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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

2 Nora Choque Olsson, september 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: Main supervisor: 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. Per-Anders Rydelius, Professor senior, Department of Women’s and Children’s Health, Karolinska Institutet Mentor:

3 Nora Choque Olsson, september

4  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) Nora Choque Olsson, september Restrictive Fixated Interests Autism spectrum disorders Social Communicati on

5 Nora Choque Olsson, september Knowledge gaps Few intervention 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 ↓ Adapted and validated outcome measures ↓ Inclusion and exclusion criteria ↓ Small sample size ↓ Secondary psychiatric comorbidity ↓ Evaluated manual-based intervention Few rigorously evaluated interventions Mechanisms, moderators and mediators of treatment outcome are still unknown

6  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

7 7

8 8 To examine the efficacy and effectiveness of social skills group training for children and adolescents with ASD (KONTAKT), compared to treatment as usual Main aim

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

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

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

12 Nora Choque Olsson, september Main aim Specific aims To examine the behavioral effects of SSGT, KONTAKT Compared to TAU To examine the efficacy and effectiveness of SSGT, KONTAKT compared to TAU

13 Nora Choque Olsson, september Main aim Specific aims To examine the behavioral effects of SSGT, KONTAKT Compared to TAU To examine the efficacy and effectiveness of SSGT, KONTAKT compared to TAU

14 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

15 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

16 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

17 STUDY 1 External validity (EV) of RCT studies on social skills group interventions  Objective:  Material & Methods:  Results: Nora Choque Olsson, september n= 7263 n= 5241 n= 204 n= 5241 n= 11

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

19 STUDY 1 External validity (EV) of RCT studies on social skills group interventions.  Objective:  Materials & Methods:  Results: Nora Choque Olsson, September

20 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

21 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). Nora Choque Olsson, september  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).

22 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

23 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 Nora Choque Olsson, september Nr. Age Gender Diagnosed Comorbid- diagnosed Treatment at clinical center 1 15 male PDD-NOS ADHD, anxiety, depression CBT individually at home, cognitive support female Asperger syndrome ADHD, anxiety, sleep disorders and aggressive behavior CBT, pharmacological, family therapy, psychoeducation 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

24 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

25 Nora Choque Olsson, september STUDY 2 Adaptation and validation of the DD-CGAS and OSU Autism CGI DD CGAS  Objective:  Materials & Methods:  Results:

26 Nora Choque Olsson, september STUDY 2 Adaptation and validation of the DD-CGAS and OSU Autism CGI 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:

27 Nora Choque Olsson, september 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:

28 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

29  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 STUDY 3 Behavioral effects of social skills group training, KONTAKT compared to Treatment as usual: an RCT-multicenter study

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

31  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 STUDY 3 Behavioral effects of social skills group training, KONTAKT compared to Treatment as usual: an RCT-multicenter study

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

33  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 STUDY 3 Behavioral effects of social skills group training, KONTAKT compared to Treatment as usual: an RCT-multicenter study

34  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 STUDY 3 Behavioral effects of social skills group training, KONTAKT compared to Treatment as usual: an RCT-multicenter study  Objectives:  Hypotheses:  Method:  Intervention

35  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 STUDY 3 Behavioral effects of social skills group training, KONTAKT compared to Treatment as usual: A RCT-multicenter study

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

37 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

38 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

39 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

40 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

41 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 Nora Choque Olsson, september

42 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

43 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

44 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. Nora Choque Olsson, september

45 Nora Choque Olsson, september

46 Time plan Activity 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 Article1 Publised Article 2 Manus- cript Artikel 5 in prepara- tion Article 3 Data collection Article 4 Data collection Nora Choque Olsson, september

47 Nora Choque Olsson, september Study progress - Timeplan To examine the behavioral effects of SSGT, KONTAKT Compared to TAU

48 Nora Choque Olsson, september KONTAKT-team

49 Thanks for your attention! Nora Choque Olsson, september

50 50 Nora Choque Olsson, september 2014

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

52 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 52 Nora Choque Olsson, september 2014

53 CAT-KIT 53 Nora Choque Olsson, september 2014

54 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 54 Nora Choque Olsson, september 2014

55 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”. 55 Nora Choque Olsson, september 2014

56 56 Nora Choque Olsson, september 2014 Preliminary support for KONTAKT in a open trial in Germany (Herbrecht, Bölte & Pouska, 2009).


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