This was a pre-post study of a CBT group intervention for social anxiety that had been modified with social skills components specifically for adults with ASD. The ‘Engage Program’ is an intervention that incorporated core CBT components of exposure, cognitive re-structuring, in-session behavioural experiments, and social skills training, and included planning and review of individualised homework tasks [33]. The study was approved by the University of Sydney Human Research Ethics Committee (no. 2015/365). All participants provided written informed consent prior to their inclusion in the study.
Participants
Participants were recruited through clinical referral or by word-of-mouth, from the community, local Headspace centres (providing mental health services for 12-25-year olds) and from referrals to the Autism Clinic for Translational Research at the Brain and Mind Centre, University of Sydney between January 2016 and March 2020. Inclusion criteria were: participants were help-seeking and had an ASD diagnosis established within the past 12 months using the Autism Diagnostic Interview-Revised (ADI-R) or Autism Diagnostic Observation Schedule-2 (ADOS-2) (n=9), or administration of the ADOS-2 on study entry (n=79). Participants were also required to be at least 16 years of age. Information on current and previous psychological or pharmacological treatment was not collected. Exclusion criteria were: ID (where estimated FSIQ < 70, as assessed by the Wechsler Test of Adult Reading (WTAR), active psychosis identified during intake assessment, inpatient admission for acute mental health concerns, low English proficiency, substance abuse issues, or significant visual or auditory impairment that would hinder engagement with audio/visual components of the program, or overall treatment engagement. While participants could withdraw before the group commenced (n=1), participants who missed more than three treatment sessions were excluded (n=5). Participants that completed the intervention but did not complete post-questionnaires were included using an intent-to-treat analysis (n=9). The total attrition from the group program was six participants (8%). Reasons for attrition included university timetable clashes, relocation to another state and low motivation (referral from parent, but no reported motivation to attend by the individual).
Eighty-eight participants were initially assessed as eligible for study, as shown on the CONSORT diagram (Figure 1). Four participants met exclusion criteria, and six participants withdrew or discontinued the intervention. Seventy-eight participants were in the final sample (47 males, 30 females, 1 non-binary) and were between 16 and 38 years of age (M = 22.77, SD = 5.31). In total, 10 intervention groups were run at the University of Sydney Brain and Mind Centre.
Figure 1:
CONSORT diagram for study participants
Intervention program
Development
The CBT program used in the current study was developed from established social anxiety treatment programs for adults [34, 35]. The adaptations considered needs of adults with SAD and comorbid ASD who have difficulty implementing typical cognitive interventions due to limited introspection and a poorer understanding of social rules and norms [36]. To make the anxiety-based interventions more effective for adults with ASD, the current intervention included structured frameworks for teaching of social skills, such as entering and maintaining conversations, and managing disagreements. In addition, cognitive work (such as identifying and challenging negative beliefs) was simplified and used to support the behavioural components (role plays, exposure tasks and out-of-session practice tasks) that formed the core interventions in the program. Behavioural intervention was integrated within treatment sessions, and as a focus of weekly homework to facilitate engagement and promote positive treatment outcomes. Such alterations have been strongly recommended for interventions targeting anxiety in ASD, both in child [37, 38] and adult populations [39, 40].
Procedure
Before commencing the eight-week group intervention, participants completed a battery of self-report measures assessing social functioning, symptom severity and mood. These measures were also completed upon completion of the intervention. Measures of social anxiety and social functioning were included as primary outcome measures, and measures of mood were included as secondary outcome measures. These measures were selected on the basis of their reliability in tracking outcomes relevant to the aims of the study, and from their previous use in assessing symptoms and treatment responsiveness in adults with ASD [7, 17, 41].
The current modified-CBT program was delivered to groups of 6 to 8 participants over eight consecutive weekly sessions that took approximately two and a half hours each. Two clinicians facilitated groups. By the end of the first session, participants were required to self-nominate a social support person to help practice skills, increase compliance with homework tasks and to increase the ability to generalise the application of CBT strategies to different social contexts. Unlike other interventions, the social support person was not required to be a parent, and could be a partner, housemate or close friend to provide support. Across the 78 participants, only five were unable to find a suitable support person.
Across the eight sessions, a consistent structure was maintained. Groups commenced with a short anxiety-reduction exercise (either breathing or body scan) to assist with focus and engagement for the session. This was then followed by an extended homework review (or a brief role-play task for those without completed homework to discuss). Homework completion was not formally monitored, but informally, through allocation of alternative tasks when uncompleted. Homework tasks included making phone calls to other group members, completion of thought/anxiety monitoring, and completing planned exposure or social engagement activities. Participants then completed a block of core content, that covered CBT for social anxiety and social skills training. Table 1 provides an overview of the core content areas of the modified-CBT program.
