Group training in interpersonal problem-solving skills for workplace adaptation of adolescents and adults with Asperger syndrome: A preliminary study

Abstract

Adults with Asperger syndrome show persistent difficulties in social situations which psychosocial treatments may address. Despite the multiple studies focusing on social skills interventions, only some have focused specifically on problem-solving skills and have not targeted workplace adaptation training in the adult population. This study describes preliminary data from a group format manual-based intervention, the Interpersonal Problem-Solving for Workplace Adaptation Programme, aimed at improving the cognitive and metacognitive process of social problem-solving skills focusing on typical social situations in the workplace based on mediation as the main strategy. A total of 50 adults with Asperger syndrome received the programme and were compared with a control group of typical development. The feasibility and effectiveness of the treatment were explored. Participants were assessed at pre-treatment and post-treatment on a task of social problem-solving skills and two secondary measures of socialisation and work profile using self- and caregiver-report. Using a variety of methods, the results showed that scores were significantly higher at post-treatment in the social problem-solving task and socialisation skills based on reports by parents. Differences in comparison to the control group had decreased after treatment. The treatment was acceptable to families and subject adherence was high. The Interpersonal Problem-Solving for Workplace Adaptation Programme appears to be a feasible training programme.

Keywords

adults Asperger syndrome autism spectrum disorders group intervention social problem-solving training workplace adaptation

Nuclear symptoms in Asperger syndrome (AS) amount to an altered social development, characterised by a severe deficit in reciprocal social skills or socialisation. Although this condition is expressed differently in each person, it appears in three main areas: social interaction, communication skills and stereotyped patterns of behaviour and restricted interests and/or rigid adhesion to routines without cognitive or language retardation (American Psychiatric Association (APA), 2000).

Social deficits in adults with autism spectrum disorders (ASDs) may lead to problems concerning important areas of quality of life such as friendship, romantic relationships and vocational success. In recent years, there has been increasing recognition of the need to carry out studies to ascertain the effectiveness and efficacy of different types of intervention and programmes aimed at training or improving pragmatics, social communication and interpersonal skills – the main areas affected in AS individuals. Recent decades have provided improved scientific knowledge on early infancy and there is now an urgent need to focus on adolescents and adults (Mazefsky and White, 2013). In fact, most of the studies have been conducted with school-age children (White and Maddox, 2013). A growing body of articles is being published concerning adolescents and adults with ASDs, although research on the feasibility and efficacy of social interventions for adults is limited (Baron-Cohen et al., 2004; Laugeson et al., 2012; White et al., 2013).

In psychology, the literature on social skills is extensive, although there are different approaches and backgrounds (psychometric perspective, clinical psychology, educational area, cognitive psychology, etc). Three main approaches could be distinguished in classifying social skills interventions developed for ASDs depending where the focus is allocated: (1) increasing positive behaviours (discrete skills) in social situations (Hops, 1983) such as the Program for the Education and Enrichment of Relational Skills (PEERS) programme (Chang et al., 2013; Laugeson et al., 2012), which aims at teaching specific behaviours that facilitate positive social interactions; (2) cognitive restructuring for social skills or cognitive-behavioural approach (Weiss and Lunsky, 2010); including interventions such as the Multimodal Anxiety and Social Skills Intervention (MASSI) programme (White et al., 2013) simultaneously targeting anxiety management and social skills and finally, (3) improving interpersonal (cognitive) problem-solving skills, which are considered a domain of intelligence. Under this perspective, special emphasis is put on the cognitive processes of problem resolution that could be trained (Chang et al., 2009). This approach highlights the importance of the role that others play in an interaction where ethical issues are integrated and need to be dealt with (Nezu et al., 2008). Despite being highly applicable in daily-life interaction, there is not an extensive literature on this matter for ASDs (Antshel et al., 2011).

