The interventions
In evaluating the feasibility and acceptability of KONTAKT© in an Australian context, a pilot version of the 16-session KONTAKT© was delivered to 16 adolescents meeting the inclusion criteria across 16 sessions in 20 weeks, with two 8-week session blocks interspersed with the Australian school holidays. After completing the KONTAKT© intervention, focus groups were held with participants, parents and trainers, capturing their perspectives of the programme. Following analysis of focus group data, final adjustments and modifications were made to the KONTAKT© 16-week variant, standardising the intervention in preparation for RCT evaluation. Tables
1 and
2 detail the structure and content of KONTAKT© (the opportunity to choose social themes/activities that reflect the participants’ personal goals or interests) and Super Chef (personal tastes for each recipe) sessions, and their emphasis on individualized activities aiming to promote motivation in the participants and generalization of skills [
32].
Table 1
The structure, objectives and individualized parts of weekly KONTAKT© sessions [
57]
Opening | Warm-up activity, initiating conversation, promoting interaction between group members, promoting eye contact | |
Reviewing homework | Reinforcing and providing feedback, troubleshooting if necessary | Sessions 2–15 |
Group discussion | Exchanging experiences, promoting social cognition and social relationship | Sessions 12–15 |
Group activities | Providing practical solutions and strategies for everyday challenging social situations, fostering a feeling of group cohesion, practicing cooperation, practising recognising and interpreting non-verbal signals, eye contact, and facial expressions | Sessions 12–15 |
Snack time | Practising small-talk and turn-taking in unstructured conversations | |
Assigning new homework | Generalizing learnt skills to everyday social situations | Fixed: sessions 1–10 Flexible: sessions 11–14 |
Closing | Evaluating the session, promoting interaction between group members | |
Table 2
The structure, objectives and individualized activities of weekly Super Chef sessions
Transition | Self-regulation and arrival into the session | |
Activity 1 | Sharing cooking experiences | |
Activity 2 | Preparation for cooking and food exploration | Every session |
Snack time | Practicing small-talk and turn-taking in unstructured conversation, participating in games and activities | |
Activity 3 | Cooking or baking | Every session |
Eating the prepared meal | Rating the prepared meal | |
Clean up | Washing up, drying dishes, wiping down benches and tables, and sweeping the floor. | Every session |
Transition | Recapping the session and feedback to the parents | |
The Australian adaptation of KONTAKT©, employing a 16-session variant, aims to improve participants’ communication and social interaction skills, ASD-related traits, and the ability to empathise and adapt in a group setting of 6–8 adolescents aged 12–17 years [
19,
21]. Groups meet weekly for an hour and a half, with two trainers delivering a programme underpinned by the principles of cognitive behaviour therapy, behaviour activation, observational learning, psychoeducation, and social cognition training [
41,
42]. Sessions scaffold knowledge of common social rules and norms, aiming to promote problem-solving strategies, emotion recognition, and emotion expression [
19].
KONTAKT© requires that at least one group trainer is a clinician with extensive experience working with children/adolescents with ASD, who has also received methodological training, or certification in KONTAKT© prior to the programme. Prior to the pilot, Australian clinicians from AAWA were trained by a Swedish team of certified KONTAKT© trainers. Requirements of KONTAKT© training certification include passing this method training, leading at least one KONTAKT© group under supervision, and achieving intervention fidelity as assessed by a KONTAKT© supervisor on the basis of submission of a filmed KONTAKT© session. A KONTAKT©-certified trainer can, in turn, instruct others in delivering KONTAKT©. In the present study, fidelity to the KONTAKT© intervention will be systematically assessed by trainers completing a session by session fidelity checklist, enabling an assessment of intervention fidelity. In addition, attendance sheets will be kept to record the participants’ compliance with the programme, with 80% attendance considered as compliant.
Super Chef is a manualised cooking-group programme specifically designed for this study (Table
2), with the goal of enabling comparison of KONTAKT© with an active social control group, enabling independent evaluation of the contribution of KONTAKT© to intervention outcomes. As in KONTAKT©, participants allocated to the Super Chef programme will meet weekly in groups of 6–8 for an hour and a half in a 16-session programme moderated by two trainers, one of which will be an occupational therapist with previous experience of working with Australian adolescents with ASD. As with KONTAKT©, each Super Chef session adheres to a specified agenda including discussions, taste testing, individual and group activities, snack time, cooking recipes, eating and rating recipes and cleaning up as rostered. Super Chef was developed by a team including occupational therapists with both clinical and research experience in working with adolescents with ASD, with consideration of the common sensory issues associated with ASD. Fidelity to the Super Chef intervention will be assessed via a fidelity checklist, specially designed for this programme, enabling assessment of the extent to which trainers followed the format of each session.
