CRITICALLY APPRAISED PAPER (CAP) Gantman, A., Kapp, S. K., Orenski, K., & Laugeson, E. A. (2012). Social skills training for young adults with high-functioning autism spectrum disorders: A randomized controlled pilot study. Journal of Autism and Developmental Disorders, 42, 1094 1103. https://doi.org/10.1007/s10803-011-1350-6 CLINICAL BOTTOM LINE This research study aimed to determine the effectiveness of the University of California, Los Angeles (UCLA), Program for the Education and Enrichment of Relational Skills (PEERS) and its use of role-playing, behavioral demonstrations, and educational lessons on social skills for young adults with high-functioning autism (HFA) attending college. The researchers used outcome measures before and after the intervention for both the treatment and the control groups to examine caregivers and young adults perceptions of social skills. Primary outcome measures used were the Social Responsiveness Scale (SRS), Social Skills Rating System (SSRS), and Social and Emotional Loneliness Scale for Adults (SELSA). Secondary outcome measures used were the Empathy Quotient (EQ), Quality of Socialization Questionnaire (QSQ), Social Skills Inventory, and Test of Young Adult Social Skills Knowledge. The authors determined this manualized skills program (PEERS) was highly effective. The program increased social skills for individuals with HFA as well as providing valuable knowledge of social coaching for their caregivers. Although this study shows statistical significance in multiple areas, there were limitations that should also be considered. The small sample size limits generalizability, and there were no reports on cointerventions. Furthermore, the statistical analyses reported the differences between posttest and baseline scores to show improvements gained in social skills, especially cooperation, mannerisms, selfcontrol, and emotions. Overall, clinicians should not rely solely on this research study, and the authors recommended further research on manualized skills programs. With additional evidence, promotion of social skills in multiple contexts would be beneficial for individuals with autism spectrum disorder (ASD). Although this study did not involve occupational therapists, it does support the need for social skills interventions for individuals with ASD. Occupational therapists are skilled professionals who use a variety of interventions to enable independence and assist with these challenges. Thus, there are emerging practice implications for occupational therapists to be involved on a college campus to provide direct services to students with HFA. 1
RESEARCH OBJECTIVE(S) To determine the value of the PEERS skills training program for young adults with HFA to increase their social skills to build relationships DESIGN TYPE AND LEVEL OF EVIDENCE Level I, randomized controlled pilot study PARTICIPANT SELECTION How were participants recruited and selected to participate? The researchers used purposive sampling methods to recruit participants from the Help Group, Regional Centers, colleges and universities [in] Southern California, community support groups, and online announcements (p. 1096). Participants were chosen after meeting inclusion criteria, and treatment groups were based on randomization by coin flip. Inclusion criteria: Participants were included if they Were 18 23 years old; Had a previous diagnosis of ASD from a clinical psychologist or psychiatrist; Had difficulty with social skills per report of a caregiver; Were willing to participate in the treatment; Spoke English fluently; Had a caregiver who was fluent in English and was willing to participate in the study; Had a composite IQ score of 70 or more on the Kaufman Brief Intelligence Test (2nd ed.); Had a score of 26 or more on the Autism Spectrum Quotient; Had score of 65 or more on the SRS; Had a score of 85 or less on the Adaptive Behavior Composite section of the Vineland Adaptive Behavior Scales (2nd ed.); and Had no comorbidity of a major mental illness, including bipolar disorder, schizophrenia, or psychosis. Exclusion criteria: None PARTICIPANT CHARACTERISTICS N= 17 2
#/ % Male: 12/(71%) #/ % Female: 5/(29%) Ethnicity: 10 individuals identified as Caucasian 5 individuals identified as Asian 2 individuals identified as Hispanic or Latino Disease/disability diagnosis: INTERVENTION AND CONTROL GROUPS Group 1: UCLA PEERS for Young Adults 4 individuals with ASD (3 in the treatment group) 11 individuals with Asperger syndrome (7 in the treatment group) 2 individuals with pervasive developmental disorder not otherwise specified (1 in the treatment group) Brief description of the intervention How many participants in the group? Where did the intervention take place? Who delivered? How often? For how long? Young adult participants and caregivers attended simultaneous sessions. Participants engaged in role-playing, social coaching exercises, and lessons involving Communication skills, Relationship skills, Appropriate verbal and nonverbal communication, and Socialization homework assignments (pp. 1096 1097). Caregivers participated in social coaching training to provide support to their young adult with homework assignments (pp. 1096 1097). Ten participants started the treatment immediately. One participant was dropped because of behavioral problems. The Help Group UCLA Autism Research Alliance The intervention was led by a licensed clinical psychologist and a postdoctoral psychology fellow. Graduate and undergraduate psychology students and research assistants were trained, supervised, and assisted with the sessions. Ninety-minute treatments sessions were conducted weekly. 14 weeks 3