Based on this perspective of interpersonal problem-solving skills training, we developed and evaluated the Interpersonal Problem-Solving Skills for Workplace Adaptation (SCI-Labour) Programme (Programa de Solución de Conflictos Interpersonales) in this trial. To the authors’ knowledge, no study, to date, has evaluated the effectiveness of interpersonal problem-solving skills training for adolescents and adults with AS focusing on typical social situations in the workplace (e.g. awareness of the unwritten rules of the workplace, development of an effective working relationship between employees, engaging in reciprocal conversation or meeting the deadline).

The SCI-Labour programme is based on an approach called social problem-solving in phases (D’Zurilla and Goldfried, 1971; Pelechano, 1995), as the cognitive process involved is based on phases of resolution such as defining problem, taking perspectives, generating solutions and considering consequences. The methodological strategy to implement the programme is mediation (Haywood and Lidz, 2007). Mediated learning assumes that during the learning process someone more competent than the trainee is tasked with selecting the relevant stimuli to address and emphasise, provide continuous feedback based on the trainee’s answers and change and interpret the environment to facilitate the learning process (Kozulin and Rand, 2000). It is believed that this approach is suitable for the ASD population in adulthood as it provides training on a thinking process that could be applied to different contexts (i.e. workplace environment).

The latest reviews on ageing in ASDs (Happé and Charlton, 2012; Howlin and Moss, 2012) emphasise the frequently reported problems with employment in adults with ASDs. People with ASDs are significantly disadvantaged regarding and maintaining employment due to sensitivity to sensory stimuli, difficulties in communication, low problem appreciation, low understanding of emotions, lack of coping skills, problems in response shifting and adapting to change and poor generation of appropriate solutions and judgement of solution quality (Barnhill, 2007; Channon et al., 2001; Parr and Hunter, 2013). Despite claims for the need of a wider database on vocational skills and employment in ASDs (García-Villamisar and Hughes, 2007; Hare et al., 2004; Morgan and Schultz, 2012), intervention research in social skills has not specifically focused on workplace adaptation. The SCI-Labour programme targets the challenges mentioned above through training the cognitive process of social-problem-solving applied to specific interpersonal situations and analyses of personal experiences shared by participants in order to favour generalisation to real-life events.

This programme was first implemented in a pilot study for four adolescents (three men and a woman) with AS between the ages of 16 and 21 years. Two of the four showed significant positive results in a social problem-solving task and parents reported improvements in socialisation skills (Bonete, 2013). After the pilot study, some changes were made to the manual programme, resulting in the final version of the SCI-Labour programme.

The purpose of this study was to further develop and assess the effectiveness and feasibility of a manualised programme, the SCI-Labour, oriented to AS adolescents and adults. Effectiveness refers to the measurement of improvement in the specific skills that appear after a psychosocial intervention has been implemented in community settings (Smith et al., 2007). Feasibility has been defined as evidence that the treatment can be reliably delivered and is acceptable to the patient population (Kraemer et al., 2006). Following the stepwise approach to the development, testing and dissemination of psychosocial interventions for the ASD population, both these stages of research are required (Smith et al., 2007).

First we aimed to test the effectiveness of the programme. It was primarily hypothesised that participants would score higher in an interpersonal problem-solving task at post-treatment and that parent-reported socialisation skills and self-reported work personality profiles would score higher compared to pre-treatment. Knowing that the AS population performs significantly worse than typically developed people, the following hypothesis was that the AS group’s performance would increase after treatment and therefore the differences between the two groups would decrease at post-treatment in the outcome measures. Second, we aimed to evaluate the feasibility of the current intervention based on attrition, treatment adherence (percentage of attendance) and fulfilment of homework. Furthermore, positive reports in consumer satisfaction questionnaires along with parent and participant reports on the maintenance of changes were expected 3 months later.

