Performance-Based Social Skills Training Improves Treatment Outcomes for Youth with Comorbid ADHD or Anxiety

Background: Group-based social skills interventions (GSSIs) are a widely-used efficacious treatment modality for children with autism spectrum disorder (ASD; Gates et al., 2016) that typically provide training rules for interaction (social knowledge), enriched social contexts (social performance), or both (Lerner & Mikami, 2012). There is a need to investigate comorbidity as a potential moderator of treatment outcomes, as it is common in youth with ASD (Simonoff et al., 2008; Lerner & White, 2015). Specifically, attention-deficit/hyperactivity disorder (ADHD) and anxiety have been linked to deficits in social skills (Barkley, 1997; Motoca et al., 2012). Research utilizing a social knowledge approach to GSSIs has found little differential benefit for youth with any comorbidity (Deckers, et al., 2016), and limited gains for youth with comorbid ADHD compared to comorbid anxiety and ASD alone (Antshel et al., 2011). As they may already exhibit intact social knowledge (e.g., Maedgen & Carlson, 2000), youth with comorbid ADHD and anxiety might particularly benefit from a social-performance training that allows them to practice skills in vivo, as compared to a social-knowledge training; however, this has never been examined.

Objectives: We examined the impact of psychiatric comorbidity on treatment response to a community-based GSSI that provides an enriched, in vivo social learning and practice opportunities for ASD youth (Lerner et al., 2011).

Methods: Seventy-five children and adolescents, ages 9 to 17 years (M=12.86 years, SD=2.19; 59 male) participated in a 6-week community-based summer GSSI. The majority of parents reported a diagnosis of ASD for their child (86.7%). Parents completed measures of broad psychopathology (BASC-2; Reynolds & Kamphaus, 2004) and ASD symptomatology (SRS; Constantino & Gruber, 2007) at baseline and endpoint.

Results: Using ANCOVA-of-change, presence of any comorbid psychiatric diagnosis was associated with improvements on the BASC-2 behavioral symptom index and externalizing problems, specifically in aggression and conduct problems (all β<=-.21, p<=.05). In addition, the presence of a comorbid ADHD diagnosis was associated with reduced BASC-2 behavioral symptoms and externalizing problems (all β<-.28, p<.049), and improved adaptive skills, notably in social skills and daily living activities (all β>.29, p<.01). Finally, presence of a comorbid anxiety diagnosis was associated with greater improvements on the SRS, driven by improvements in social awareness and cognition (all β<-.23, p<.04).

Conclusions: As hypothesized, the presence of a comorbid psychiatric disorder moderated the treatment outcomes for youths participating in a GSSI. Consistent with previous research, participants with anxiety made larger gains on the SRS compared to other participants (Antshel et al., 2011). Unlike previous studies, youth with comorbid ADHD showed augmented improvements in externalizing problems and improved their adaptive skills. This suggests that GSSIs employing social-performance approaches can be particularly beneficial for youth with ADHD. This is supported by recent research indicating that impaired social decision-making mediated the relationship between ADHD symptoms and social skills deficits for youth with ADHD (Humphreys, Galan, Tottenham, & Lee, 2016). Future research should examine the mechanisms of change for performance training GSSIs, which may further elucidate unique benefits for those with comorbid ADHD.