• Introduce your case study, clinical question and evidence found. Did you need to respond to feedback or make changes from Part A (about 1 minute)

My patient:

• Andrew is an 8-year-old boy
• Received the diagnosis of ASD when he was 4 years old
• He encounters difficulty with several activities of daily living however his main inability is struggling to socially interact with peers his age within his school environment.
• Andrew has difficulty socially interacting with peers, connecting emotionally with others, participating in cooperative play, initiating interactions, reading verbal and non-verbal cues and maintaining eye contact.
• When arriving at school, Andrew often experiences anxiety such as a racing heartbeat, upset stomach, sweating and tenseness in his muscles.
• These symptoms are associated with ASD and have restricted and prevented Andrew from participating in meaningful activities within his school environment amongst peers his age.

Responding to feedback/changes from Part A:

• I was eager to find out whether social group interventions are beneficial and improve social skills in children with Autism spectrum disorder.
• In my CAT assignment, my clinical question was ‘Do social group interventions help with improving social skills in children with Autism Spectrum Disorder compared to typically developing children.
• The feedback I was provided with advised that it would be better for me to just focus on the population group children with ASD and not typically developing children. Therefore, my PICO question has changed to: ‘Do social group interventions improve social skills in children with ASD”.
• After conducting my new search; removing the comparison, I decided that I would still utilise the articles by Cotugno (2009) and Kylliainen et al (2020) as the best evidence being completely relevant to social interventions that help autistic children with their social skills.

• Discuss with your examiner key points from your evidence appraisal and application to your clinical case. (about 14 minutes)

What is the relevance, recency, strength and consistency of the evidence?

• Level
• To begin with, both articles that I selected to use are randomised control trials.
• These are on level II on the NHMRC level of evidence hierarchy
• In these studies, the participants were randomly assigned to groups, thus reducing the risk of selection bias, allowing me to determine the effectiveness of the study between the intervention and the outcome. I will be able to decide whether these studies are good to use for Andrew’s intervention.
• Recency
• The article by Kylliainen et al (2020) is a recent article allowing it to have good currency which ensures that the article consists of accurate and up to date information relating to my client in the case study and the intervention.
• The article by Cotugno (2009) is not recent and classified as a ‘older’ article as it was published 13 years ago. Although the article is old, there were many reasons as to why I selected it as the best evidence:
• Firstly, it answers my PICO question as it thoroughly addresses social group interventions amongst children with ASD.
•  Also, as I mentioned before, it is of high-level evidence in the NMHRC hierarchy. Other articles I found were of lower evidence. The systematic reviews I did find were not relevant and did not relate to my PICO question.
• With the articles I also did use the Critical Appraisal Skills Programme tool (CASP) specifically for randomised control trials and the article is seen to have good quality and strength.
• Relevance
• Both articles that I selected are relevant to my clinical question which is ‘‘Do social group interventions improve social skills in children with ASD”.
• The articles by Cotugno (2009) and Kylliainen et al (2020) addressed all PICO terms in my clinical question and also included correct and relevant terms I was searching for which was about social group interventions to improve social skills in children with autism.
• Unlike the other articles, they did not include the terms I was looking for to answer my question.
• Consistency
• In the article by Cotugno (2009), the results were consistent as they increased overtime. This is also seen in the article by Kyllainen et al (2020).
• In the article by Cotugno (2009), the therapy sessions for the children were constructed to maintain high degree of consistency from session to session therefore resulting in reliable and valid results.
• In the article by Kyllainen et al (2020) each group session was also structured with programs and activities that promote progress in specific goals towards social competence.
• The results of both studies match the authors findings and conclusions.

• Strength/Quality
• To assess the strength and quality of the article, I utilised the Critical Appraisal Skills Programme Tool (CASP) specifically for randomised control trials. Many of the criteria was met in both articles.

SECTION A: IS THE BASIC STUDY DESIGN VALID FOR A RANDOMISED CONTROLLED TRIAL?

1. Did the study address a clearly focused research question?
2. The articles by Cotugno (2009) and Kylliainen et al (2020) both clearly addressed a focused issue as they both mention the aim of the study being to assess whether social group interventions are beneficial in improving social skills in children with autism.
3. Both articles include a population group, intervention, comparison and an outcome which is relevant to my client.
4. Was the assignment of participants to interventions randomised?
5. Randomisation was utilised in both of the studies by Cotugno (2009) and Kylliainen et al (2020).
6. It specifically mentions in both studies, how participants were drawn from a clinical sample and then divided into groups.

SECTION B: WAS THE STUDY METHODOLOGICALLY SOUND?

• • Were the participants ‘blind’ to intervention they were given?
• In both of the articles, the participants were blinded to the intervention they were given. The participants had no knowledge of whether they were receiving a new intervention or not.

• Were the investigators ‘blind’ to the intervention they were giving to participants? • Were the people assessing/analysing outcome/s ‘blinded’?

• In the articles by Cotugno (2009) and Kyllainen et al (2020), it was not specifically mentioned if investigators and people analysing and assessing outcomes were blinded.
• Were the study groups similar at the start of the randomised controlled trial?
• In the article by Kyllainen et al (2020) the study groups were similar at the beginning of the RCT. The participants age was within a small range and all participants were boys.
• In the article by Cotugno (2009), the children in the study were also aged within a small range however included both genders.
• Apart from the experimental intervention, did each study group receive the same level of care (that is, were they treated equally)?
• Both of the articles ensured that they outlined the design of the study and clearly described the objectives and the methodology. They also both included detailed information on the social group interventions implemented.

