Dr Elizabeth Laugeson Hi, I’m Doctor Elizabeth Laugeson, and I’m a Clinical Professor at the UCLA School of Medicine, and I’m very happy to be here today to tell you a little bit about the science of making friends for autistic youth, and specifically we’ll be talking about the UCLA PEERS programme. Now, I want to begin with just this really brief disclosure statement. It is important for me to mention that I do receive book royalties from Taylor and Francis, and Wiley & Sons for the sales of my books, and I also receive research funding from the National Institutes of Health, the Administration for Community Living, and also, Autism Speaks. Now, in terms of what I was hoping to discuss today, I wanted to begin with talking about what are some of the common social challenges among autistic youth, and some of the consequences of these challenges. I’ll give you a little overview of the PEERS intervention, as well as giving you some strategies today for things like how to meet new people and, you know, enter conversations, as well as how to handle things like teasing and bullying. And then we’ll wrap up the talk with talking a little bit about some of our research outcomes in PEERS, including a comparison study looking at telehealth delivery versus in-person delivery. We’ll round things out with some final resources. So, in terms of, you know, thinking about what are some of the common challenges among autistic youth, we know that poor social communication can sometimes be a difficulty for autistic youth. And this might include things like difficulty with topic initiation or knowing what to talk about, it could involve very repetitive themes in conversations and talking about the same thing repeatedly, and even having things like one-sided conversations. And so, when trying to help, you know, autistic youth with making and keeping friends, this will have to be, sort of, a target in our treatment. We also know that many of our young people might struggle with things like poor social awareness, and this might involve, you know, difficulty understanding social cues. They may also have less constructive social engagement, that might involve things like, you know, less involvement in extra-curricular activities, or clubs, sports, places where they might meet people. There can also be a greater tendency to do things like, you know, maybe barging into conversations or being off-topic, things that are maybe seen as intrusive by peers. So, again, this will be – have to be an area that we’ll target in this type of intervention. We also know that poor social cognition can be a challenge for many autistic youth, and so this is really just difficulty with perspective-taking, knowing how to anticipate how someone might think, or feel, or react in a given situation. So again, this will have to be something we target in our, you know, development of these skills. But finally, you know, just the bottom line is that a lot of autistic youth do report difficulty with developing close, meaningful friendships with others, and it’s often that, you know, they have that desire, they want to make friends, but they often don’t know how to make friends. So, the consequences of some of these social challenges is that there’s a greater risk of things like peer rejection during adolescence, and that peer rejection has a lot of significant consequences. So, we happen to know, not just within the field of autism research, but just in research in general for adolescents, we know that peer rejection is one of the strongest predictors of mental health problems later in life. So, things like depression and anxiety are significantly, you know, impacted, and very much related to things like peer rejection. If you want to predict who’s going to be depressed or anxious, you know, later in life, go into a typical secondary, you know, educational setting and look for the kids who are being rejected, and that will be one of the strongest predictors. We also know that peer rejection is very much related to things like feelings of loneliness and poor self-esteem, even substance abuse, poor academic performance, early withdrawal from school, school dropouts, very much predicted by peer rejection. And really also at its worst, you know, suicidal ideation and suicide attempts, also strongly predicted by peer rejection. So, there’s a lot of reasons why this is an area that we need to focus on, particularly during adolescence. Now, the focus of this talk is about autistic youth, but truthfully, it’s not just autistic youth that are struggling socially. So, this graph represents what we call peer sociometric data, and the research comes out of North America, it’s kind of an aggregate, a number of studies have looked into categories of peer acceptance among adolescents. And what they do in this research is they’ll go into a typical middle school or high school and they’ll ask kids to identify who they’re friends