Method

Participants

Data for a group of 50 adolescents and adults with AS were included (43 men and 7 women). The participants’ ages ranged from 16 to 29 years and their global IQ was within the limits of normality (M = 96.26; standard deviation (SD) = 16.13; nonverbal-IQ (NV-IQ) standard scores: M = 47.96; SD = 11.45) measured by the Reynolds Intellectual Screening Test (RIST; Reynolds and Kamphaus, 2003). The following criteria were observed in the selection process: (1) All the participants presented an earlier diagnosis of AS (DSM-IV-TR criteria; APA, 2000) which was confirmed by the chief researcher; (b) all the participants fulfilled the minimum criteria of Autism Diagnostic Interview–Revised (ADI-R; Rutter et al., 2003) and the Autism Diagnostic Observation Schedule–Generic (ADOS-G; Lord et al., 2009) for ASDs; and (c) exclusion criteria were also followed for comorbid major psychiatric disorders including attention-deficit hyperactivity disorder (ADHD), obsessive compulsive disorder (OCD) or other disorders, learning disability or any history of illness or injury involving the brain. Assessments were conducted before and after intervention (pre- and post-treatment) and a questionnaire on the maintenance of changes was answered 3 months later. See Figure 1 for the flow diagram.

Figure 1.

Flow of participants through the clinical trial.

Only 14% of the participants had been diagnosed before 5 years of age, 48% were diagnosed before 15 years of age and 38% during adulthood. With regard to intervention, 48% had received early intensive intervention during infancy, while 52% had no experience of any kind in social skills therapy.

Criteria for outcome were included to rate functionality based on Cederlund et al. (2008). A total of 21 participants (42%) were classified as having a good outcome (conditions to fulfil this level included both being employed, having achieved higher education or vocational training, and living independently or having a group of friends), 22 participants (44%) were assigned a fair outcome (because of their high education or having at least one close friend) but 7 participants (14 %) lacked both of these characteristics. Measures to rate severity of symptoms, the ADOS-G, Module IV (ADOS-G; Lord et al., 2009) and the Autonoma Scale for AS and High-Functioning Autism (Belinchón et al., 2005) were used as a symptomatology screening tool, and the Children’s Communication Checklist (CCC-2; Bishop, 2003) was used as a measure of pragmatic language (Spanish translation). Table 1 presents the mean symptom severity characteristics of the AS group.

Table 1.

Mean symptom severity characteristics of AS group.

Variable	Mean	SD
ADOS total	14.06	5.13
Autonoma Scale	53.40	6.92
VABS-CD	17.00	7.54
PCI	44.98	10.93

ADOS: Autism Diagnostic Observation Schedule; VABS-CD: Disadaptive Behaviour Scale from Vineland Adaptive Behaviour Scales–Second Edition. PCI: Pragmatic Communication Index on Children’s Communication Checklist.

A comparison control group (CG) was included. The group composed of student volunteers, and they were recruited from two high schools and different degree courses at the University of Granada, through an open invitation letter or e-mail (this was sent to parents for students under 18). Upon confirmation by students and their parents, there was a randomly selected group of 50 typically developing participants that matched the gender ratio (43 men and 7 women), age (M = 19.54; SD = 3.46) and NV-IQ standard scores (M = 51.62; SD = 9.35) of the AS group. The participants had no history of injury or illness involving the brain. No differences were found in educational level compared with the AS group (Fisher (3, n = 100) = 4.01, p = .279, V de Cramer = .203).

Procedure

Following approval by the University Research Ethics Committee, consent was obtained prior to any data collection. As part of a research project, members of AS associations in various Spanish cities were encouraged to participate voluntarily. For the AS group, assessment was carried out individually in two sessions in their local building prior to the treatment. The first focused on the application of the ADOS-G diagnostic interview, and the second on the remaining tasks. During the same period, parents were convened to make an independent and individual assessment of diagnostic confirmation by means of the ADI-R and to provide information for the Vineland Adaptive Behaviour Scales–Second Edition (VABS-II). After treatment, there was a final group session for assessment on the outcome measures (Assessment of Social Problem Solving Task (Evaluación de Solución de Conflictos Interpersonales (ESCI) and the Osnabrück Ability to Work Profile (O-AFP)) and, during the same week, a short interview with the parents took place.

