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Napat Sittanomai, M.D.*, Elizabeth Laugeson, PsyD.**, Sasitorn Chantaratin, M.D.*, Jariya Tarugsa, M.D.*,

Duangduean Sainampran, M.Sc.*, Vipavee Sathirangkul, M.Sc.*, Suvimon Apinantanakul, M.Ed.*, Nattawee

Songrujirat, R.N.*, Vitharon Boon-yasidhi, M.D.*

*Division of Child and Adolescent Psychiatry, Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700,

ailand. **UCLA PEERS® Clinic, Semel Institute for Neuroscience and Human Behavior, University of California Los Angeles, Los Angeles, CA, USA.

Social Skills Training Using the Thai Version of

UCLA PEERS

in Thai Adolescents with Autism

Spectrum Disorder

ABSTRACT

Objective: To study the feasibility and eectiveness of the ai version of UCLA PEERS® in ai adolescents with

autism spectrum disorder (ASD).

Materials and Methods: e UCLA PEERS® was modied to t with ai culture. Twelve adolescents, aged 11-19

years old, with ASD participated in this modied 10-session weekly group intervention during March to October

2015 at Siriraj Hospital, Bangkok, ailand. Feasibility was assessed by parent satisfaction and session attendance

rate. Eectiveness was assessed by social skills improvement rated by parents, Vineland Adaptive Behavior Scales

(VABS), the Children’s Depression Inventory (CDI), and the Clinical Global Impression-Improvement Scale (CGI-I).

Results: All enrolled participants completed the study. Parents’ satisfaction with the program was 81.92%. e

session attendance rates ranged from 83.3 to 100%. At the end of intervention, all of the skills trained in the program

were rated as improved by at least half of parents. At 4-month follow-up, all but two skills (entering conversation

and handling bullying) were still reported as improved by more than 50% of parents. VABS raw scores signicantly

increased in the domain of communication (95% condence interval (CI): -2.25 to -0.89; p=0.036), daily living skills

(95% CI: -3.70 to -0.47; p=0.016), and socialization (95% CI: -1.77 to -0.40; p=0.005), and signicantly decreased

in maladaptive behaviors domain (95% CI: 0.24 to 2.10; p=0.002). Six adolescents had CGI-I scores of very much

improved or much improved.

Conclusion: e ai version of UCLA PEERS® is a feasible and eective social skills intervention for ai adolescents

with ASD.

Keywords: Social skills training; Program for the Education and Enrichment of Relational Skills (PEERS®); ai

adolescents; autism spectrum disorder (Siriraj Med J 2021; 73: 471-477)

Corresponding author: Vitharon Boon-yasidhi

E-mail: vitharon.boo@mahidol.ac.th

Received 12 March 2021 Revised 12 May 2021 Accepted 31 May 2021

ORCID ID: http://orcid.org/0000-0002-6573-8044

http://dx.doi.org/10.33192/Smj.2021.61

INTRODUCTION

Autism spectrum disorder (ASD) is a neurodevelopmental

disorder characterized by decits in social communication

and restricted, repetitive patterns of behavior and interests,

as well as impairments in multiple other areas.

Social

skills decit is one of major areas of impairment in ASD,

particularly in adolescence. Diculty in achieving social

competence can adversely impact peer acceptance, and

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472

may lead to anxiety, depression, and low self-esteem.

erefore, an eective social skills training intervention

should be part of a comprehensive treatment plan for

adolescents with ASD.

While there have been no well-studied social skills

training interventions available for ASD patients in

ailand, a multidisciplinary care team at Siriraj Hospital

initiated a pilot program of social skills intervention

for adolescents with ASD, using the UCLA Program

for the Education and Enrichment of Relational Skills

(PEERS®) developed by researchers from University of

California, Los Angeles (UCLA). e program has been

systematically proven in dierent cultural and linguistic

contexts.