with, you know, who they like, maybe they don’t like, and they’ve discovered in this research that about half of kids are doing fairly well socially, they’re, kind of, in the average range of peer acceptance. They have friends, they’re not necessarily popular, but they’re doing well. Then you get about another 15 to 17% of kids who are considered popular. Now, popular doesn’t necessarily mean well liked, it means well known, so you can actually get some pretty controversial kids in there as well. You can get some bullies and gossips, but these are just kids that are, sort of, well known among their peers. Then you have about 15% of kids who are considered peer rejected, these are the kids who are actively seeking out their peers, but they’re actively getting pushed away. They might be teased or bullied, they might have bad reputations with their peers, and then on top of that you have another 15% of kids who are socially neglected. So, these are the kids who aren’t even trying to socially engage their peers. They’re often seen as shy or timid, kind of withdrawn, and they often go unnoticed. So, what this research tells us is that in any typical middle school or high school, in at least North America, one third of kids are struggling socially, right? It’s not just autistic youth that are struggling socially, and in PEERS, which is a programme that I developed back at UCLA in 2004, this programme, you know, initially started in helping autistic youth with making and keeping friends. But really the programme has evolved a lot over these last 20 years, and we don’t just work with autistic youth, we work with anyone who’s struggling socially that wants to learn the skills that we’re teaching. And so, the programme initially started though as an adolescent programme, was parent-assisted, we had parents come and act as social coaches to their kids while their kids were learning about making and keeping friends. That programme evolved into a school-based curriculum where we’re teaching these strategies in the school setting, again, for adolescents. From there we discovered, you know, a lot of the skills we’re teaching adolescents, they apply to adults too, and that led to the PEERS for Young Adults programme, and now this programme has evolved to the point where it’s used in over 150 countries and has been translated into over a dozen languages. And these are just some of the manuals that are publicly available, that focus on the PEERS curriculum. We also have PEERS for Preschoolers which is – will be the next published manual to come out sometime in 2023, and then we also have some programmes that we’re researching currently, PEERS for Careers, which is what it sounds like, a college to career transition programme, and also PEERS for Dating. So, lots of interesting programmes, but really what makes PEERS unique from other programmes is that it’s one of the only evidence-based or research-supported programmes that’s publicly available. It’s also unique in that it has this parent or caregiver-assisted model where there’s some type of social coach that’s going through the programme in tandem with the young person. We’re also unique in that in PEERS we’re only teaching ecologically valid social skills. So, we’re not teaching what we think that young people should do in social situations. We’re teaching what we know actually works, based on research, and so I’m going to give you some examples of how that plays out in this curriculum. And then finally, PEERS is unique in that it’s one of the few cross-culturally validated programmes used, again, across the globe. Now, in terms of the skills that we teach, you know, depending on the programme, at least for adolescents and adults we focus a lot on friendship skills and even romantic relationship skills in our Young Adult programme. So this would include things like finding and choosing appropriate friends, or romantic partners in our Young Adult programme. We teach conversational skills, things like starting, entering and even exiting conversations. We’ll talk about electronic communication, you know, appropriate use of humour, as well as things like good sportsmanship and having get-togethers with friends. I mentioned in our Young Adult programme we also have sessions on dating etiquette, so that would include things like letting someone know that you like them, or flirting, you know, asking someone on a date, kind of, just general dating dos and don’ts. So, that’s all the making and keeping friends, you know, romantic partners skills, but then we also have this other side of the programme that focuses on managing conflict and rejection. So, in dating etiquette for adults that would be things like taking no for an answer, or politely turning someone down, maybe even handling unwanted dating pressure from a partner. But in friendships it involves things like handling arguments and disagreements, even changing a bad reputation