Group 2: Control group Brief description of the intervention How many participants in the group? Where did the intervention take place? Who delivered? How often? For how long? The control group delayed their start of the social skills training until Week 15, when the treatment group had finished the UCLA PEERS for Young Adults. 8 participants The Help Group UCLA Autism Research Alliance The intervention was led by a licensed clinical psychologist and a postdoctoral psychology fellow. Graduate and undergraduate psychology students and research assistants were trained, supervised, and assisted with the sessions. Ninety-minute treatments sessions were conducted weekly. 14 weeks INTERVENTION BIASES Contamination: YES NR There was no information in the article regarding contamination; however, there was a possibility of contamination on the basis of where the sample came from. Co-intervention: YES NR There was no information regarding other services obtained by the participants. Timing of intervention: YES NR There was no information regarding the timing of the interventions. Site of intervention: 4
YES NO NR The treatment occurred at a separate and private location (the Help Group UCLA Autism Research Alliance). Use of different therapists to provide intervention: NR Even though training was provided for all research assistants, it is possible that a variety of people ran the interventions, which could have led to a bias in the research. Baseline equality: NR Both groups had participants with diagnoses of ASD, Asperger syndrome, and pervasive developmental disorder not otherwise specified. The mean age was approximately the same in both groups (treatment group = 20 years, delayed treatment group = 21 years). The delayed treatment group had a higher percentage of men (75% vs. 55.6% in the treatment group), but that is consistent with the diagnoses. MEASURES AND OUTCOMES (Only on measures relevant to occupational therapy practice) Measure 1: SRS Name/type of measure used: What outcome is measured? Is the measure reliable (as reported in the article)? Is the measure valid (as reported in the article)? When is the measure used? SRS: primary outcome measure Social functioning traits, such as communication and interpersonal behaviors in natural contexts, to assess ASD symptoms YES Not Reported YES Not Reported The SRS was completed preintervention and postintervention for the treatment group and at baseline and at the end of the 14-week wait period for the control group. Measure 2: SSRS 5
Name/type of measure used: What outcome is measured? Is the measure reliable as reported in the article? Is the measure valid as reported in the article? When is the measure used? SSRS: primary outcome measure Social and academic competence during interaction with individuals in a variety of contexts Not Reported YES Not Reported The SSRS was completed preintervention and postintervention for the treatment group and at baseline and at the end of the 14-week wait period for the control group. Measure 3: SELSA Name/type of measure used: What outcome is measured? Is the measure reliable as reported in the article? Is the measure valid as reported in the article? When is the measure used? SELSA: primary outcome measure Self-report of solitude relating to romantic and emotional aspects of life Not Reported YES Not Reported The SELSA was completed preintervention and postintervention for the treatment group and at baseline and at the end of the 14-week wait period for the control group. Measure 4: EQ Name/type of measure used: What outcome is measured? EQ: secondary outcome measure Empathy as reported by caregivers 6
Is the measure reliable as reported in the article? Is the measure valid as reported in the article? When is the measure used? Not Reported YES Not Reported The EQ was completed preintervention and postintervention for the treatment group and at baseline and at the end of the 14-week wait period for the control group. Measure 5: QSQ Name/type of measure used: What outcome is measured? Is the measure reliable as reported in the article? Is the measure valid as reported in the article? When is the measure used? QSQ: secondary outcome measure Invited and hosted get-togethers; completed by caregivers and participants YES Not Reported YES Not Reported The QSQ was completed preintervention and postintervention for the treatment group and at baseline and at the end of the 14-week wait period for the control group. MEASUREMENT BIASES Were the evaluators blind to treatment status? NR All evaluators were directly involved in the treatment interventions, because there was a lack of third-party assessments; therefore, the evaluators were not blind to the treatment status (p. 1101). Was there recall or memory bias? All outcome measures were based on self-report or caregiver report. These reports are subjective and rely on an individual s ability to accurately recall information. 7
Other measurement biases: Because of the limited outcome measurement tools that are designed specifically for young adults with ASD, biases may exist. There is potential measurement bias with the SSRS, because it was designed for adolescents, not adults. Also, the Test of Young Adult Social Skills Knowledge is a criterion-referenced measure for neurotypical adolescents that was modified for this study. RESULTS 8
