Toward an integrative socio-cognitive approach in autism spectrum disorder: NEAR method adaptation-study protocol.

Background: The cognitive impairments exhibited by people with ASD, threaten the development of social skills that are essential for establishing and maintaining harmonious social relationships. Cognitive remediation and social skills training are now considered as crucial therapeutic approaches in the management of these disorders. Several programs have already been validated and have shown improvements in social skills or cognitive performance. However, the effects of these training methods seem to be difficult to generalize to other everyday life. The aim of our study is to alleviate cognitive and social deficiencies by using a socio-cognitive framework to adapt the Neuropsychological Educational Approach to Remediation (NEAR) method for adolescents with ASD. Methods/design: Adolescents meeting the DSM-5 criteria for ASD, older than 13 years, and following a regular school curriculum will be recruited from clinical population at the Child and Adolescent Psychiatry in Razi University Hospital-Manouba- Tunisia. Our study is an open and non-randomized controlled trial including 30 patients: NEAR group / control group. The NEAR method combines computerized cognitive exercises and bridging groups inspired from cognitive behavioral therapy. NEAR group will be divided into three groups of five patients each. The duration of the sessions will vary according to the capacities of the participants and the exchanges between them (about 60­120 min). In our study, bridging groups will be amended by adding other tasks including planning role plays and scenarios of problematic social situations in autism, taking into account cultural particularities in order to promote social skills. Computerized exercises will be enriched by adding other tasks aiming to improve the recognition and expression of facial emotions by using digital videos and photographs expressing the six basic emotions. The duration of the program will be about 6 months. All selected patients will have an assessment of cognitive function: social cognition, neurocognition and pragmatic skills, social skills, self-esteem and global functioning at baseline, 1 week after the end of the NEAR program and 6 months later. Conclusion: This adaptive program is a promising socio-cognitive intervention that create new perspectives for adolescents with autism spectrum disorder.

Assessment of theory of mind in Tunisian verbal children with autism spectrum disorder.

The present study examined performance in Theory of Mind (ToM) in a group of 31 Arabic-speaking verbal children (7-12 years-old) with autism spectrum disorder (ASD), in comparison with neurotypical controls (NT) matched for age and for cognitive abilities. An innovative task in a digital format named "The Tunisian Social Situations Instrument" (TSSI) was used and allowed us to study four different subdomains of ToM: attribution of intention and epistemic ToM (cognitive ToM), affective ToM, and detection of faux pas (advanced ToM). Our study showed impairments in ToM in children with ASD, similar to those reported in the literature. Our findings additionally suggested that affective and advanced ToM, specifically the detection of faux pas, might be more challenging for ASD children than other components of ToM. Future studies with larger number of children may lead us to specify which subdomains are the most impaired in order to develop specific tools targeting these specific impairments.

Validation of the Tunisian Social Situation Instrument in the General Pediatric Population.

BACKGROUND: In order to better understand the deployment of the theory of mind (ToM) in Tunisian neurotypical children, we have developed a new tool of assessment of the ToM called the "Tunisian Social Situations Instrument" (TSSI). We opted for the creation of this test in view of the intercultural differences in the development of social skills. Our purpose was to validate this tool in general pediatric population. METHODS: It was a cross-sectional evaluative study that aimed to validate the TSSI in the general pediatric population. We initially conducted a beta test and a pre-validation study before taking the initial version of the TSSI on 123 neurotypical children. Then, we followed the typical validation procedure: appearance validity, content validity, construct validity, and reliability study. RESULTS: Regarding the validity of appearance, the TSSI was comprehensible and adapted to the Tunisian pediatric population. About content validity, the exploratory factor analysis extracted 6 factors that explain 69.3% of the total variance. These factors were respectively social clumsiness types 1 and 2, intention attribution, emotional ToM, epistemic ToM, and simple comprehension questions. The subdomains of social clumsiness (types 1 and 2) and emotional ToM had a Cronbach alpha higher than 0.8. This factor structure as well as the significant inter-correlation between subdomains and the global score were in favor of a good construct validity. The internal consistency study showed good reliability of the final version of the TSSI (alpha of Cronbach at 0,809). Regarding the performance of children at the TSSI, we have noticed a significant association between the global score, age, and verbal intelligence. CONCLUSION: This work offers valuable insights about ToM and provides clinicians with a reliable tool to assess social clumsiness and emotional ToM in typically developing children.

Cognitive remediation therapy in autism spectrum disorder: Tunisian experience.

BACKGROUND: Cognitive dysfunctions associated with Autism spectrum disorder (ASD) are nowadays highlighted. These cognitive impairments include mainly executive dysfunctioning and are linked with academic difficulties, thus representing one of the treatment targets. Cognitive remediation therapy (CRT) is a new promising program aiming to remediate cognitive impairments by targeting executive functions. It attempts to teach information processing strategies through guided mental exercises. AIM: To assess the effectiveness of the cognitive remediation program CRT (Cognitive Remediation Therapy) on executive abilities and school results, in children and adolescents with ASD. METHODS: Cross-sectional study involving children and adolescents with ASD according to DSM-5. The CRT program was conducted individually at the rate of one session per week of 45 minutes each.  Outcome measures were intellectual abilities, cognitive flexibility, working memory and school performance. RESULTS: Of the 25/24 patients included, 16 had reached the end of the program. Their average age was 10.87 years. The mean number of sessions performed was 22.38. After completion of CRT, patients showed significant improvement on intellectual abilities (p<10-3), phonemic fluency (p=0.032), « animal ¼ category of semantic fluency (p=0.045), working memory (p=0.001 for forward digit-span and p=0.006 for backward digit span) and school results (p=0.001). Patients made more repetitive and intrusive errors in semantic fluency with significant increase in the "clothes" semantic category (p=0.019). CONCLUSION: Cognitive remediation enhances cognition directly and positively acts on clinical course. It appears to be a relevant new method in the management of ASD. Yet, further research is required in order to confirm the efficiency of this treatment and to better define its optimal settings.