with our peers, and then handling all the different forms of direct and indirect bullying. And so, really the research tells us that there’s four types of bullying. So, two of those types are more direct bullying, that would include things like teasing or name-calling, and also physical bullying, which would be more aggressive. The more indirect forms of bullying are things like cyberbullying, or even rumours and gossip, and so of course because there’s – those are four very different behaviours we’re going to have completely different strategies, based on the type of bullying. Okay, so before I get into some of the strategies that we teach in PEERS, I think it’s also important to talk about the role of neurodiversity, and the importance of social motivation in programmes like PEERS. So, sometimes people get the impression that, you know, things like social skills training programmes, if you want to call it that, are about changing a person somehow, changing who they are. I actually more believe that learning and using social strategies really should be, first of all, voluntary and, you know, that participants need to be intrinsically motivated, you know, to learn these new ways of interacting with other people, because we have to consider the role of neurodiversity and these different ways of thinking. But learning new kinds of social strategies really should not be about changing a person, that’s not the point of this, right? Instead, using these social strategies should be about enhancing our social interactions with others so that people can appreciate us for who we already are, right? You don’t have to change the person, right, it’s just enhancing those interactions. I also would argue that it’s really not ethical to force social skills or social strategies on people who don’t want to learn them, right? It’s not going to work, first of all, but it’s just not ethical to do that. But I would also argue that it’s not ethical to deny the opportunity to learn these social strategies to people who want to learn them. So, important caveat to think about when you’re thinking about this type of intervention. Alright, so I want to give you a little snapshot of some of the skills that we teach in PEERS, and one of the skills relates to how to meet new people. And it was interesting, and we discovered in our research over the many years is that really well-intentioned adults will sometimes give really bad advice when it comes to social interactions and, you know, I don’t think they realise the advice that they’re giving maybe isn’t so helpful. So, we often ask young people the question, you know, “What do most adults tell young people to do to meet new people?” Right, so imagine it’s, you know, it’s the first day of school, you’ve never met anyone, you know, what are adults likely to tell you to do? Alright, well you can probably imagine, they’re often told to go up and say hi, or go up and introduce themselves, right? I think we’ve all heard that advice before, but have we ever thought about what that would look like? You know, imagine that it’s my first day at school, I’ve never met this group of people, and I walk up and say, “Hi, I’m Liz,” right, what are they going to think of me? They’re going to think I’m, kind of, weird, that’s, sort of, a random thing to do. It’s not actually ecologically valid, right? Ecological validity is important when you’re thinking about something like social skills, right? You want to make sure that what you’re teaching works in reality. You want to teach what people who are successful at entering conversations are doing. And so, very important to be thinking about the importance of that, ‘cause I think a lot of social skills interventions don’t do that. They often teach a lot of what adults think that young people should do, rather than what works in reality. So, we have a whole method for how we teach these social strategies in PEERS, and it involves a lot of roleplaying demonstrations, right? So that’s where we’re acting out certain behaviours, and we don’t only show the appropriate examples, the ecologically valid, we also have to show the, kind of, inappropriate examples. The things that aren’t likely to lead to successful, you know, in this case, peer entry, right, they’re not likely to want to talk to us if we do this thing. So, we’ll start with that example first, right? So, in this video you’re going to see a group of people talking, and then you’re going to see someone enter the sca – the shot there, and her name is Elina. I want you to watch this roleplay and think about what Elina is doing wrong as she enters this conversation. [Beginning of Video] [Girl 1 Hey, Darina, you’ll never guess, I saw Gabe at my favourite sushi restaurant this weekend. Darina No way, what restaurant was it? Girl 1 And just the one right around the corner. Darina Oh, I’ve been meaning to try that place. Girl 1 Yeah. Gabe Yeah, it’s so close-by. I