A Randomized Controlled Trial of PEERS in Israel: Behavioral and Questionnaire-Based Outcomes

Background: Social communication impairments are a fundamental characteristic of autism spectrum disorder (ASD). Social skills training groups are the most common intervention for individuals with ASD and has been found to be an effective treatment mode. The Program for the Education and Enrichment of Relational Skills (PEERS; Laugeson & Frankel, 2010) is an evidence-based parent-assisted social skills training program for teens with ASD, which has been well validated in North America. PEERS has been adapted for clinical use in Israel, with promising results in adolescents, as well as elementary school aged children.

Objectives: The main aim of the current study was to conduct a randomized control trial (RCT) of the culturally adapted version of PEERS in Israel. Whereas previous evaluations of PEERS have mostly relied on questionnaires, this study employed a live role-play assessment of conversational skills as an ecologically valid outcome measure, in addition to parent, teacher, and self-report questionnaires.

Methods: Forty one participants (2 females) aged 12-18 (M= 14.04, S.D=1.71), who were diagnosed with ASD without an intellectual disability (diagnoses validated using the ADOS-2) were randomly assigned to an immediate treatment (IT, n=20) or to a delayed control treatment (DCT, n=21) group and were evaluated at three time points: pre and post intervention for both groups, and 16 weeks after treatment completion for the IT group. Behavioral assessment was conducted using the interested condition of the Contextual Assessment of Social Skills (CASS; Ratto et al., 2011). This semi-structured role-play comprises a three minute conversation with a confederate. Trained, independent, blind judges coded adolescents' conversational skills, including question asking, topic changing, vocal expressiveness, gestures, positive affect, kinesic arousal, social anxiety, quality of involvement, and quality of rapport. In addition, we assessed the intervention outcomes using various parent, teacher and self-report questionnaires: Social Skills Improvement System (Gresham & Elliott, 2008), Social Responsiveness Scale (Constantino & Gruber, 2012), Quality of Play Questionnaire (Laugeson & Frankel, 2010), Test of Adolescent Social Skills Knowledge (Laugeson & Frankel, 2010) and Empathy Quotient (Baron-Cohen & Wheelwright, 2004).

Results: In accordance with previous studies, compared to the DCT, significant intervention effects were found in the IT group. These included improved parent reported social skills and reduced autism symptomatology, and improvements on teacher reported communication skills, teen social knowledge, number of social encounters, and teen reported empathy. The analyses of the behavioral data revealed that following the intervention, compared to the DCT group, IT participants asked more questions and showed an improvement on the overall involvement subscale as well as on the total score of the CASS (see Figure 1). Most of these gains maintained on a 16 week follow up. Improvement on CASS involvement in conversation positively correlated with teens’ gains on social skill knowledge and parent reported social and communication skills’ improvement.

Conclusions: The current study validates the efficacy of the adapted PEERS program for adolescents' with ASD in Israel. The ecological validity of the impact PEERS has on adolescents' social skills had been corroborated by a behavioral outcome measure.