Data on social functioning of the group participants were taken before treatment (pre-treatment) and immediately after completion of the group treatment (post-treatment). A follow-up questionnaire was completed 3 months later. Ten AS groups were held over an academic year. Each group included between four and six participants with ASDs. One year after the training intervention, a feedback session was organised for participants and individualised reports were delivered.

The CG was assessed during an individual session in their own school or at the Clinic of Psychology at the University of Granada. Parents were contacted by phone to answer the VABS-II. There was no intervention for the CG. Results were used for sample comparisons. All assessments were carried out by the first author, a trained psychologist experienced in working with people with ASDs.

Treatment intervention

The principal author was trained on mediation approach during the pilot study. Training consisted of two regular meetings per week with the first author of the programme manual. Group therapy sessions were carried out by the principal investigator.

Programme

In general terms, the intervention consisted of 75-minute sessions, delivered once a week over a 10-week period to groups of four to six people with ASDs assisted by a therapist. Being a programme specifically developed for the ASD population, it takes into account particular difficulties and strengths of this population. A mediational approach was adopted for learning, and the therapist’s aim was to provide the participants with the necessary clues to understand and verbalise, session by session, the phases regarding the solution of interpersonal problems. Through sequential training in a cognitive and metacognitive process, the programme focuses on the interpersonal problem-solving process by working on a phase during each session: (1) introduction to interpersonal problem-solving skills and description of AS’s characteristics; (2) conversational skills; (3) defining a problem; (4) different points of view; (5) thinking of causes; (6) generating solutions; (7) considering consequences and choosing the best option; (8) plan of action; (9) evaluating actions and facing failures; and (10) reviewing the process. The content of each session focuses on one particular phase of the process supported by examples on common interpersonal problems that take place in a work environment in combination with participant personal experiences. Appendix 1 provides an overview of the 10-session intervention. At the end of each session, two homework tasks were given concerning the step-by-step resolution of two interpersonal problems. They related to short narratives involving an interpersonal problem (in a workplace context) to be solved in phases (see Appendix 2). At the end of the programme, participants received a portfolio with their homework and a few templates for new interpersonal problem situations to be added as needed in the future.

Subject involvement

Therapist-recorded assistance and homework completion after each individual session were rated as follows: 1 = empty, 2 = partially completed, 3 = completed.

Subject satisfaction

At the final session of assessment, following the treatment, adolescents were asked to rate their satisfaction with the programme on a Likert scale ranging from 1 (no change) to 4 (very clear change), rating the programme as a whole and providing personal comments on what they liked the most and what could be changed. Scores ranged between 12 and 48.

Three-month follow-up questionnaire

An independent questionnaire was sent by post to parents and participants. It was composed of 12 items on a Likert scale of 0 (never) to 4 (a lot) referring to the steps trained during the programme, the utility of the portfolio and the observed changes in relationships. Two items focused on the social validation of the programme.

Measures

Due to the lack of ‘gold-standard’ outcome measures (Cunningham, 2012), measures not specifically designed for the AS population were used in this study.

The ESCI (Calero et al., 2009) consists of 12 sequences of images representing an interpersonal conflict, shown on the computer. Participants are required to give written answers to the following questions: (1) How does the principal character in the drawing feel? (2) Why does he/she feel this way? (3) What could he/she do to improve this situation? The task provides a total score and a score for each dimension: Emotion (ESCI-E), Situational Concordance (ESCI-C) and Solutions (ESCI-S). The instrument has been validated in a sample of adolescents from Granada, Spain (Molinero, 2010). As for reliability, a Cronbach index of over α = .57 was obtained for each area, while the analyses of factorial validity revealed 6 independent factors in the area of Emotions, 6 in Situational Concordance and 5 in Solutions. It was used as the primary outcome measure.