feel bad that I’d never gone, but I went, and it was so good. Darina Nice, what did you guys get? Gabe I got the spicy tuna with crispy rice. Darina Hmmm, yeah. Girl 1 Yeah, it looked awesome, and I just… Elina Have you guys ever been roller-skating? Girl 1 Sorry. I just got a regular salmon roll. Elina There’s this new skate park that just opened up, it’s really fun. Darina I’m sorry, what did you get? Girl 1 Just the salmon roll. Darina Oh. Girl 1 It was plain, but it’s so good. Elina They have a Thursday night student night. A lot of people go to it. Girl 1 Sorry… Darina I’ve been meaning to go there. Girl 1 & Gabe Yeah. Darina I really wanted to try it out. Elina It’s really, really fun. Girl 1 & Gabe Yeah. Elina There’s also this other place by the beach… Gabe What would you get if you went? Elina …that I’ve been roller-skating. Darina I’m sorry, what? Gabe What would you get if you went? Elina It’s really cool. Darina I… Elina It’s like right by the water, and lots of people go.] [End of Video] Dr Elizabeth Laugeson Alright, so we would timeout that roleplay and we would ask our young people, you know, “What did Elina do wrong in that situation?” right, and it’s, kind of, comical, like, they’re laughing at the video and everything, it’s pretty funny, ‘cause what she’s doing, it’s clearly not working, and so they’ll say, “Well, she just barged in, you know, she was talking about roller-skating and they were talking about sushi.” And so, then I would ask, you know, “Did it seem like they wanted to talk to her?” and they would say, “Well, no,” and then I would ask, “Well, you know, how could you tell?” And so the thing is, is that a lot of people when you ask, you know, “How can you tell if you’re accepted or not accepted in a conversation?” many people will say it’s a feeling that you get. But in reality, not everybody gets that feeling, and if we do get that feeling, we’re usually picking up on some concrete behaviours that give us the feeling, right? So, what would the group be doing if they wanted to talk to me, and what would they do with their eyes? Well, they’d be looking at me, right, and not rolling their eyes or making a face. And what would they be doing with their bodies? Well, they would be facing me, right? Not turned away, given the cold shoulder, and they would actually be talking to me and not giving rude remarks or rude replies. These are the three behavioural signs that tell us if people want to talk to us, right? You can just ask yourself, “Are they looking at me? Are they facing me? Are they talking to me?” You don’t have to rely on the feeling, you can rely on the behaviours. So, in that example they definitely were not doing those things. They weren’t looking at Elina, except, kind of, to look at her strangely, like, with confusion, right? They weren’t what we call opening the circle, right? They didn’t open that circle to let her talk, they weren’t turning towards her, and they certainly weren’t talking to her. So, now we have to get into that perspective-taking and that social cognition piece, right? We have to get into the mind of that group. What was that like for the group? Well, it was probably, kind of, annoying, maybe a little frustrating. They were trying to talk to each other and this person’s interrupting them, maybe even a little confusing, right? Really awkward. Would they want to talk to Elina again after that, or what do they even think of her? They probably think she’s a little strange, right? That maybe she’s a little intrusive, a little odd, and maybe a little clueless, she’s not, you know, picking up on the signs that they’re not interested. And, you know, no offense, but would they want to talk to her again? I mean, probably not, right? I mean that wasn’t a good way to meet people, right? It was kind of intrusive, and might even result in further rejection, maybe even result in a bad reputation if we do that frequently with people. So, instead what we want to do is we want to teach what people who’ve been successful at entering conversations will do and, you know, it’s interesting, this is something that you all maybe naturally do, but maybe didn’t think about it, right? So, what’s the first thing that we do with our ears if we’re trying to join a conversation? Should be listening, right? Figure out what they’re talking about, and sort of watching from a distance, you know, showing some interest, but you don’t want to be, like, staring at the group, that’s kind of creepy, right? So, instead people will use a prop, like a phone, like, look at a text message or something, or some reading material, in which you’re, kind of, looking distracted in some way, because really what you’re doing is you’re eavesdropping, but you don’t want to look like you’re eavesdropping, so you use this prop. And as you’re listening to this conversation, you’re really trying to identify the topic, right? Figure out what they’re talking about, and