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تعداد صفحات این فایل: ۲۴ صفحه

بخشی از مقاله انگلیسیعنوان انگلیسی:Randomized Comparative Trial of a Social Cognitive Skills Group for Children With Autism Spectrum Disorder~~en~~

Objective This study evaluated the efficacy of a targeted social skills training group in school-aged children with autism spectrum disorder (ASD). The intervention, Seaver-NETT (Nonverbal communication, Emotion recognition, and Theory of mind Training), is a 12-session cognitive-behavioral intervention (CBI) for verbal, school-aged children targeting ASD-specific social behavioral impairments.

Method Sixty-nine children with ASD, 8 to 11 years of age, with verbal IQs greater than 70, participated in a randomized comparative trial to examine the efficacy of NETT relative to a facilitated play group. Treatment outcomes included caregiver reports of social behavior and neuropsychological assessments of social cognition conducted by blinded raters. Outcomes were collected at baseline, endpoint, and 3 months posttreatment.

Results Significant improvements were found on social behavior outcomes such as nonverbal communication, empathic responding, and social relations in the NETT condition relative to the active control at endpoint. Verbal IQ moderated the interaction effect on social behavior, with higher verbal IQ associated with improvements in the CBI condition. No significant improvements were found on social cognitive outcomes. No significant group differences were found at 3-month follow-up conducted with approximately half the sample (n = 34).

Conclusion These data indicate that targeted CBI social skills groups such as NETT improve social communication deficits in verbal, school-aged children with ASD. The moderating effects of high verbal IQ suggest a need to consider participant and treatment characteristics associated with outcomes in future studies.

۱ Introduction

Socialization groups are a widely used modality for addressing core social impairments in verbal, schoolaged and older individuals with autism spectrum disorder (ASD). Socialization groups hold appeal as a costeffective method to facilitate social contact for individuals at increased risk for social isolation and rejection.1,2 In addition, empirical support is building for cognitivebehavioral intervention (CBI) approaches, such as social skills training (SST) groups for verbally fluent, school-aged children with ASD.3 Notable methodological advances are represented in a few recent studies, including the use of randomized controlled trials (RCTs), manualized interventions, standardized outcomes, and fidelity checks.4 However, several reviews3-5 point to methodological limitations that question recent practice recommendations, which suggest that SST groups are evidence-based interventions in ASD.6,7 Specifically, existing research fails to meet core design criteria for evaluating treatment efficacy such as use of adequate sample sizes, active treatment controls, independent outcome evaluations, and data on maintenance and generalization.

The use of waitlist controls in RCTs8-13 is a particular hurdle for evaluating treatment efficacy of SST groups. Parents report high levels of satisfaction across models including interest-based social clubs, leisure activities groups, supportive play (e.g., board games), as well as CBI-based SST groups.11,14 In addition to methodological and ethical concerns associated with waitlist controls, the efficacy of therapeutic SST group models must be demonstrated against less costly recreational social group models. From an implementation perspective, the use of active treatment controls will inform the selection of optimal modalities (e.g., skills-based, recreational) and providers (e.g., clinicians, paraprofessionals, peers). From a treatment development perspective, active treatment controls are needed to guide research on mechanisms and common factors associated with outcomes.

To date, 3 randomized comparative trials have been reported in the literature.15-17 Small samples (n < 14) and limited effects in 2 comparative trials limit interpretation due to underlying assumptions of randomization and statistical models.16,17 DeRosier et al. conducted the largest comparative trial in 55 youths with ASD between the ages of 8 and 12 years.15 The study evaluated the efficacy of S.S.GRIN, a 15-session CBI curriculum with empirical support for youth with emotional and learning disorders, relative to a modified version for children with “high-functioning autism” (S.S.GRIN-HFA). Significant group differences were found on the Social Responsiveness Scale (SRS) and measures of perceived self-efficacy. However, caregivers in the unmodified S.S.GRIN group reported an exacerbation of ASD symptoms and reduced feelings of self-efficacy, which requires further exploration, given the high parental satisfaction reported in other SST studies.11,12

Comparison across SST group studies in ASD is also complicated by variability in outcome measures and treatment targets. Social communication impairments in ASD are developmentally specific and may be associated with cascading effects on other social and mental health domains. Published curricula target social impairments found across social-emotional learning disabilities such as listening skills, friendship skills, and assertiveness training.9,10 Other studies emphasize ASD-specific impairments in social communication and social cognition,8,12-14,16-21 whereas still others take a broad-based approach including both general and ASDspecific impairments, such as S.S.GRIN-HFA.15

Targeted interventions for core social-communication impairments are of particular interest given the dearth of treatments for core deficits in older children and individuals with ASD. Baghdadli et al. conducted a randomized comparative trial of a 20-session social cognitive intervention targeting nonverbal communication, emotion recognition, stress management, and theory of mind in 14 children with ASD.17 Although no differences were found in total face recognition scores on the Diagnostic Analysis of Nonverbal Accuracy 2 (DANVA2),22 the targeted social cognitive intervention was associated with improvements in identification of low-intensity (i.e., difficult-to-identify) adult emotions and quality of life outcomes relative to the active treatment control. However, as previously noted, small sample sizes limit the interpretation of findings from this trial.

This study builds upon prior research by addressing methodological weaknesses limiting interpretation of efficacy of targeted, social cognitive skills training groups. In this study, we evaluated the efficacy of a targeted, 12-session, CBI SST group curriculum: Seaver-NETT (Nonverbal communication, Emotion recognition, and Theory of mind Training). NETT uses targeted and top-down processing approaches characteristic of CBI similar to recently published reports of targeted social cognitive curricula.12,17,20 The current study uses a randomized comparative design, manualized interventions, fidelity checks, and theoretically based outcomes to evaluate treatment efficacy. The study evaluated dual treatment targets associated with ASD and social learning, specifically, social cognition and social behavior. Treatment moderators were evaluated to help inform a more personalized approach to social skills interventions in ASD. Baseline participant characteristics including verbal abilities, age, and psychiatric comorbidities were evaluated as potential variables associated with treatment response. Moderator analyses may also inform sample selection for future studies seeking to constrain heterogeneity in this treatment area.23 Given that maintenance data is rarely reported but greatly needed,4 this study includes a 3-month follow-up evaluation in a subset of participants to estimate durability of treatment effects.

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