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Social skills group training for children and adolescents with high-functioning autism spectrum disorders Nora Choque Olsson PhD student, Dept. of Women's.

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Presentation on theme: "Social skills group training for children and adolescents with high-functioning autism spectrum disorders Nora Choque Olsson PhD student, Dept. of Women's."— Presentation transcript:

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 Center, BUP-KIND Firstly, I’d like to thank you all for coming to this seminar on social skills group training for children and adolescents with HFASD My name is NCO, phd student at department Women's & Children’s health, Pediatric Neuropsychiatry Unit, KIND at Karolinska Institutet and Psychologist at Child and Adolescent Psychiatry Research Center, BUP-KIND

2 Nora Choque Olsson, september 2014
Main supervisor: Sven Bölte, Professor of Child and Adolescent Psychiatric Science, Head of Pediatric Neuropsychiatry Unit, Director of KIND, Dept. of Women's & Children's Health. Co-supervisors: Eva Serlachius, PhD, Docent, Department of Clinical Neuroscience, Karolinska Institutet. Juha Kere, professor, Professor of molecular genetics, Department of Molecular Medicine and Surgery, Karolinska Institutet. Mentor: Per-Anders Rydelius, Professor senior, Department of Women’s and Children’s Health, Karolinska Institutet Nora Choque Olsson, september 2014

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Background Study progress Time plan I’ve divided my presentation into three main parts. I like to begin by giving you some background Nora Choque Olsson, september 2014

4 Restrictive Fixated Interests
Background Study progress Time plan Evidence-based interventions for individuals with autism spectrum disorders (ASD) is lacking (Bölte 2014; SBU 2012; Reichow & Volkmar 2012 ;Choque Olsson et al., 2010). Prevalence of ASD: ~1% and ~2.6% (Baird, 2006; Gillberg, 2006; Kim, 2011) Multiple psychiatric comorbidities: anxiety, depression, OCD ADHD (Mucaddes et al. 2010) Parental stress, depression, anxiety, addiction and increased risk of divorce and sick leave (Mungo et al. 2007) Societal costs ranges between 10 and 16 million SEK (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) Autism spectrum disorders Social Communication Restrictive Fixated Interests The are several reasons or background for caring ut this investigation. A important reason is that evidence-based interventions tageted to school age and adolescents with Autism Spectrum Disorders (ASD) is laking in Sweden as well as internationally. ASD is characterized by dificullties in social communication and repetitive behavior and restrictive fixated interests According to recient studies the prevalence is estimated between ~1% and ~2.6% and the need of intervention for this population is increasing. Studies in the field have shown that individuals with ASD develop secondary psychiatric disorders such as depression, obsessive-compulsive disorders (OCD), anxiety and also It Is not uncommon that Parents… It is estimated that the costs to society for care and loss of productivity per person with ASD ranges between 10 and 16 million SEK (Knapp et al. 2009). According to a Cochrane review there is some evidence for social Nora Choque Olsson, september 2014

5 Knowledge gaps Background Study progress Time plan
Few intervention for school age children and adolescents with ASD Few rigorously evaluated interventions RCT on social skills group training, more focus on internal validity (efficacy) but the external validity (effectiveness) is unknown Despite the need for interventions aimed towards children and adolescents with high functioning ASD (HFASD) Social skills group training (SSGT) has been implemented as treatment for HFASD in the past 20 years Lack of psychometrically evaluated outcome measures Unclear inclusion and exclusion criteria Limited sample sizes and lacking suficient power Not included indv with secondary … Lack of prior evaluated manual-based interv. Mechanisms, moderators and mediators of treatment outcome are still unknown ↓ Adapted and validated outcome measures ↓ Inclusion and exclusion criteria ↓ Small sample size ↓ Secondary psychiatric comorbidity ↓ Evaluated manual-based intervention Methodological flaws Nora Choque Olsson, september 2014

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Background Study progress Time plan One of the programs on SSGT is 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 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) Nora Choque Olsson, september 2014

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Background Study progress Time plan Lets look now on study progress Nora Choque Olsson, september 2014