The VABS-II (Sparrow et al., 2005) is designed to measure adaptive behaviour in subjects up to 90 years old, on the basis of a report with a Likert-type scale completed by parents or informers. For this study, only two subscales were considered to be relevant: Socialisation area (VABS-S) and Disadaptive Behaviour (VABS-DB; included for symptom severity description). The first explores domains of interpersonal relations (VABS-S-Relations), leisure and free time (VABS-S-Leisure) and coping skills (VABS-S-Coping), while the second provides a general index relating to internalised and externalised disadaptive behaviour. The reliability assessment included an analysis of internal consistency for the total score (.93–.97) for different age groups, test–retest analysis (.76–.92) and inter-rater analysis (.73–.76) for the different domains, subdomains and ages. Content, construct, factorial and criterion validity were confirmed with respect to the earlier version, VABS (.69–.96) and the Adaptive Behaviour Assessment System–Second Edition (ABAS-II, score = .70) (Sparrow et al., 2005).

The O-AFP (Wiedl and Uhlhorn, 2006) is the German scale that represents an adaptation of Bolton and Roessler’s (1986) Work Personality Profile. In order to explore its use, a Spanish translation of the German scale version was elaborated for the assessment of work capabilities at programme intake and at programme termination. It consists of 30 items using a Likert-type scale. Assessment was carried out by the participant’s supervisor and self-reports. The scale ranges from 1 (total lack of skill) to 4 (always present). Assessment of rehabilitants was performed on three subscales, each with 10 items: learning ability (LA), social communication and interactional competence (SIC) and social adaptation and motivation (SAM). Internal consistency for the German scales were α = .954 for LA, .909 for SIC and .899 for SAM.

Statistical analysis

This was an open trial for an intervention of a structured interpersonal problem-solving implementation in group format. Due to its implementation in community settings, participants were selected through convenience sampling (Lucas, 2013). To evaluate changes after treatment in the outcome measures (interpersonal problem-solving, parents’ reports on social skills and work capabilities), a one-way repeated measures analysis of variance (ANOVA) was conducted to compare scores on the outcome measures in pre-treatment and post-treatment within the AS group and the effect sizes were reported (Cohen d). Clinical significance or magnitude of each subject’s change was determined by Computing Reliable Change Indices (RCI; Jacobson and Truax, 1991). Based on this model, change scores greater than 1.96 were considered statistically significant and clinically meaningful. Finally, pre-treatment and post-treatment scores for the AS group were compared to the CG in order to explore the decrease in effect sizes (Cohen d) following treatment. Intergroup t-test analyses were carried out for the different static measures. Results from the test statistic, p values (two-tailed) and effect sizes are reported (Fild, 2009).

Feasibility was explored by calculating attrition, treatment adherence based on percentage of attendance, fulfilment of homework and reports in participant satisfaction questionnaires completed by participants and parents (rating how helpful was the intervention).

Results

Changes after treatment

The means, standard deviations and effect sizes in the outcome measures are presented in Table 2 (Greenhouse–Geisser correction). Significant differences were found in the socialisation total scale (VABS-S) (F (1, 49) = 61.13,p < .0001) and subscales VABS-S-Relations (F (1, 49) = 136.29, p < .005), VABS-S-Leisure (F (1, 49) = 15.39, p < .005) and VABS-S-Coping (F (1, 49) = 97.38, p < .005) in the social problem-solving task total score (ESCI-Total) (F (1, 49) = 43.92, p < .0001), Situational Concordance domain (ESCI-C) (F (1, 49) = 15.51, p < .0001) and Solutions domain (ESCI-S) (F (1, 49) = 35.27, p < .0001). Emotion domain was not significant. For the O-AFP, only the Learning subscale self-report version showed significant higher scores after intervention (F (1,47) = 10.01, p = .003) but a small effect size. Effect sizes were large for VABS-S-Total, ESCI-C and ESCI-S.

Table 2.

Pre- and post-treatment and effect size in outcome measures.