SECTION C: WHAT ARE THE RESULTS

• Were the effects of intervention reported comprehensively?
• Yes, both articles comprehensively explain
• Was the precision of the estimate of the intervention or treatment effect reported?
•  
• Do the benefits of the experimental intervention outweigh the harms and costs?
• Yes, as there was significant improvement in results in both studies.

SECTION D: WILL THE RESULTS HELP LOCALLY?

• Can the results be applied to your local population/in your context?
• Yes, the results of both studies can be used with my client. The outcomes of the studies are important, and I believe would be beneficial to my client if he would undergo this intervention. The results display significant changes in children social competence post intervention.
• One limitation that would affect my decision is that the sample sizes of both articles was fairly small. If they were larger clinical trials it would strengthen the validity of the studies.
•  

How have you contrasted and integrated the evidence findings of individual articles into one body of evidence?

RESULTS

• Confidence intervals in both articles:
• Integration of results of both articles:

INTERVENTION

• In regard to the intervention, both examined the efficacy of social competence and social skills group programs amongst children, however focused on different categories.
• The article by Kyllainen et al (2020) specifically addresses 3 main components including improving social competence, reinforcing executive functions and supporting realistic self-image and self-esteem.
• The article by Cotugno (2009) addressed 3 significant issues related to social interactions including the experience and management of stress and anxiety, joint attention and flexibility transitions
• Although all categories are relevant and related to social competence and the intervention, they are assessing different things which therefore means different results that cannot be exactly compared but rather contrasted. However, all categories addressed in both articles are related to my client.
• Cotugno (2009)’s intervention program went for 30 weeks and Kyllainen et al (2020)’s went for 39 weeks.

PARTICIPANTS/INCLUSION CRITERIA

• In regard to the participants used in both studies, the age range of the participants used are similar.
• In the article by Cotugno (2009) the participants are aged 7-11 and in the article by Kyllainen et al (2020) the participants are aged 7-12 years.
• The articles both addressed children with the ASD diagnosis.
• The inclusion criteria’s for both articles have some similarities and some differences.
• In the article by Cotugno (2009), the criteria consisted of children between the ages of 7 and 11, have a diagnosis of ASD, have obtained a full scale or verbal scale within the average range,  have no language or communication deficits and have participated in a partial inclusion program in a regular education curriculum.
• The inclusion criteria by Kyllainen et al (2020) clear symptoms or suspicion of ASD, parental commitment to the intervention and cognitive functioning in the normal or higher range.

OUTCOME MEASURES

• Different outcome measures were used in both studies.
• In the study by Kyllainen et al (2020), intervention outcomes were measured with questionnaires for parents/teachers, neuropsychological tests and observations.
• In the study by Cotugno (2009) outcome measures utilised was the Walker-McConnell Scale of Social competence and Social Adjustment (WMS) and The MGH Youth care Social competency/social skill developmental scale (SCDS) which were both used pre and post treatment.

Although these are differences and similarities when contrasting the two articles, overall, the results of implementing the intervention in both articles portrayed that social group interventions are effective in improving social deficits in children with ASD.          

What is the overall best evidence summary for your original question?

In summary, social group interventions are great and beneficial to be utilised in occupational therapy amongst children with ASD. The evidence portrayed in the articles by Cotugno (2009) and Kylliainen et al (2020) can most certainly be applied to my client Andrew. The articles present good results post intervention, significantly improving children’s social competence and skills, their join attention, ability to be flexible and transition well, anxious symptoms, reaction to peers, recognition skills and social overtures. By examining the level, quality, relevance, currency, strength and consistency of the articles it allowed me to select these articles as best evidence. Although the studies have their own limitations, overall, they provide the strong indication that social competency groups can benefit ASD children with social deficits. 

Can you estimate a clinical effect size, or range of effect from the evidence? If not, why? 

What is your clients minimal important difference (MID) for the intervention?

• I have decided to utilise the Canadian Occupational Performance Measure with my client in order to gather the minimal importance difference for the intervention.
• I worked collaboratively with my client and had discussions about what his goals are with therapy.
• Andrews main occupational performance problem is his inability to socialise.
• He scored an 8/10 in importance, demonstrating how important it is for Andrew to improve this problem he encounters difficult in. He rated his performance in socialising currently a 3 and a satisfaction score of 2.
• My client mentioned that they want to be able to socially interact with peers, connect emotionally with others, participating in cooperative play, initiate interactions, have the ability to read verbal and non-verbal cues and maintaining eye contact. He also mentioned that he wants to be able to reduce the anxious symptoms he experiences.
• At the end of the intervention I’ll be reconducting the Canadian Occupational Performance to examine whether Andrews satisfaction and performance levels improved.

How does this effect size compare to the MID?

What implications does this have for your client?

• Implementing a social group intervention for Andrew will be effective and beneficial.
• When reflecting on the results and data, implementing these interventions have been seen to significantly improve children’s social skills, those who have a diagnosis of ASD.
• The implications may be:
• That the intervention will be overwhelming for Michael as he is currently used to occupational therapy sessions being one on one and not a group setting.
• Another implication is that Michael will miss out on schoolwork as he will need to take time to be involved in the intervention.
• Finally, the intervention is costly which may be an implication for Andrews parents.

Are there any ICF contextual factors to be considered in clinical reasoning for this client?

Are there any professional or values-based influences to be considered in clinical reasoning for this client? How might you communicate your evidence-based reasoning recommendations to your client during shared decision making?

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