Table 1
Outline of core CBT components across the eight-week program.
Session
|
Approx. time
|
Core components:
|
1
|
-5min
-55min
-60min
-30min
|
-Paced breathing exercise
-Orientation to CBT skills group
-Social skills training
-Homework allocation and Café time (Skills practice/exposure)
|
2
|
-5min
-45min
-70 min
-30min
|
-Paced breathing exercise
-Homework review
-Social anxiety psychoeducation –
-Avoidance and exposure
-Homework allocation and Café time (Skills practice/exposure)
|
3
|
-5min
-45min
-60min
-30min
|
-Paced breathing exercise
-Homework review
-Social skills training
-Homework allocation and Café time (Skills practice/exposure)
|
4
|
-5min
-30min
-15 min
-70min
-30min
|
-Paced breathing exercise
-Homework review
-Psychoeducation: Negative thinking patterns and behavioural experiments
-In session behavioural experiment
-Homework allocation and Café time (Skills practice/exposure)
|
5
|
-5min
-45min
-20min
-35min
-15min
-30min
|
-Body scan/grounding exercise*
-Homework review
-Behavioural experiment
-Social skills training
-Psychoeducation: Selective attention
-Homework allocation and Café time (Skills practice/exposure)
|
6
|
-5min
-45min
-20min
-50min
-30min
|
-Body scan/grounding exercise
-Homework review
-Anxiety surfing
-Social skills training
-Homework allocation and Café time (Skills practice/exposure)
|
7
|
-5min
-45min
-20 min
-50 min
-30min
|
-Body scan/grounding exercise
-Homework review
-Behavioural activation
-Social skills training
-Homework allocation and Café time (Skills practice/exposure)
|
8
|
-5min
-45min
-30min
-25min
-15min
-30min
|
-Body scan/grounding exercise
-Homework review
-Behavioural experiment
-Relapse and response prevention
-Group wrap up
-Café time (Skills practice/exposure)
|
*Note: Introductory exercise changed from breathing to grounding at week 5 to enable participants to gain mastery of two techniques.
Following the core content, relevant homework was explained and allocated. The final 30 minutes of the group program was ‘café time’, where participants practiced skills learnt in session in a kitchen area, as a closer approximation to ‘real life’. This café time was also used by facilitators for individual follow-up, to plan appropriate homework tasks and addressing participant’s specific fears or negative thinking patterns. Participants’ nominated support person was emailed each week with a copy of the session slides and additional explanatory materials that provided suggestions to generalise skill development throughout the week.
Facilitators
Two members of clinical staff (clinical psychology, E.B; B.L; M.C; clinical social work, E.T) facilitated group sessions. All staff had experience and clinical training facilitating groups with adolescents and adults with ASD. Each group session was followed by a 60 minute debrief between the facilitators involved, which included formulation and review of specific goals for individual participants.
Measures
Autism Diagnostic Observation Schedule-2 (ADOS-2)[42]. The ADOS-2 assesses ASD symptomatology in children and adults. The ADOS-2 consists of a semi-structured observational assessment, with scores generated across three domains; social interaction, communication and imaginative use of materials. Module four, designed for verbally fluent older adolescents and adults was used in the current study. Higher scores for each domain indicate increased symptom severity.
Wechsler Test of Adult Reading (WTAR)[43]. The WTAR is a neuropsychological assessment tool that provides an estimate of Full-Scale Intelligence Quotient (FSIQ; M=100, SD = 15) based on participants’ age-normed ability to read aloud 50 irregular words of increasing difficulty.
Primary Outcome measures
Liebowitz Social Anxiety Scale -Self Report (LSAS-SR) [44]. The LSAS-SR is a 24-item measure assessing anxiety and avoidance of social situations. Two subscale scores (avoidance and fear) and a total score are derived from the measure, with higher scores indicate of greater symptom severity. Social anxiety difficulties are indicated within the following ranges; 50-64: moderate social phobia, 65-79: Marked social phobia, 80-94: Severe social phobia, ≥95: very severe social phobia. The LSAS-SR is one of the most commonly used measures of social anxiety in adult ASD populations [24, 45]. The scale had high internal consistency, as determined by a Cronbach's alpha of 0.96.