	AS Group M (SD)	CG M (SD)	Effect size^a (between groups)
VABS-S-Total
Pre	155.63 (11.29)	191.7 (3.97)	3.01
Post	167.92 (12.84)		1.77
Effect size	0.555
VABS-S-Relations
Pre	61.26 (3.23)	74.50 (1.16)	3.85
Post	65.78 (3.31)		2.48
Effect size	0.736
VABS-S-Leisure
Pre	51.81 (4.14)	60.82 (1.42)	2.05
Post	53.71 (4.09)		1.64
Effect size	0.239
VABS-S-Coping
Pre	41.92 (6.26)	56.82 (2.26)	2.24
Post	49.57 (6.54)		1.05
Effect size	0.665
ESCI-Total
Pre	54.42 (8.54)	65.28 (4.36)	1.13
Post	60.89 (8.62)		0.52
Effect size	0.473
ESCI-E
Pre	11.54 (1.74)	12.76 (0.59)	0.66
Post	11.56 (1.32)		0.82
Effect size	0.000
ESCI-C
Pre	31.84 (4.49)	36.80 (2.01)	1.01
Post	34.10 (3.44)		0.68
Effect size	0.240
ESCI-S
Pre	11.05 (4.61)	15.73 (3.82)	0.78
Post	15.22 (5.74)		0.07
Effect size	0.419
O-AFP-P Total
Pre	83.21 (13.04)	93.18 (9.06)	0.64
Post	85.27 (12.04)		0.52
Effect size	0.061
O-AFP-T Total
Pre	79.61 (18.66)	–	–
Post	85.00 (16.71)		–
Effect size	0.135

VABS-S: Socialisation scale from the VABS–Second Edition; VABS-S-Relations: Interpersonal relations scale from the VABS–Second Edition; VABS-S-Leisure: leisure and free time scale from the VABS–Second Edition; VABS-S-Coping: Coping skills scale from the VABS–Second Edition; ESCI: Assessment of Social Problem-Solving Task and corresponding dimensions; ESCI-E: Assessment of Social Problem-Solving Task–Emotion dimension; ESCI-C: Assessment of Social Problem-Solving Task–Situational Concordance dimension; ESCI-S: Assessment of Social Problem-Solving Task–Solutions dimension. O-AFP-P: Self-report version of the Osnabrück Ability to Work Profile; O-AFP-T: Tutor report version of the Osnabrück Ability to Work Profile.

Both (pre- and post-treatment scores) were compared with the control group and effect size calculated.

Statistically, significant change was expected for individual scores in outcome measures. A total of 25 of the 50 participants (50%) showed statistically significant change (RCI > 1.96) for at least one area of the social problem-solving task (ESCI-E, ESCI-C or ESCI-S). On the socialisation skills reported by parents (VABS-S), 21 of the 50 participants (42%) obtained statistically significant change. A total of 15 of the 50 participants (41%) showed significant change on the ESCI and the VABS-S simultaneously. Two participants (4%) showed RCI > 1.96 on the work personality profile (O-AFP) self-report while only one participant (2 %) on the O-AFP tutor report.

In order to test decreasing effect sizes, comparing the sample with task performance of a CG, t-test comparisons were calculated for both groups, pre-treatment and post-treatment. The effect sizes based on post-treatment scores were compared with the effect sizes found at baseline for the AS group compared with the CG (see Table 2). Values diminished in all cases except for ESCI-E (see Figure 2).

Figure 2.

Effect sizes of differences between AS group (pre- and post-treatment) and CG.

Feasibility

Generally, 48 out of 50 participants (96 %) completed the intervention. Only two of the 50 participants dropped out due to reasons unrelated with the programme. The overall rate of attendance (a total of 110 sessions, 10 groups × 11 sessions – including the final assessment) for the 50 participants was 70%; the range per participant was 6% (1 session) to 100% (11 sessions). Two participants (4%) dropped out during the first session; 24 participants (48%) attended all sessions, 19 participants (32%) missed one session and 7 participants (10%) missed more than one session. Based on the benchmarks of 70% for overall attendance, these attendance rates were considered satisfactory to indicate that the families adhered to the treatment programme (White et al., 2010).

Participant compliance with homework assignments, defined as at least partially completed between-session assignments, ranged from 20% to 100% across participants (mean compliance = 87%). The lowest rate of homework completion was for the phase concerning Session 9 (Dealing with failure), which required filling out the handout for the given situation which included a section of self-assessment based on a group role-play at the beginning of Session 10. Session 5 seemed to be the second most difficult task based on compliance which was specifically focused on detecting causes of problems.

