT-KIT 55 Nora Choque Olsson, September 2014

56. Activities Obligatory Intermittent Flexible  Contact initiation  Of interaction between group members  Group rules  Homework  Affect recognition  Group discussions  Interaction and communication games  Role play  Group activities 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 56 Nora Choque Olsson, September 2014

57. Activities Obligatory Intermittent Flexible  Contact initiation  Of interaction between group members  Group rules  Homework  Affect recognition  Group discussions  Interaction and communication games  Role play  Group activities Eye- contact Focussing on cooperation Watching each other closely Recognition of non verbal signals “What has changed?”,“Fruit basket overturning”. 57 Nora Choque Olsson, September 2014

58. 58 Nora Choque Olsson, September 2014 Preliminary support for KONTAKT in a open trial in Germany (Herbrecht, Bölte & Pouska, 2009).