It is a manualized 14- weekly sessions treatment

employing various evidence-based strategies to teach

social skills to adolescents with ASD, and emphasizing

parental involvement in coaching the adolescents.

4,5

Our

group modied the UCLA PEERS® to suite with ai

culture. e objective of this pilot study was to assess

the feasibility and eectiveness of this modied (ai)

version of UCLA PEERS® in ai adolescents with ASD.

MATERIALS AND METHODS

Participants

Twelve adolescents with ASD, aged 11-19 years

old, and their parents participated in a 10-week ai

version of UCLA PEERS® at the Division of Child and

Adolescent Psychiatry, Department of Pediatrics, Faculty

of Medicine Siriraj Hospital, from March to October

2015. All participants were previously given a diagnosis

of ASD by a certied child and adolescent psychiatrist.

To be eligible to the program, participants must have an

ability to communicate verbally, an intelligence quotient

(IQ) above the intellectual disability level (>70), and no

comorbid severe psychiatric or medical conditions. is

study was approved by the Siriraj Institutional Review

Board (Si 267/2017).

Intervention

Prior to the intervention, the researchers conducted

a brief survey in the participating parents to explore the

participants’ social skills decits related to the skills listed

in the original UCLA PEERS® manual.

Modications

were then made according to the decit social skills in

the participants and ai cultural context. e number

of intervention sessions was changed from the original

14 to 10, accordingly.

Some of the modications made were as follow: (1)

in the session focusing on electronic communication,

didactic content related to making phone calls and leaving

voice messages was substituted with communication

networks popular among ai adolescents (e.g., Facebook,

LINE, and Instagram); (2) the homework assignment to

have a get-together, possibly in one’s home, was changed

to a “going out” with friends in settings outside of the

home, since home-based get-togethers are less common

in ailand; and (3) the period of time conducting the

intervention was changed from during school days to during

summer vacation in order to circumnavigate problems

associated with school schedules and transportation

diculty in Bangkok. A description of the intervention

content in targeted lessons is outlined in Table 1.

e adolescents were participating in this modied

10-session weekly group intervention led by the investigators,

one of whom (NS) received a UCLA PEERS® provider

certication. Each weekly session consisted of a 90-minute

adolescent group and a separate 60-minute parent group.

e session included a lesson on targeted social skills, and

a homework assignment to promote the generalization

of the learned skills to real-life settings. Aer the rst

week, each session started with a review of the assigned

homework from the previous session, followed by didactic

teaching and demonstrated role playing, and behavior-

oriented rehearsal exercises to practice newly learned

skills. e investigators met aer each weekly session

to review the intervention process, and to make minor

adjustments to the intervention manual according to

the observed responses of the participants.

Measurements

Demographic and clinical data were collected from

medical records and parent intake records.

Participation and parent satisfaction

Participation in the program was abstracted from

weekly participation logs. Aer the intervention was

completed, parents were asked to rate their satisfaction

with the program on a 5-point Likert scale (5 indicating

the most satisfaction).

Parent report of changes in social skills

Parents were asked to rate the changes in their

child’s social skills relative to each of the 10 targeted

lessons (as improved, unchanged, or worse) at the end

of intervention and at 4-month follow-up.

Vineland Adaptive Behavior Scales (VABS)

e VABS measures adaptive behavior skills needed

for everyday living in the domains of motor skills,

communication skills, daily living skills, and socialization,

and a separate domain of maladaptive behaviors, with

test-retest reliability of 0.8-0.9.

Higher scores represent

better adaptive functioning. e VABS was administered

through a parent interview by a clinical psychologist at

baseline and at the end of intervention.