The parents of the 32 participants completed the Programme Satisfaction Survey (this questionnaire was not offered to the first three groups run). In general, participants seemed to be satisfied with what they learned from the programme (M = 33.74, SD = 11.48). The highest score was achieved for items I get on better with my group peers, I learnt to think about what could be the causes of negative feelings in others or problems and I am more conscious to pay attention to others’ feelings. The item with the lowest rate was Now, I start more conversations about topics which are interesting for others even if they are not for me.

A total of 48 participants and 47 parents answered the 3-month follow-up questionnaire. As a group, participants reported a medium change (a score of 3) on the majority of items except for Having a written plan of action helps me to cope with interpersonal problems, Using the portfolio to solve problems and Family interactions have become better. However, change was reported for better relations with friends and less problems with others. In general, all parents reported that they observed change on items such as Solving problems more efficiently, Better definition of problems, Family interactions have become better, Better reactions with friends and Less problems with others. Some change (scoring 2) was also reported for Improving in generating solutions and Thinking about consequences before acting. Overall, 100% of the participants and parents agreed that intervention should be funded by a public or private enterprise and all of them recommended the programme for someone with their condition. Summarising the participants’ responses to the open-ended questions, most parents reported feeling that the programme was too short and more sessions would have improved outcomes. Furthermore, they said that a simultaneous guide for parents would have been useful to continue practicing with their children at home. Participants agreed that homework tasks were hard to do but were needed to improve their knowledge in the interpersonal problem-solving process.

Discussion

This study begins to address the issue of intervention in interpersonal problem-solving skills for a well-defined sample of young adults with AS, through sequential training in a cognitive and metacognitive process across ten weekly sessions. The goals were to examine treatment effectiveness and feasibility.

Analysis of treatment effectiveness was based on changes in participants’ performance of a social problem-solving task (primary outcome measure) and parent and tutor reports (secondary outcome measures). The initial hypothesis was confirmed; the AS group showed significant improvements after treatment in ESCI (Situational Concordance and Solution dimensions) and VABS-S. Participants also reported changes in the Learning subscale of the O-AFP. Moreover, analyses of RCI showed significant changes individually. A total of 25 participants showed statistically significant change in the social problem-solving task. Also, parents reported significant changes in 15 of participants based on the VABS-S. Two of these ‘responders’ simultaneously reported changes in work capabilities. Thus, using a more conservative method (RCI), positive effects of the treatment were also detected. Although interpretation needs to be attentive as statistically significant, change does not necessarily equate to positive change that is personally meaningful to the client and worth the costs associated with the treatment (Kraemer et al., 2006). Further research is critical to determine if changes do generalise out of sessions. Follow-up reports after 3 months pointed to some changes being maintained in social problem-solving areas. The AS group scores pre- and post-treatment were compared with the CG performances and the effect sizes were reported in order to examine the decrease in differences with the CG after treatment. The general pattern indicated that the differences between the AS group and the CG decreased after treatment. Thus, using a variety of methods, significant changes were found after treatment.

Qualitative data supported the feasibility of the SCI-Labour programme. Attendance of the group was quite satisfactory. General attendance was 70%, a value which meets the minimum required for a clinical trial (White et al., 2010) and only two participants dropped out for reasons out of programme’s control. The average homework completion rate by the adolescents in this trial was higher than the compliance reported in previous psychoeducational interventions with adolescents, which have indicated that participants complete only approximately half of assigned between-session tasks (Gaynor et al., 2006; White et al., 2013). These results may indicate high motivation among adolescents and adults who are concerned about their impairments and would like to face possible employment. During the feedback session one year later, participants and parents highlighted the lack of long-term social support or training interventions for youngsters with AS.