Secondary outcome measures
The Social Responsiveness Scale - Second Edition (SRS-2) standard version is a 65-item parent rating scale, designed to measure autistic-like traits in individuals aged 4–18 years. The SRS-2 enables calculation of a total score and five subscales: social awareness, social cognition, social communication, social motivation, and restricted interests and repetitive behaviour. The scale is scored on a 4-point Likert scale, ranging from “not true” (0) to “almost always true” (3). Scores range from 1 to 195 with the expected value for individuals with a primary diagnosis of ASD being approximately 100 [
61]. Previous studies in individuals with ASD show good psychometric properties for SRS-2 (internal consistency of 0.9) [
62,
63]. As recommended for research, the raw scores of the measure (total and subscale) will be used in this study [
63].
The Circumplex Scale of Interpersonal Efficacy (CSIE) [
64] measures an individual’s confidence in their ability to successfully perform behaviours associated with each facet of the interpersonal circumplex (assert, distance, yield, and connect). Each octant scale shows a progressive blend of two axial dimensions (e.g. “speak up” representing an assertive action, “get them to leave me alone” a distancing action, and “tell them when I am annoyed” combining these two actions) [
65]. As suggested by previous research, this study will use these dimensional scores instead of the eight octants to predict the outcome [
66]. Previous studies in adolescents with ASD have demonstrated acceptable internal consistency of 0.78 for this measure [
64].
The Perth Aloneness Scale (PLS) is a self-report measure consisting of 24 statements such as “I feel left out of things at school”, or “I get along with my classmates”, measuring four dimensions of loneliness in young people (isolation, friendship, and positive and negative attitudes toward solitude) [
67‐
69]. Responses are recorded on a 6-point Likert scale indicating agreement with a statement, ranging from “never” (1) to “always” (6), with higher scores suggesting higher levels of loneliness and negative attitude towards solitude. This scale has yielded good reliability for the overall scale and subscales (Cronbach’s alpha = 0.84). The use of the scale in the current study is further supported by established norms for Western Australian adolescents [
67].
The Emotion Regulation and Social Skills Questionnaire (ERSSQ) is a 27-item measure assessing emotion regulation and competency in social skills [
70]. The questionnaire is designed to measure frequencies of effective engagement in social behaviours (e.g. “chooses appropriate solutions to social problems” or “deals effectively with bullying”), examining the competency of these skills [
70]. Responses are rated on a 5-point Likert scale, ranging from “never” (0) to “always” (4), yielding a total score of 0–108, with higher scores indicating higher competencies in social behaviour. ERSSQ has demonstrated good internal consistency for children with ASD (Cronbach’s alpha = 0.89) [
70].
The Paediatric Quality of life Inventory ™, version 4.0 (PedsQL ™ 4.0) is a 23-item parent proxy report and an adolescent self-report measure of adolescent’s quality of life underpinned by the four subscales of physical, emotional, social, and school functioning [
39,
71]. Responders rate items according to if they have been a problem for them, on a 5-point Likert scale ranging from “never” (0) to “almost always” (5), with lower scores indicating better quality of life. Although there is no ASD-specific module available, the questionnaire has high validity and reliability (Cronbach’s alpha = 0.97) and has been used in adolescents with ASD [
12,
39], including Australia youths with ASD [
72,
73].
The Social Interaction Anxiety Scale (SIAS) is a 20-item measure assessing adolescents’ self-reported anxiety in social situations, via items such as “I become tense if I have to talk about myself” or “I find it easy to make friends my own age”. Items are rated on a 5-point scale ranging from “not at all” to “extremely”. Total scores range from 0 to 80 with higher scores indicating greater anxiety in social situations. The scale has a good internal consistency and test-retest reliability (Cronbach’s alpha = 0.94) [
74] and has been validated in an Australian setting in Australian adults [
75].
The Child Health Utility 9D (CHU9D) is a 9-dimension health-related quality of life scale (worried, sad, pain, tired, annoyed, school work, sleep, daily routines and activities), designed to estimate the adolescent’s quality-adjusted life years (QALYs), providing a standardised measure of disease burden. The measure is rated on a 5-point scale with a “don’t” sentence linked with no problems (e.g. “I don’t feel sad today”) and “very” with the participant experiencing many problems (e.g. “I feel very sad”). Calculation of a universal score is supported by an adolescent-specific scoring algorithm, with 1 representing “full health” and 0 “death” [
76]. Previous research suggests that the CHU9D supports appropriate calculation of QALYs [
77].
Healthcare consumption and productivity loss will be measured via a tailored version of the Trimbos/iMTA questionnaire for patients with a psychiatric disorder (TiC-P), a well-established questionnaire examining health care usage and any work, education, and productivity losses incurred by participants and their carers. The modified version of the TIC-P employed in this study comprises six sections enquiring about healthcare visits, support received both at and outside of school, medications and supplements, work, and education and productivity losses incurred by both parents and adolescents. The feasibly of the inventory was evaluated in the KONTAKT© pilot study.