really make sure that you have some kind of common interest. You know, if they’re talking about something that you really don’t know anything about it’s, kind of, risky to join that conversation ‘cause you might slow that conversation down, right? It might be, kind of, boring for them, maybe boring for you, so you should probably share some kind of common interest with the topic. Now, let’s say you find that common interest, now you want to join, well, you’re not going to just yell from across the room, right? You need to move a little bit closer. What’s the appropriate distance? Most people will say an appropriate distance in conversations is no closer than about an arm’s length away, right? When it’s not a global pandemic, about an arm’s length away is usually appropriate, and then you’re going to mention the topic, right? But before you even mention the topic you, kind of, have to wait for something, right, ‘cause you don’t want to barge into the conversation. So, most people will wait for a little pause in the conversation. It doesn’t have to be a perfect pause. It’s usually the best time to join is when one person stops talking and another person is starting to talk, and that’s where you, kind of – you mention that topic, right, whatever they’re talking about. You can do that in one of three ways. You can either make a comment about what they’re talking about, you can ask a question about what they’re talking about, or you could give a compliment, right, about what they’re talking about, but it’s got to be on-topic. Then right away we have to start assessing their interest, right? Are they looking at us? You know, are they are facing us? Are they talking to us? Did they open that circle? That’s a buzz phrase, by the way, that we use to describe when we’re accepted into a conversation. I don’t know if you’ve ever noticed before, but when people talk in groups they often talk in a circle, right? So, what do they do with the circle when they want to talk to you? They open the circle, right? What do they do when they don’t want to talk to us? They close the circle, right? They give the cold shoulder. So, that’s what we’re, sort of, looking at to assess interest. Now, if things are going well, they seem interested in us, and we’ve never met them before, then we can introduce ourselves, and how do we do that? “By the way, I’m Liz,” or, “I don’t think we’ve met before, I’m Liz,” but it’s optional, you don’t have to do that, and again, if there are going to be introductions, they come later in the conversation. They don’t begin the conversation. Alright, so if we’re following the formula for teaching these, you know, strategies, we showed an inappropriate example first of what not to do. It’s, kind of, a common social error that a lot of our young people might make. We did some perspective-taking around what was wrong with that, then we taught these, sort of, ecologically valid strategies or steps for entering a conversation, but it’s not just enough to talk about those steps, you have to see what they look like. So, of course the next step in teaching the skill is to show it, to show a roleplay of what this is supposed to look like. So, I would introduce this roleplay by saying, “Watch this roleplay, and think about what Elina is doing right this time in entering this conversation.” [Beginning of Video] [Girl 1 So, Darina, you’ll never guess, I saw Gabe at my favourite sushi restaurant this weekend. Darina Nice, what restaurant was it? Girl 1 And just the one right round the corner. Darina Oh, I’ve been meaning to check that place out. Girl 1 Hmmm. Gabe Yeah, it’s so close-by and I’d never gone, but I went, it was really good. Darina Cool, what did you guys get? Gabe I got a spicy tuna roll and I loved it. Darina Ooh, yum. Elina You got the spicy tuna roll? That’s what I always get. Gabe Yeah, how good is it? Elina It’s so good there. Have you guys tried the rainbow roll there? Girl 1 I haven’t. Gabe I Haven’t. Girl 1 No, I actually got the salmon roll. Elina Oh okay, that’s good too… Girl 1 Yeah. Elina …but I think the rainbow roll’s, like, their specialty. Gabe I’ll try it. Girl 1 Cool. Elina Yeah. Gabe If you were going to go, what’d you get? Darina I would pick the California roll, it’s my favourite. Girl 1 Hmmm hmm. Elina I tried that one there actually, it’s really good. Darina Oh nice. Girl 1 Nice.] [End of Video] Dr Elizabeth Laugeson Alright, so then I would timeout that roleplay, I would ask what Elina did right this time, and we would go through all the different steps that she followed, and then do some perspective-taking. So, first of all, did it seem like the group wanted to talk to her this time? And they’ll say, “Yes, they did,” and then I’ll ask, “Well, how could you tell?” right? Well, this time they were looking at her, right? They were facing her. They were talking to her. They opened that circle. So, what was that like for the group? Well, it