Gender and Psychiatric Comorbidity Moderate Outcomes of a Community-Delivered Group Social Skills Intervention for Youth with ASD

Background: The most widely used treatment for social competence in youth with autism spectrum disorder (ASD) is group social skills interventions (GSSIs; McMahon et al., 2013); however, effect sizes are variable (Gates, Kang, & Lerner, 2017). One empirically supported GSSI for youth with ASD that has been successfully delivered in both controlled and “real world” community-based settings is socio-dramatic affective-relational intervention (SDARI; Lerner et al., 2011). A major challenge in implementing empirically-supported GSSIs in the “real world,” however, is the complex clinical heterogeneity exhibited by youth with ASD in the community (Wood et al., 2015), which can lead to considerable variability in outcomes for community-delivered interventions (Perry et al., 2008). Thus, it is particularly important to identify individual difference factors (i.e., potential moderators) among participants in community-delivered interventions to optimize their effectiveness. In particular, three variables that have particularly strong theoretical promise – yet little previous examination – as moderators of GSSIs (Lerner & White, 2015): gender, psychiatric comorbidity, and psychotropic medication use.

Objectives: Based on prior research (Lerner & White, 2015), we hypothesized that female participants, as well as those with comorbid anxiety, would demonstrate larger treatment gains, but those with ADHD would experience attenuated effects. Given the limited research on medication use, we conducted exploratory analysis of its effects.

Methods: Seventy-five youth, ages 9 to 17 years (M=12.86 years, SD=2.19; 59 male; 86.7% parent-reported ASD) participated in a 6-week community-based summer GSSI in groups of 5-9. Parents completed pre-post measures of broad psychopathology (BASC-2; Reynolds & Kamphaus, 2004), ASD symptomatology (SRS; Constantino & Gruber, 2007), and social skills (SSRS; Gresham & Elliot, 1990). Participants completed a computer-based emotion recognition task (DANVA-2; Nowicki, 2004). We utilized generalized estimating equations (GEE) in an ANCOVA-of-change framework to account for nesting within groups.

Results: Participants with unitary anxiety displayed greater improvements in ASD symptom severity and vocal emotion recognition relative to those without anxiety or with multiple comorbidities (see Table 1). Additionally, participants with unitary ADHD demonstrated greater gains in adaptive skills compared to those without. Multiple comorbidity of ADHD and anxiety was associated with limited improvements in ASD symptom severity and social skills, and a decrement in vocal emotion recognition (see Figure 1) relative to all other participants. Additionally, females experienced greater improvements in facial emotion recognition, while males experienced greater improvements in vocal emotion recognition. There were no effects of medication.

Conclusions: This is among the first studies to examine the impact of outcome moderators in a community-based GSSI. Extending prior work (Antshel et al., 2011), we found that participants with both ADHD and anxiety made the fewest gains and, in fact, experienced no gains and even iatrogenic effects across several measures. Given the complexity of comorbidity in youth with ASD (Simonoff, 2008), this illustrates the importance of a thorough assessment of comorbid symptomatology. We also found evidence that gender moderated the effects of a GSSI when other studies have not (McVey et al., 2017). This again highlights the impact of phenotypic heterogeneity in community-based interventions on treatment effectiveness.