Social Responsiveness Scale-2 – Adult Self-Report (SRS-2)[46]. The SRS-2 is a 65-item rating scale that measures social skill functioning and ASD symptoms in adults. Five subscale scores, measuring social ‘Awareness’, ‘Cognition’, ‘Communication’, ‘Motivation’ and ‘Restricted Interests and Repetitive Behaviours’ (RRB), as well as a total score are derived from the measure. Both the RRB, and a combined ‘Social Communication and Interaction’ subscale are compatible with DSM-5 criteria for ASD. Raw scores on the SRS-2 are converted to T scores which are indicative of social functioning difficulties within the following ranges; ≤ 59: normal, 60-65: mild difficulties, 66-75: moderate difficulties, ≥76: severe. The scale had high internal consistency, as determined by a Cronbach's alpha of 0.94.
Secondary Outcome measures
Depression Anxiety Stress Scales (DASS-21)[47]. The DASS-21 is a self-report measure of depression, anxiety and stress, and assesses symptom severity over the past week, and has recently been validated for use in ASD populations [48]. Higher scores correspond to increased symptom severity. Severity ranges (after doubling the raw scores) are indicated for depression as; 10-13: Mild, 14-20: Moderate; 21-27: Severe, ≥28: Extremely Severe. For Anxiety, ranges are: 8-9: Mild, 10-14: Moderate, 15-19: Severe, ≥20: Extremely Severe. For Stress, ranges are; 15-18: Mild, 19-25: Moderate, 26-33: Severe, ≥34: Extremely Severe. The scale had high internal consistency, as determined by a Cronbach's alpha of 0.95.
Kessler Psychological Distress Scale (K10) [49]. The K10 is a well-validated 10-item rating scale commonly used to measure psychological distress over the past four weeks. Higher scores correspond to greater self-reported distress. Scores ranges on the k10 indicate level of psychological distress as; 20-24; Mild, 25-29; Moderate; 30-50; Severe level of disorder. It has been used in similar studies to measure overall symptoms of distress, rather than disorder-specific (anxiety/depression) symptoms in adults with ASD [7]. The scale had high internal consistency, as determined by a Cronbach's alpha of 0.92.
Social Interaction Anxiety Scale (SIAS) and Social Phobia Scale (SPS)[50]. The SIAS and SPS are partner measures used to assess social anxiety, and have previously been used to measure SAD levels in ASD populations [10]. Both measures have also been recently validated for use in ASD populations[51]. The SIAS requires participants to rate 20 items about anxiety related to initiating and maintain conversations, while the SPS requires ratings on 20 items related to fears of being observed or evaluated in daily activities (public speaking, eating etc) [52]. Clinical cut-off scores to indicate the suggested presence of SAD for the SIAS and SPS are 34 and 24 respectively. Higher scores on each measure indicates greater symptom severity. The scales had high internal consistency, as determined by a Cronbach's alpha of 0.86 (SIAS) and 0.94 (SPS).
Tolerability measures. Participants were also invited to complete a survey at the mid-point of treatment, assessing expectations of, and engagement with the intervention, as well as potential barriers. This questionnaire consisted of six free response, and two Likert-scale questions (refer to Appendix A). Upon completion of the intervention, participants were offered the opportunity for a one-on-one interview with a group facilitator, and were invited to provide written feedback on their experience of the intervention.
Statistical Analysis
An a priori power analysis was conducted using G*Power 3 [53] to test the differences between two paired-sample group means using a two-tailed test, a small-medium effect size (d= .40), and an alpha of .05. Result showed that a total sample of 52 pairs was required to achieve a power of .80.
All analyses were two-tailed, and alpha was set at .05. Statistical computations were performed using the Statistical Program for Social Science (SPSS), version 26. Data was inspected visually for normality, and using skewness, kurtosis values, and Shapiro-Wilk’s test of equality of variance. All data met normality assumptions. Primary analyses were undertaken on an intention-to-treat basis, including all eligible participants. Multiple imputation was used to handle the missing data. The multiple imputations were conducted with the Markov Chain Monte Carlo (MCMC) method with 10 iterations using predictive mean matching for missing values. Paired-samples t-tests were applied to compare pre-treatment to post-treatment scores on self-report questionnaires.
Multiple regression analysis examined the predictive value of demographics variables and the alternate primary outcome measures (age, gender, IQ estimate, ADOS-2 total score and either LSAS-SR or SRS-2 total change scores) on social anxiety or social skills change (indexed by the LSAS-SR or SRS-2 total change score). Cohen’s d was calculated to determine treatment effect sizes, using the accepted cut-offs of 0.2 (small), 0.5 (medium) and 0.8 (large)[54].