Limitations

Among the limitations of the study, we should first mention the specific content of the programme which is focused on interpersonal problem-solving skills trained in group format. Therefore, it is not a comprehensive treatment nor is it completely individualised. Maintenance of change is based on parent report and self-report, which would have been enriched with additional direct measures of skill acquisition. There is a lack of explicit analysis of generalisation to natural settings. Second, motivation was different among participants and their parents, which may have influenced treatment improvements. Another possible limitation concerns the lack of an independent evaluator who would be blind to the treatment process. Possible violations might have been compensated by the quality of most of the measures applied. The training showed consistency delivered by one single therapist. It was not influenced by personal factors by different trainers, which assures a higher degree of integrity when compared to the manual during the treatment process. However, multiple informants and the use of independent raters are highly recommended to avoid potential bias. Also, randomised group assignments were not controlled for comparison with a waiting list group which limits generalization of conclusions. However, having provided a programme delivered in community settings for a unique population, results are still suitable for answering needs of adulthood population with AS (Small, 2009). Furthermore, the lack of ‘gold-standard’ measures to evaluate treatment outcomes meant that new measures were used with the AS population for the first time (ESCI and O-AFP).

Social problem-solving skills are frequently impaired in the ASD population. The ability to properly address interpersonal problems is especially required during adolescence and adulthood as it is a critical period for employment development. However, research evidence focused on this type of intervention is still at a very young stage. Training in understanding and acquisition of the social problem-solving skills is the first step. This study raises the question of intervention package and the amount of doses for the different phases trained. Further study of SCI-Labour programme is warranted. Future research should focus on the measure of actual behavioural change and generalisation to different contexts.

Conclusion

This study represents one of the largest intervention samples for adolescents with AS recruited in this country. This study describes the development of a treatment programme specifically designed for young people affected by AS and effectiveness and feasibility data are presented. Collected data show that participants’ performance increases after treatment. Results are promising, indicating that the programme was acceptable to consumers and that it could be delivered in community settings and attended by general clients. Further research should study efficacy of the training based on maintenance of change, generalisation to untaught behaviours and randomised control trials or wait-list group assignments (Smith et al., 2007).

In conclusion, this study represents a novel contribution in terms of the evaluation of treatment effects based on a manual programme specifically developed for people affected by ASDs.

Footnotes

Appendix

Appendix 1.

Outline of the content of the Interpersonal Problem-Solving Skills for Workplace Adaptation (SCI-Labour) programme.

Session	Didactic lesson	Content of the session
1.	Introduction	Interpersonal problem-solving skills can be trained; description of Asperger Syndrome’s characteristics
2.	Conversational skills	Importance of listening; starting and maintaining conversation; asking questions
3.	Identifying and defining a problem	Participating; following instructions; looking for ‘clues’ to discover a problem; personal problems vs. interpersonal problems; defining problems
4.	Different points of view	Detecting and expressing your own feelings; understanding other’s feelings; changing perspectives; expressing affection.
5.	Thinking of causes	Influence of different factors on an interpersonal problem; collecting information about causes; different causes of problems
6.	Generating solutions	Generating different solutions; making decisions
7.	Considering consequences; choosing the best option	Examining consequences for each solution; consequences based on time versus consequences based on severity
8.	Plan of action; detecting obstacles	Developing a plan of action for the chosen solution; looking for possible obstacles and factors influencing the final result
9.	Evaluating actions and facing failures	Assessing results; feedback; dealing with failure through concrete actions and feelings
10.	Reviewing the process	Going through the whole resolution process. Applying the full handout to a personal situation for each participant and share it with the group.

Acknowledgements

We are grateful to the participants, their parents and staff from the following associations who cooperated in the study: Asociación Asperger Madrid, Asociación Asperger Granada Centro Hans Asperger Sevilla, Asociación Asperger ASPALI and Asociación Asperger Valencia. We also thank Mariana Ciuffreda for her help with the English translation. This project was approved by the Ethics Committee of the University of Granada.

Declaration of conflicting interests

The authors declare that we have no conflict of interest.

Funding

This project was partially supported by the University of Granada FPU Plan Propio grant.

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