SELSA On the basis of difference scores (posttest baseline), negative scores indicated improvement in social and emotional loneliness. Nine participants in the treatment group had a mean difference of 12.67, with a standard deviation of 17.6. The 8 participants in the delayed treatment control group had a mean difference of 4.50 (SD = 14.6). Results of this primary measure outcome were reported to have a statistical significance of p <.05. SRS On the basis of difference scores (posttest baseline), negative scores indicated improvement in social responsiveness in particular, social communication and autistic mannerisms. The mean difference for the treatment group was 18.7 (SD = 23.7). The mean difference for the control group was 6.25 (SD = 21.2). Statistical significance was p <.04. The mean difference for the treatment group for social communication was 6.11 (SD = 7.75), and the mean difference for the delayed treatment control group was 2.25 (SD = 7.59), p <.04. The mean difference for autistic mannerisms was 3.22 (SD = 4.32) for the treatment group, and the mean difference for the delayed treatment control group was 2.13 (SD = 3.60), p <.02. SSRS On the basis of difference scores (posttest baseline), positive scores on this primary measure outcome indicated improvement in social skills. Four out of 52 items had results of statistical significance. The treatment group reported a mean difference in social skills of 6.67 (SD = 9.50), and the delayed treatment control group reported a mean difference of 5.63 (SD = 5.50). Social skills outcomes resulted in the greatest significance (p <.01). The treatment group reported a mean difference in cooperation outcomes of 2.56 (SD = 3.05), and the delayed treatment control group reported a mean difference of 1.00 (SD = 2.27). Cooperation outcomes resulted in statistical significance of p <.02. The treatment group reported a mean difference in self-control outcomes of 1.22 (SD = 3.99), and the delayed treatment control group reported a mean difference of 2.38 (SD = 2.56). Differences in outcomes were statistically significant (p <.05). The treatment group reported a mean difference in assertion outcomes of 2.00 (SD = 2.50), and the delayed treatment control group reported a mean difference of 0.22 (SD = 1.39). Assertion outcomes resulted in statistical significance (p <.05). EQ On the basis of difference scores (posttest baseline), positive scores on this secondary measure indicated improvement in empathy. The treatment group reported a mean difference in empathy outcomes of 7.00 (SD = 9.75). The delayed treatment control group reported a mean difference of 1.13 (SD = 3.60). Empathy outcomes resulted in a significance of p <.04. QSQ On the basis of difference scores (posttest baseline), positive scores on this secondary measure indicated improvement in get-togethers, both invited and hosted. For invited get-togethers, the treatment group reported a mean difference of 0.89 (SD = 0.93). The delayed treatment control group reported a mean difference of 0.13 (SD = 0.64). Invited get-together outcomes resulted in a significance of p <.03. For hosted get-togethers, the treatment group reported a mean difference of 1.00 (SD = 1.41). The 9
delayed treatment control group reported a mean difference of 0.00 (SD = 0.75). Hosted get-together outcomes resulted in statistical significance (p <.05). Was this study adequately powered (large enough to show a difference)? YES NR Statistical power and effect size were not reported, even though several results were found to be significant. Were the analysis methods appropriate? Analysis methods were appropriate; however, given the number of different tests completed, there was an increased chance of a Type I error. Were statistics appropriately reported (in written or table format)? The authors presented statistics both in paragraphs and in tables to demonstrate the results of the study. Was participant dropout less than 20% in total sample and balanced between groups? YES NO One individual from the treatment group was dropped because of extreme behaviors. What are the overall study limitations? This study had many limitations, including the following. The researchers made limited use of comprehensive standardized assessments. For example, they did not assess the Autism Diagnostic Interview Revised and the Autism Diagnostic Observation Schedule because of financial restrictions in the study. The researchers made limited use of informal assessments, such as behavioral observations and third-party assessments for the use of primary outcome measures. Most of the participants and their families did not include independent rater reports for social functioning. The small sample size limited generalizability, and authors recommended using larger homogeneous samples for the further development of clinical trials and stronger external validity. CONCLUSION 10
The authors concluded that the manualized skills program had therapeutic benefits for both young adults with HFA and their caregivers. The results from this study support interventions on overall social skills, empathy, social responsiveness, loneliness, and get-togethers. Overall, the young adult participants with HFA and their caregivers reported they had noticed increased social skills and were more willing to engage in relationships with other individuals after the intervention. This work is based on the evidence-based literature review completed by Annika Eckholm; Karol Santistevan; and Julie Grabanski, Ph.D., OTR/L, University of North Dakota. CAP Worksheet adapted from Critical Review Form Quantitative Studies. Copyright 1998 by M. Law, D. Stewart, N. Pollack, L. Letts, J. Bosch, and M. Westmorland, McMaster University. Used with permission. For personal or educational use only. All other uses require permission from AOTA. Contact: www.copyright.com 11