8 Main aim To examine the efficacy and effectiveness
Background Study progress Time plan Main aim To examine the efficacy and effectiveness of social skills group training for children and adolescents with ASD (KONTAKT), compared to treatment as usual Nora Choque Olsson, september 2014

9 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 Main aim Specific aims To examine the efficacy and effectiveness of SSGT, KONTAKT compared to TAU Nora Choque Olsson, september 2014

10 Review on external validity of RCT on SSGT
Interrater reliability of two tolls 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 Main aim Specific aims To examine the efficacy and effectiveness of SSGT, KONTAKT compared to TAU Nora Choque Olsson, september 2014

11 Review on external validity of RCT on SSGT
Interrater reliability of two tolls Behavioural effects of KONTAKT in comparison with TAU Investigate the impact of moderator and mediators Examine the effects of SSGT as experienced by participants Main aim Specific aims To examine the efficacy and effectiveness of SSGT, KONTAKT compared to TAU To examine the behavioral effects of SSGT, KONTAKT compared to TAU Nora Choque Olsson, september 2014

12 Review on external validity of RCT on SSGT
Interrater reliability of two tolls Behavioural effects of KONTAKT in comparison with TAU Impact of moderator and mediators Examine the effects of SSGT as experienced by participants Main aim Specific aims To examine the efficacy and effectiveness of SSGT, KONTAKT compared to TAU To examine the behavioral effects of SSGT, KONTAKT Compared to TAU Nora Choque Olsson, september 2014

13 Review on external validity of RCT on SSGT
Interrater reliability of two tolls Behavioural effects of KONTAKT in comparison with TAU Impact of moderator and mediators Qualitative study on effects of SSGT Main aim Specific aims To examine the efficacy and effectiveness of SSGT, KONTAKT compared to TAU To examine the behavioral effects of SSGT, KONTAKT Compared to TAU Nora Choque Olsson, september 2014

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Background Study progress Time plan 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 SSGT Nora Choque Olsson, september 2014

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Background Study progress Time plan 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

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Background Study progress Time plan 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

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Background Study progress Time plan STUDY 1 External validity (EV) of RCT studies on social skills group interventions Objective: Material & Methods: Results: n= 7263 n= 5241 n= 5241 Using our kywords reserach we found mor than records After excluded records we hade 204 assessed for eligibility And 11 RCT studies was included. n= 204 n= 11 Nora Choque Olsson, september 2014

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Background Study progress Time plan STUDY 1 External validity (EV) of RCT studies on social skills group interventions Objective: Material & Methods: Results: Figure1: Overall view of reporting data related to external validity of included trials. Nora Choque Olsson, september 2014

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

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Background Study progress Time plan 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” Review complete manuscript in preparation, The generalizability of the accumulated evidence is limited and the determinants of external validity are often not adequately reported. In order to allow assessment of the applicability of the intervention, more attention should be given to external validity within this research field. Nora Choque Olsson, september 2014

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Background Study progress Time plan STUDY 2 Adaptation and validation of the Children's Global Assessment Scale for Developmental Disabilities (DD-CGAS) and OSU Autism Clinical Global Impression Scale (OSU Autism CGI). Objective: To investigate the clinical utility and inter-rater reliability of the Swedish versions of the DD-CGAS (Wagner, 2007) and the OSU Autism CGI (RUPP, 2005). Nora Choque Olsson, september 2014

22 STUDY 2 Adaptation and validation of the DD-CGAS and OSU Autism CGI
Background Study progress Time plan STUDY 2 Adaptation and validation of the DD-CGAS and OSU Autism CGI Objective: Materials & Methods: Study sample: Assessment: DD-CGAS OSU AUTISM GCI Nora Choque Olsson, september 2014