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TABLE 1. Topics and Abbreviated Content of the ai PEERS®

Session Targeted Lessons Contents Homework

 1 Sharingofinformation Sharinginformationwithpeerstond Practicingsharing

   acommoninterest informationonthephonewith

    anassignedgroupmember

 2 Two-waycommunication Keyelementsofhavingatwo-way Practicingsharinginformation

   conversationwithpeers onthephonewithan

   Parentsidentifyteenactivitiesthatcould assignedgroupmember

   leadtopotentialsourcesoffriendship

 3 Electroniccommunication Appropriateuseofelectronicandonline Beginningtopursue

  andchoosingappropriate communication(e.g.,telephone,email, extracurricularactivities,

  friends LINE,Facebook,Twitter,Instagram,and andsharinginformationwith

   Skype) membersofthisgroup

   Parentsandteensidentifyinterest-based

   extracurricularactivitiesthatcouldleadto

   potentialsourcesoffriendship

 4 PeerentryI:Entering Precisestepstoenteringconversations Practicingentering

  conversations withpeers conversationswithpeers

 5 PeerentryII:Exiting Assessmentofpeerreceptivenesswhen Practicingenteringandexiting

  conversations enteringaconversation,andhowtoexit conversationswithpeers

   aconversationwhennotbeingaccepted

 6 Goodsportsmanship Therulesofgoodsportsmanship Practicinggood

sportsmanship at home

 7 RejectionI:Teasingand Howtoappropriatelyrespondtoteasing Practicingcopingwithteasing

  embarrassingfeedback Howtodifferentiatebetweenteasingand appropriatelyinrelevant

  frompeers embarrassingfeedback,andhowto situations

   modulateyourresponse

 8 RejectionII:Physical Strategiesforcopingwithphysicalbullying Practicingnewstrategiesfor

  bullyingandchanging andhowtochangeabadreputation copingwithbullyingand 

  abadreputation  physicalthreatsinrelevant

    situations

 9 Goodsportsmanship Goodsportsmanshiprehearsal Practicinggood

  practicum:Playingchairball  sportsmanship

 10 Copingwithdisagreements Elementsnecessaryforresolving Practicingcopingwith

  &programconclusion argumentsanddisagreementswithpeers argumentswithparentsand

    peersviatherole-playing

    exerciseinrelevantsituations

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Children’s Depression Inventory (CDI)-ai version

e Children’s Depression Inventory (CDI) consists of

27 self-reported items measuring symptoms of depression

in children and adolescents aged 7-17 years.

Each item

is scored from 0 to 2 to dene the severity of depressive

symptoms within the past two weeks. e higher the

scores indicate more severe depressive symptoms. In

this study, the participants completed the ai version

of the CDI

, at baseline and the end of intervention.

Clinical Global Impression (CGI) scale

e CGI is a clinician-rated 7-point scale for rating

global improvement in the patient’s illness. e CGI-I rates

the patient’s illness improvement or decline relative to the

patient’s baseline, as follows: 1 = very much improved;

2 = much improved; 3 = minimally improved; 4 = no

change; 5 = minimally worse; 6 = much worse; and, 7 =

very much worse

. e CGI-I was administered aer

the intervention was completed.

Statistical analysis

Demographic and clinical data were analyzed and

described using descriptive statistics. Pre- and post-

intervention scores were analyzed using either paired

t-test or a Chi-square test, and results are shown as

either number with percentage or mean ± standard

deviation. Data analyses were performed using PASW

Statistics version 18.0 (SPSS, Inc., Chicago, IL, USA). A

p-value less than 0.05 was regarded as being statistically

signicant.

RESULTS

Participant’s mean age was 14.8 years (range: 11-

18), and 83.8% were male (Table 2). Nine participants

had comorbid psychiatric diagnoses (4 ADHD, 4 anxiety

disorders, and 2 mood disorders). Participants had a

mean IQ of 94.7±20.21 and a baseline VABS score of

58.75±16.90. e three most common reported social

TABLE 2. Demographic and Clinical Characteristics of the Enrolled Adolescents (N=12)

Characteristics

Age(yrs),mean±SD(range) 14.8±1.99(11-18)

Malegender,n(%) 10(83.8%)

Livingwithbiologicalparents,n(%) 12(100%)

Father’seducation,n(%)