The Mindreading Battery enables assessment of facial emotion recognition accuracy [
78], with this study measuring adolescents performance across 40 basic and complex emotions, over 6 developmental levels with level 1 being the simplest (e.g. happy) and level 6 being the most complex (e.g. exonerated) (Table
3). Emotions are displayed in the form of 2–5-sec silent coloured video clips, with four multiple choice options, one of which is the correct emotion label and three of which are distractor items. The distracter options were randomly selected from the entire Mindreading Battery emotion groups, excluding the emotion group from which the target stimuli originated. Further details of the stimuli are outlined in Table
4. During the presentation of stimuli, eye-tracking data will be recorded via a remote eye tracker device (RED) developed by SensoMotoric Instruments, enabling examination of fixation patterns and fixation durations [
79]. While the eye tracker accommodates small head movements, a chin rest will be available to participants who find it hard to sit still. Outcome measures will be assessed in relation to accuracy, response time, and number of and duration of fixations to dynamically defined areas of interest including the eyes, nose, and mouth of the stimuli [
80,
81].
Table 4
Overview of the Mindreading Stimulus Battery
Valence |
Negative | 22 |
Positive | 16 |
Gender |
Male (Pre) | 17 |
Male (Post) | 18 |
Female (Pre) | 21 |
Female (Post) | 20 |
Emotion level |
Basic | 6 |
Level 1 and 2 | 6 |
Level 3 and 4 | 15 |
Level 5 and 6 | 11 |
The Negative Incidents and Effects of Psychological Treatment (NEQ) assesses potential adverse and unwanted events associated with attending the groups at the completion of each programme, via adolescent self-report [
82]. The NEQ is a 32-item questionnaire requiring adolescents to quantify, on 5-point Likert scale with response options ranging from “not at all” to “extremely”, any negative events experienced during the intervention period, asking participants to attribute their causality to either the programme or external circumstances. Analysis of the measure has shown good reliability (Cronbach’s alpha = 0.95) [
82].
The Experience Sampling Method (ESM) will evaluate adolescents’ everyday quality of life via daily responses from both adolescent and parent proxy report [
83‐
85]. This 5-item measure, specifically designed for the purposes of this study, asks “In the last 24 hours, on a scale of 1 to 10 I have been feeling … ” with answers rated on a 10-point scale in five dichotomised emotional sets (sad/happy, lonely/unlonely, angry/calm, scared/unafraid, and anxious/confident). Questions are texted via mobile phones to adolescents and parents once daily from commencement of the groups to the final follow-up time point. The feasibility of this approach was assessed during a pilot study, with this method previously showing consistency across experiences and in examining the effect of social context on the daily experiences of adolescents with ASD [
86].
The Treatment Satisfaction Scale (TSS-2) [
87] is a short, 6-item parents’ and adolescents’ self-report instrument, measuring satisfaction with group attendance. Each item is scored on a 4-point Likert scale with response options ranging from “yes, very much” to “no”, with an open comment section, encouraging participants to freely share their experiences with the intervention.
Blind expert rating of social functioning will be assessed by an occupational therapist or psychologist, experienced in working with adolescents with ASD, and blinded to the study hypothesis, via a rating scale designed specifically for the purposes of this study. The scale requires a rating of participant’s social communication and interaction on a scale of 0–10 as observed during three video recordings of the snack times of sessions 2, 10, and 15 in both the intervention group and control groups presented in random order.
Statistical analyses
As suggested by previous research, reliability of the GAS goals will be investigated via examination of their measurability, equidistance, and difficulty [
57]. A random effects regression model will be used to explore those factors associated with the raw data on the GAS scores (dependent variable), over the 9-month duration of the study. Independent variables for the model will be time, group (KONTAKT© versus Super Che’), age, IQ, gender, centre, and comorbidity as fixed effects, with follow up being the primary endpoint of the study. The random effect will be the participant’s ID number, thus accounting for the correlation between measurements made on the same individual within the model.
Analysis of secondary outcomes (interpersonal efficacy, quality of life, social anxiety, loneliness, facial emotion recognition, and eye-tracking behaviour) will be conducted in a similar manner (random effects regression model). Analysis will be based on an intent-to-treat approach [
84], considering each participant as belonging to the study group they were initially allocated, regardless of treatment actually received. Missing data will be accounted for according to the guidelines specified for each measure; if no guidance is provided, missing data will be handled in accordance with the CONSORT statement for conducting high-quality RCTs [
48]. Data analysis will be conducted using the SPSS version 24 statistical software [
88].
The outcomes of the present study will be compared to results obtained by previous evaluations of the short and long variant of KONTAKT© undertaken in Sweden.