23 STUDY 2 Adaptation and validation of the DD-CGAS and OSU Autism CGI
Background Study progress Time plan STUDY 2 Adaptation and validation of the DD-CGAS and OSU Autism CGI Objective: Materials & Methods: Study sample: 16 clinicians from 9 BUP- clinics Experienced (> 2 y) Inexperienced (< 2 y) 8 clinical vignettes Nr. Age Gender Diagnosed Comorbid- diagnosed Treatment at clinical center 1 15 male PDD-NOS ADHD, anxiety, depression CBT individually at home, cognitive support. 2 11 female Asperger syndrome ADHD, anxiety, sleep disorders and aggressive behavior CBT, pharmacological, family therapy, psychoeducation. 3 16 DCD, stress. Psychoeducation, kognitv stöd. School help. 4 8 ADHD, Social skills training, CBT, 5 Female Asperger syndrome, ADD, depression, stress syndrom, CP. CBT, 6 ADHD, depression KOMET, psychoeducation, 7 PDD NOS Anxiety UNS CBT, psychoeducation, 14 ADHD Social skills training Nora Choque Olsson, september 2014

24 STUDY 2 Adaptation and validation of the DD-CGAS and OSU Autism CGI
Background Study progress Time plan STUDY 2 Adaptation and validation of the DD-CGAS and OSU Autism CGI Objective: Materials & Methods: Statistic analysis Two-way random intraclass correlation coefficients (ICC) Pearson correlation Nora Choque Olsson, september 2014

25 STUDY 2 Adaptation and validation of the DD-CGAS and OSU Autism CGI
Background Study progress Time plan STUDY 2 Adaptation and validation of the DD-CGAS and OSU Autism CGI Objective: Materials & Methods: Results: DD CGAS Nora Choque Olsson, september 2014

26 STUDY 2 Adaptation and validation of the DD-CGAS and OSU Autism CGI
Background Study progress Time plan STUDY 2 Adaptation and validation of the DD-CGAS and OSU Autism CGI Objective: Materials & Methods: Results: 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. Nora Choque Olsson, september 2014

27 STUDY 2 Adaptation and validation of the DD-CGAS and OSU Autism CGI
Background Study progress Time plan STUDY 2 Adaptation and validation of the DD-CGAS and OSU Autism CGI Objective: Materials & Methods: Results: Conclusions: ICC of all raters for DD-CGAS and the OSU Autism CGI indicate good to substantial agreement. In a heterogeneous naturalistic clinical setting the tools showed sufficient inter-rater reliability without explicit a priori training. The results is even better the rater have clinical experience. The correlation between DDCGAS and OSU Autism CGI was high, which indicate that they are equivalent. Status: Nora Choque Olsson, september 2014

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Background Study progress Time plan STUDY 3 Behavioral effects of social skills group training, KONTAKT compared to treatment as usual: A 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

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Background Study progress Time plan STUDY 3 Behavioral effects of social skills group training, KONTAKT compared to Treatment as usual: an RCT-multicenter study Objectives: Hypotheses: SSGT ≠ TAU SSGT ↑ social skills and improved levels of adaptive behavior ↑ increase every day functioning ↓ symptom severity and ↓ stress in both participants and their parents Nora Choque Olsson, september 2014

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Background Study progress Time plan STUDY 3 Behavioral effects of social skills group training, KONTAKT compared to Treatment as usual: an RCT-multicenter study Objectives: Hypotheses: Methods: Design RCT multicenter study Participants: Large sample size: N= 288 (today n= 230) Nora Choque Olsson, september 2014

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Background Study progress Time plan STUDY 3 Behavioral effects of social skills group training, KONTAKT compared to Treatment as usual: an RCT-multicenter study Objectives: Hypotheses: Method: Participants: Inclusion criteria: HFASD (ICD-10 and ADOS) aged 8-17 years old. IQ > 85 (Wechsler scale) Psychiatric co morbidity: ADHD, Anxiety disorder, Depression (K-SADS). Exclusion criteria: Self-injury, Conduct disorder, Antisocial personality disorder Borderline personality disorder Schizophrenia or related psychotic disorder Nora Choque Olsson, september 2014

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Background Study progress Time plan STUDY 3 Behavioral effects of social skills group training, KONTAKT compared to Treatment as usual: an RCT-multicenter study Objectives: Hypotheses: Methods: Participants: Recruits from 10 child and adolescent psychiatric clinics (BUP) in Stockholm County. Nora Choque Olsson, september 2014