was nice, right? It was interesting, pleasant. And what did they think of Elina this time? She seemed nice, right? She seemed friendly, and would they want to talk to her again? Yeah, probably. This is actually how people meet new people. It’s not by going up and saying, “Hi,” and introducing yourself, it’s actually by entering conversations with people. Alright, so in terms of thinking about the next step for how to learn this skill, again, not just enough to talk about the skill or even to see the skill, you actually have to practice this strategy. And so this is where, in our groups, we would have each of our young people practice entering conversations with other group members, following these steps. And then, in order to generalise that new strategy outside of our group, we would have a homework assignment to practice this. And because we include parents and other caregivers as social coaches, those social coaches would be out there in the real world providing some support around the utilisation or the practicing of these skills. Alright, so another strategy that I wanted to share with you that relates to the skills that we teach in PEERS focuses on handling teasing. And so this is another example of where really well-intentioned adults will sometimes give pretty bad advice about how to handle teasing. Okay, so think about that, I ask every group of young people that I work with what they’re told to do in response to teasing, and they always say the same three responses. They say that they’re told to ignore, they also mention that they’re told to walk away, or they’re told to someone, like tell an adult if it’s a teenager. Then I ask them if those strategies work, and do you want to guess what they say? They say, “No, they often don’t work.” Well, why is that? Well, they’re not really ecologically valid, right? Think about that. Imagine if somebody is teasing me and I ignore them, what will they do? Well, they’ll keep teasing me, right, and I look, sort of, weak because I didn’t do anything, so I’m more likely to get teased, right? What if I walk away, what will they do? Well, they’ll follow me, right, and keep teasing me, and again I, sort of, look weak because I didn’t do anything. I’m making it easy for them, I’m more likely to get teased in the future. Now, imagine I go tell someone, I go tell a Teacher, right, now what do they want to do? Well, now they want to retaliate against me, they want to get back at me. I tried to get them in trouble. I am more likely to get teased by that person. So, these are not ecologically valid strategies, and don’t feel bad if you’ve told kids to do that. Guess what? Everybody tells kids to do that, I mean, across the globe. We train people over 150 countries, guess what? All over the globe kids are told to do the same thing, ignore, walk away, tell an adult, and it just doesn’t work, unfortunately. So, instead what we want to do is we want to do what kids who have been successful at stopping that teasing, what have they done? We want to teach that. Well, first thing we have to do is get into the mind of the teaser, right? What does the teaser want us to do? Well, they want to get a reaction out of us, right? They want to make us mad, or sad, or upset in some way, they want us to tease back, like it’s fun. Those are not good strategies, because you’re making it fun for the teaser if you give that reaction. So, instead, what kids who are successful at escaping the teasing do is something quite simple. They just, sort of, act like what the person said didn’t bother them, and that in fact what they said was maybe even, kind of, stupid, and it’s just a very short comeback, right? So, kind of depending on where you live in the world there might be some cultural differences, but at least in a lot of English-speaking countries they’ll say things like, you know, “Whatever,” or, “Anyway,” or, “Am I supposed to care?” “Was that supposed to be funny?” “So what?” “You know, big deal.” “Who cares?” “And your point is?” Or, “Yeah, and?” And they roll their eyes, and they shrug their shoulders, and they act like what the person said didn’t bother them. And there’s, sort of, different ways of doing this, right? They could, sort of, sound bored, or indifferent, or they might, kind of, have a little attitude, a little dramatic flair. To use an example of that, so someone sounding bored might say, like, you know, “Whatever,” and then someone with a little bit more dramatic flair, someone with a little bit more attitude, might say something like, “Whatever.” You know, whatever it is, whatever your personality wants to do, both of those work, both strategies, but it’s giving the impression that what the person said didn’t bother us, right? It wasn’t funny, and that makes it not fun for the teaser. In fact it, kind of, embarrasses the teaser a little bit, which is what you want, right? You want them to not have fun teasing you. And then