Studying ADHD and autism together is crucial because they frequently overlap, with ADHD affecting roughly 28% of autistic individuals. Their combination complicates social functioning, intervention responses, and outcomes.
Understanding how ADHD modifies social skills support for autism helps tailor coping strategies, improve individual outcomes, and ensures more effective support for autistic individuals who face additional challenges from co-occurring ADHD symptoms.
Fridell, A., Olsson, N. C., Coco, C., Bölte, S., & Jonsson, U. The moderating role of co-occurring attention-deficit hyperactivity disorder in social skills group training for autistic children and adolescents. Autism. https://doi.org/10.1177_13623613251331993
Key Points
- Focus: The study explores how co-occurring ADHD affects outcomes of social skills group training (SSGT) for autistic children and adolescents.
- Aims: The research aimed to investigate whether the presence of ADHD moderates the effectiveness of KONTAKT™, a social skills intervention for autistic youth, and to further explore if this moderation differs by age (children vs. adolescents).
- Findings: Co-occurring ADHD significantly moderated the intervention’s effectiveness; autistic adolescents and children without ADHD benefited significantly more from KONTAKT™, whereas preadolescent children with ADHD showed minimal improvements.
- Implications: The findings suggest that autistic children with ADHD may require tailored or supplementary interventions beyond standard SSGT.
Rationale
Autistic youth commonly face challenges with social skills, negatively impacting mental health and quality of life.
Although Social Skills Group Training (SSGT) programs have been moderately effective, outcomes vary widely among individuals.
ADHD, common among autistic youth, may complicate these outcomes. Past research is inconsistent about ADHD’s role in SSGT effectiveness.
Addressing this gap, the current study utilizes randomized trials to clarify whether ADHD status moderates SSGT outcomes.
Understanding such moderators could enhance clinical decision-making and intervention design, leading to better individualized support.
The next step involves refining interventions specifically for autistic youth with ADHD to maximize their social skills development.
Method
The study employed a secondary analysis of data from two pragmatic randomized controlled trials (RCTs) of KONTAKT™, conducted across 13 clinical centers.
Participants received either the intervention alongside standard care or standard care alone, with outcomes measured pre-intervention, post-intervention, and at 3-month follow-up.
Procedure
- Participants randomly assigned (1:1) to KONTAKT or standard care.
- Sessions: 12 or 24 weekly group training sessions.
- Parent-rated assessments completed pre-intervention, immediately post-intervention, and at 3-month follow-up.
Participants performed:
- Goal identification exercises.
- Group discussions and role-playing.
- Emotion-processing activities.
- Homework tasks supported by parent participation.
Sample
- Total N = 241 autistic children (8–12 years, n=130) and adolescents (13–18 years, n=111).
- 178 participants had co-occurring ADHD.
- Majority had IQ above 70; balanced gender representation.
Measures
- Social Responsiveness Scale (SRS): Parent-rated scale assessing social awareness, cognition, communication, motivation, and autistic mannerisms.
Statistical measures
- Logistic regression analyzed moderation by ADHD and age.
- Reliable improvement defined by ≥25-point reduction on SRS.
- Clinically relevant improvement defined by ≥10-point reduction sustained at follow-up.
- Odds Ratios (OR), adjusted Odds Ratios (aOR), and Numbers Needed to Treat (NNT) calculated.
Results
- Overall, KONTAKT significantly improved social skills compared to standard care (aOR ≈ 2, NNT=6–8).
- Adolescents showed stronger improvements than younger children.
- Children without ADHD significantly benefited (NNT=3), whereas children with ADHD did not.
- Adolescents improved irrespective of ADHD, although those without ADHD gained more.
Insight
This study highlights ADHD as an important moderator influencing the effectiveness of social skills interventions.
The finding is particularly significant because it identifies a subgroup—preadolescent autistic children with ADHD—who derive limited benefits from conventional group interventions.
This extends previous research, emphasizing the importance of age and co-occurring conditions in intervention effectiveness.
Future research should explore ADHD-specific strategies, such as parent involvement and less theoretical content, to optimize intervention outcomes for autistic youth with ADHD.
Clinical Implications
Clinicians and policymakers should recognize that autistic children with ADHD might not benefit adequately from standard SSGT programs alone.
Practitioners are encouraged to:
- Closely monitor ADHD participants’ progress.
- Integrate enhanced parental support and hands-on training methods.
- Tailor interventions to account for ADHD-related challenges (e.g., attention difficulties). The challenge lies in practically implementing these tailored methods within clinical and educational services already strained by resource limitations.
Strengths
This study had several methodological strengths, including:
- Utilization of rigorous RCT data.
- Robust methodological framework (large sample, validated measures, standardized protocol).
- Inclusion of clinically relevant outcome metrics (reliable and clinically meaningful improvement).
Limitations
This study also had several limitations, including:
- Moderation analyses not originally designed in initial trials (potential power limitations).
- Imbalanced subgroup sizes, with ADHD overly represented.
- Reliance on parent-rated single outcome measure (SRS) may not fully capture nuanced social improvements.
- ADHD diagnoses were clinically derived without additional independent validation by researchers.
Socratic Questions
- What could explain why younger autistic children with ADHD benefit less from group-based social skills training than adolescents?
- How might the involvement of parents and teachers specifically enhance intervention outcomes for autistic children with ADHD?
- Are there alternative explanations or variables, not measured in this study, which could impact the effectiveness of social skills interventions?
- How might the findings of this study inform the development of future, more targeted interventions for autistic youth with ADHD?
- Given resource limitations, what practical steps can clinicians take immediately to improve intervention outcomes for this subgroup?
- In what ways might the reliance on parent-reported outcomes have influenced the study’s findings?
- How generalizable do you think these findings are to other contexts or intervention programs?