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Background Study progress Time plan STUDY 3 Behavioral effects of social skills group training, KONTAKT compared to Treatment as usual: an RCT-multicenter study Objectives: Hypotheses: Methods Outcome measures Primary outcome measures SRS (parent and teacher), Secondary outcome measures ABAS II (parents and teachers), BUS (children and adolescent), PSS (parents), CGI (expert) DD-CGAS (expert) Nora Choque Olsson, september 2014

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Background Study progress Time plan STUDY 3 Behavioral effects of social skills group training, KONTAKT compared to Treatment as usual: an RCT-multicenter study Objectives: Hypotheses: Method: Intervention 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

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Background Study progress Time plan STUDY 3 Behavioral effects of social skills group training, KONTAKT compared to Treatment as usual: A RCT-multicenter study Objectives: Hypotheses: Method: Statistical analysis To test the demographic variables. t-test and X2 tests To evaluate the treatment effect Mixed-model MANOVA pre-, post and follow-up to compare KONTAKT and TAU Intention to treat (ITT) principle. Nora Choque Olsson, september 2014

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Background Study progress Time plan STUDY 3 Behavioral effects of social skills group training, KONTAKT compared to Treatment as usual: an RCT-multicenter study Objectives: Hypotheses: Method: Statistical analysis Status: 230 participants have participated in the study. Nora Choque Olsson, september 2014

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Background Study progress Time plan 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

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Background Study progress Time plan STUDY 4 Moderators and mediators of treatment outcome in a SSGT for children with HFASD and psychiatric comorbidity Objectives: Hypotheses: Moderators as: age, sex, 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

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Background Study progress Time plan 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

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Background Study progress Time plan 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

41 Nora Choque Olsson, september 2014
Background Study progress Time plan 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

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Background Study progress Time plan STUDY 5 Qualitative evaluation of social skills training, KONTAKT: a responder analysis Objective: This qualitative study aims to examine SSGT participant experiences and treatment processes during and following intervention in responders and non-responders. Nora Choque Olsson, september 2014

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Background Study progress Time plan STUDY 5 Qualitative evaluation of social skills training, KONTAKT: a responder analysis Objective: Method: Study Sample: Based on STUDY 3 Based on Social Responsiveness Scale (SRS) = responders and no responders n =12 (6 responders and 6 non-responders) from 169 participants of STUDY 3 and their parents. Deep interview Data analysis Thematic analysis Nora Choque Olsson, september 2014

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Background Study progress Time plan 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 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. Improved social skills increased awareness of one’s own impairments, Higher self-confidence, increased independence and a new way of thinking about consequences. Good group cohesion Differences between responders and non-responders were few, Suggesting that even non-responders benefited from the treatment Nora Choque Olsson, september 2014

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Background Study progress Time plan Where are we now? Nora Choque Olsson, september 2014

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Time plan Activity Spring 2012 Autumn 2012 Spring 2013 Autumn 2013 Spring 2014 Autumn 2014 Spring 2015 Autumn 2015 Spring 2016 Mars- Jun August-Dec. Jan - Jun Aug – Dec Aug - Dec Aug - Dec Adapt. Manual & pilot Recruitment and education: group trainers Group training Supervising support to group trainers Collection Analysis Article Progress Article1 Publised Article 2 Manus-cript Artikel 5 in prepara-tion Article 3 Data collection Article 4 Nora Choque Olsson, september 2014

47 Study progress - Timeplan
Review on external validity of RCT on SSGT Interrater reliability of two tolls: DD-CGAS & OSU Autism CGI Behavioural effects of SSGT, KONTAKT in comparison with TAU Impact of moderator and mediators Qualitative study on effects of SSGT Study progress - Timeplan To examine the behavioral effects of SSGT, KONTAKT Compared to TAU Nora Choque Olsson, september 2014

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KONTAKT-team Nora Choque Olsson, september 2014

49 Thanks for your attention!
Nora Choque Olsson, september 2014

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

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

53 CAT-KIT Nora Choque Olsson, september 2014

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

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

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


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