Highschoolorlower 4(33.3%)

University 8(66.7%)

Mother’seducation,n(%)

Highschoolorlower 3(25.0%)

University 9(75.0%)

Familymonthlyincome(Thaibaht),n(%)

10,000-50,000 6(50.0%)

>50,000 6(50.0%)

Numberofsiblings,n(%)

0  3(25.0%)

1  6(50.0%)

2  3(25.0%)

Numberofyearsreceivingtreatment,mean±SD 6.80±4.93

Educationalstage,n(%)

Elementary 3(25.0%)

Secondary 9(75.0%)

Note. SD = standard deviation; CGI-S = Clinical Global Impression-Severity scale.

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skill problems were peer rejection, inability to handle

disagreements with peers, and diculty developing

friendships.

Participation and parent satisfaction

All participants completed the program. e session

attendance rates ranged from 83.3% to 100%, and the

individual participant attendance rates ranged from

70% to 100%. e rate of homework completion was

60%. e average parent satisfaction score was 4.10

out of 5. Common reasons for the satisfaction included

applicability of the program content, structured home

practice, and parent coaching guidance.

Outcome measurements

Data specic to social skills reported as improved

by the parents are shown in Table 3. All of the 10 social

skills trained in the program were rated as improved by

at least half of the parents. e skills rated as improved

by the highest percentage of parents (83.3%) included

trading information, two-way communication, and good

sportsmanship. At the 4-month follow-up, all but two

skills (entering conversation and coping with physical

bullying) were still reported as improved by more than

50% of parents.

Post-intervention CGI-I was rated as very much

improved or much improved in 6 adolescents (50%).

Mean CDI scores decreased from 18.08 at baseline to

16 at post-intervention; however, the change was not

statistically signicant (p=0.345).

Signicant improvements were observed in the raw

scores of the VABS in the daily living skill domain, the

socialization domain, and the communication domain

(p’s < 0.05). e maladaptive behavioral domain score

decreased signicantly from 5.33 to 4.17 (p< 0.05). Changes

in the VABS domain scores aer the intervention are

shown in Table 4.

DISCUSSION

is study examined the feasibility and eectiveness

of the ai version of UCLA PEERS®, a parent-assisted

social skills intervention, in 12 ai adolescents with

TABLE 3. Social Skills Reported as Improved by Parents of Adolescent Participants

Skills

After 10

session (N=12) At 4-month follow-up (N=9)

n (%) n (%)

Sharingofinformation 10(83.3%) 5(55.6%)

Two-waycommunication 10(83.3%) 7(77.8%)

Electroniccommunicationandchoosing 8(66.7%) 5(55.6%)

appropriatefriends

PeerentryI:Enteringconversations 6(50.0%) 2(22.2%)

PeerentryII:Exitingconversations 6(50.0%) 6(66.7%)

Goodsportsmanship 6(50.0%) 5(55.6%)

RejectionI:Teasingandembarrassing 9(75.0%) 5(55.6%)

feedbackfrompeers

RejectionII:Bullyingandchangingabadreputation 9(75.0%) 4(44.4%)

Goodsportsmanshippracticum:Playingchairball 10(83.3%) 7(77.8%)

Copingwithdisagreements 9(75.0%) 5(55.6%)

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ASD. To our knowledge, this is the rst study of parent-

assisted social skills training program in adolescents

with autism in ailand. We found a high attendance

rate (>80% attendance with no dropouts) and high

parent’s satisfaction. We also found improvements of the

participant’s social skills aer the intervention, measured

by parent report, VABS, and CGI-I.

e high participation rate and high parent satisfaction

demonstrates feasibility of the ai version of UCLA

PEERS® in ai adolescents with ASD. is might be

due to the fact that this intervention emphasizes parental

involvement in the social skills training process in everyday

living, and the skills taught in the program address the

common social problems reported by parents. e program

includes several activities that have been proven eective

for teaching social skills to children and adolescents with

ASD. Moreover, the evidence-based strategies used in

the program were modied to t with ai culture and

social context.

