Paper describes novel psychotherapeutic approach in a boy with Asperger's syndrome

This paper reports a stable improvement in social skills in a 15-year-old boy diagnosed with Asperger's syndrome (AS), after an outpatient treatment with Social Effectiveness Therapy for Children and Adolescents (SET-C), a specific and intensive type of social skill training. Its effectiveness should be further tested in randomized controlled and long-term follow-up studies.

A case report that was published in one of the last issue of Psychotherapy and Psychosomatics describes a novel psychotherapeutic approach in a boy with symptoms related to the autistic spectrum.

Asperger's syndrome (AS) is characterised by marked deficits in social skills, restricted interests and repetitive behaviour. Differently from full-blown autism, however, general cognitive functioning and intelligence are preserved in AS, and there is no significant language delay. It also seems likely that in the forthcoming DSM-V, AS as a denomination will disappear to be encompassed within the autism spectrum disorders. In AS, social skills deficits manifest early in life, and typically worsen during the school years, often resulting in rejection by the peer group; during adolescence and adulthood, the social skills deficits persist and impact negatively on occupational functioning.

This paper reports a stable improvement in social skills in a 15-year-old boy diagnosed with AS, after an outpatient treatment with Social Effectiveness Therapy for Children and Adolescents (SET-C) a specific and intensive type of SST. Parental ratings with the Childhood Asperger Syndrome Test corroborated the clinical diagnosis. To assess the degree of current social impairment and in order to identify the feared social situations, the boy completed the Social Phobia and Anxiety Inventory for Children and Adolescents (SPAI-C) and the Liebowitz scale, while the mother filled in the Child Behavior Checklist (CBCL) 6-18. Moreover, a test of facial emotion identification yielded a higher than-average rate of errors (n = 6, corresponding to 50% misclassified emotional stimuli) in identifying fear, anger and neutral pictures.

The boy also presented with tics, OCD symptoms as reported in the Y-BOCS structured interview (including fear of being contaminated by germs or contaminating others, with consequently prolonged washing/cleaning). This prompted a pharmacological treatment with citalopram 40 mg/day, which yielded a 50% improvement in distress on the Y-BOCS at 2 months. In spite of a good IQ (total: 116, without a significant difference between verbal and nonverbal abilities), academic difficulties had begun during the elementary school and had persisted thereafter and, although he was never given a remedial teacher, he repeated a class at the first year of high school. When interacting with doctors, the boy would talk at length and in details about a restricted span of idiosyncratic interests (such as insects), but proved poor at talking on most other topics, with manifest anxiety whenever conversation shifted to personal issues, such as social activities or personal feelings.

He described himself as having no friends, and there were no peer interactions outsideschool: social situations and peer interactions - even with small groups - were feared and avoided. In treating AS patients with SSTs, the available evidence is in favour of behavioural approaches based on teaching practical skills, rather than extensive cognitive intervention. Therefore, a SST program based on the SET-C was implemented.

The SET-C is a multifaceted behavioural treatment originally aimed at improving social skills and interpersonal functioning in youths with social anxiety and avoidance. This is a goal-directed and practical program particularly oriented at improving several of the language and social skills (such as: initiating a conversation, maintaining a conversation, being assertive) that are suboptimal in AS.

The SET-C is designed to progressively reduce social fear, so that interpersonal functioning gradually improves and participation in social activities increases as the treatment proceeds. After 4 months of pharmacological treatment with citalopram without psychotherapy, the OCD symptoms were reduced, while the social performance levels had remained substantially the same. The SET-C treatment was implemented weekly for 3 months. At the beginning of SET-C treatment, the SPAI-C and the Liebowitz total scores were 22 and 17, respectively.

The CBCL anxiousdepressed, social problems, withdrawn/depressed and thought problems subscales were all over the 97th percentile; attention problems scored at the 93rd percentile, while social competences scored lower than the 7th percentile. Behavioral homework consisting of exposure to feared social situations was assigned at the end of each session; the parents had been involved in the treatment to support the boy, and were instructed on how to be consistent in exposure tasks. At the end of the SET-C program, the S PAI-C total score was 19 and the Liebowitz scale score was 12 (decreases from the beginning of SET-C: 13.6 and 29.4% respectively).

Meanwhile, the boy reported that he had engaged into a wider array of social situations with peers, mediated by cell phone and computer, as confirmed by parents. Academic performances had also improved, and several marks improved from sufficient to intermediate. The CBCL scores yielded a social competences score at the 31st percentile (30% improvement from the beginning of SET-C), while all other subscales remained stable.

A facial emotion test repeated at the end of treatment yielded no errors (100% improvement), also suggesting improved social-emotional skills. At 12-month follow-up (no specific psychotherapy was administered meanwhile, but pharmacotherapy had continued unvaried, and was checked bimonthly), the SPAI-C score was 15, the Liebowitz score was 12 (decreases from the beginning of SET-C: 13.6 and 31.8%, respectively) and the CBCL social competences had remained stable.

These percentage improvements in symptom scores and parental report on social competences are similar to the figures reported in recent literature for other types of social competence intervention programs in youths with AS. Although these results need replication and expansion, this preliminary report supports the use of the SET-C with children and adolescents diagnosed with AS, and suggest that the SET-C could be added to the armamentarium of the psychotherapies that may prove effective in treating some specific aspects of autism spectrum disorders.