Eectiveness of this intervention is demonstrated by

the improvement of the participant’s social skills reported

by parent and the CGI-I rated by treating psychiatrists. It

is also supported by more objective measures of adaptive

functioning on the VABS, which revealed improvements

in socialization and other adaptive domains, as well as

a decrease in maladaptive behaviors. Our ndings are

consistent with other studies on eectiveness of the PEERS®

intervention in the USA and other countries.

11-14

While

other studies demonstrated a decrease in depression

score

, post-intervention CDI scores did not decrease

signicantly in the present study, possibly due to lack

of power related to small sample size. e participant’s

CDI scores were not signicantly elevated at baseline.

Furthermore, the commitment by parents to participate in

the training and to coach their children was encouraging,

and would be expected to have positively inuenced

the observed improvement in social skills in this study.

Conversely, the eectiveness of ai PEERS® for youth

whose parents do not fully participate in treatment is

unknown and requires further investigation.

It was also observed that the areas of social skills

with the highest percentage of improvement according

to parent reports, such as coping with rejection, good

sportsmanship, and coping with disagreement, were

the skills identified to be the most problematic by

parents at baseline. is suggests that the contents of

the intervention are well-suited to meet the needs of

the parents. e dierence in the percentage of parents

TABLE 4. Pre- and Post-Intervention Domains on the Vineland Adaptive Behavior Scales

Measurement Pre-intervention Post-intervention p-values 95% CI

Dailylivingskillsdomain 131.83 133.92 .016 [-3.697,-0.470]

Personal 71.67 71.92 .082 [-0.537,0.037]

Domestic 21.83 22.33 .026 [-0.928,-0.072]

Community 38.33 39.67 .031 [-2.525,-0.142]

Socializationdomain 89.50 90.58 .005 [-1.772,-0.395]

Interpersonalrelationships 37.75 37.83 .777 [-0.716,0.550]

Playandleisuretime 26.25 26.83 .027 [-1.087,-0.080]

Copingskills 25.83 26.08 .082 [-0.537,0.037]

Communicationdomain 116.08 117.25 .036 [-2.245,-0.89]

Adaptivebehaviorcomposite 58.75 59.67 .255 [-2.597,0.763]

Maladaptivebehaviordomain 5.33 4.17 .019 [0.235,2.099]

Note. CI = condence interval.

p-values < .05 are in boldface, indicating statistical signicance.

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that reported improvement in each skill is likely due

to session attendance. More specically, parents and

adolescents that didn’t attend a certain session would

presumably have been less likely to report improvement

for that training topic. We found that more than 50% of

the parents still reported improvements in most of the

trained social skills at 4-month follow-up, suggesting this

social skill intervention program has some long-term

eects. However, since the percentage of improved cases

decreased, continued parent coaching and/or boosting

interventions may be required to enhance the sustainability

of the social skills improvement.

is study has some limitations. First, the sample

size was small and there was no control group. Second,

the improvement in social skills reported by parents was

subjective, which renders the present study vulnerable to

some potential parent bias. ird, information from other

sources, such as teachers or parents/caregiver unaliated

with the program was not collected. Lastly, other co-

occurring interventions that could have contributed to

improvements in social skills were not controlled in the

current study.

Despite these limitations, this study demonstrates

that the ai version of UCLA PEERS® is feasible in ai

adolescents with ASD and this intervention is eective

in improving social skills in this population. Future

studies using larger randomized controlled trials with

independent raters, more objective measures, and longer

follow-up assessment periods would further elucidate

the eectiveness of this intervention.

ACKNOWLEDGMENTS

e authors gratefully acknowledge the adolescents

and their parents for participating in this study. We

would like to express our gratitude to Julaporn Pooliam

of the Division of Clinical Epidemiology, Department of

Research and Development, Faculty of Medicine Siriraj

Hospital for her assistance with statistical analysis.

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