after you’ve given, you know, a couple or a few comebacks if that’s needed, then you can remove yourself, then you can walk away, or turn away or start talking to someone else. But you never want to do those things without first giving the impression that what the person said didn’t bother you. Okay, so I want to show an example of what this looks like, and in this roleplay we’re going to see Gabe being teased, and I want you to watch to see what Gabe does right in handling this teasing. [Beginning of Video] Boy Hey dweeb, reading again? Gabe Whatever. Boy You’re such a loser, you’re always reading. Gabe Am I supposed to care? Boy Yeah, because everyone thinks you’re a loser. Gabe Anyway.] [End of Video] Dr Elizabeth Laugeson Okay, so we would timeout, we’d ask what Gabe did right there. Now, notice in this example we’re just showing the appropriate response, right? And the reason is, the reason we don’t show the inappropriate example, is that could actually be very emotionally triggering for some of our young people, to see someone get teased and get upset, and so we’re not trying to trigger tha – those emotions, instead we’re just showing the appropriate example. And we’ve got to get into the mind of that teaser, right? So what was that like for the person teasing Gabe? Not very gratifying, right? I mean, not what he expected. And what did he think of Gabe? Wasn’t really bothered, right? And would he want to tease him again? I mean, probably not, it wasn’t really fun to tease him. So, again, you know, of course if we want to teach this new social strategy, it’s not just enough to talk about it and to see it, the next step of course is to practice this. So, we’ll have all of the teens practice using these comebacks, and then we’ll have assignments to, kind of, practice outside of the group as well. Alright, well, that’s a little snapshot of some of the skills that we teach in PEERS and what I want to do now is segue into talking a little bit about some of our research outcomes, so you can get a sense of what to expect from this programme. As I mentioned earlier, you know, PEERS is one of the few evidence-based social skills interventions out there, and it’s publicly available, which is also rather rare, and so it’s been used quite a bit, again, across the globe, and this is a study that was not conducted by my group at UCLA. It was actually conducted at UC San Francisco, University of California San Francisco, and it was published in 2021 in the Journal of Autism and Developmental Disorders, and this is a meta-analysis using PEERS for Adolescents. Now, in this study, they started with over 1,300 research articles and narrowed it down to about a dozen that focused on using the PEERS Curriculum for Adolescents. And they only included empirically, you know, supported programmes and programmes that had some kind of an empirical design with a pre/post comparison. They also made sure that there were the appropriate outcomes it was focused on, you know, making and keeping friends, or improving social functioning. They, again, narrowed it down to about a dozen articles, and what they did in this meta-analysis is they looked at effect sizes. So, effect sizes tell you how meaningful the relationship is between variables, okay? So, a large effect size is at .8 or larger, and that tells you that the research findings have some kind of practical significance, okay? Small effect sizes, which are at .2 or less, indicate that there’s very limited practical application, and then a medium effect size would be around .5. So, the first thing that they looked at in this meta-analysis was the improvement in social skills knowledge following PEERS, and again, this is PEERS for Adolescents and they were looking specifically at autistic adolescents. And so they found in this part of the research, large effect sizes across numerous studies. I also wanted to report in this domain around social skills knowledge, just, kind of, give you an example of what the improvements look like. So I’m also including, on the right there, a bar graph of – comparing the outcomes in improvement in social skills knowledge in the PEERS condition, to a control condition, this would be a like a wait list control condition, and this is the change in scores from pre to post-test. So, definitely they’re learning the skills, in those who received the PEERS intervention, and again, across studies we’re seeing large effect sizes there. Now, they also looked at overall social skills, using a measure called the Social Skills Improvement System by Gresham and Elliott, and this is, kind of, considered to be the gold standard for assessing social functioning in adolescents. And here we see medium to large effect sizes across the various studies, and typically what we see, if you take a look at the bar graph on the right, we’ll typically see almost a full standard deviation change from pre to post-test in PEERS. And so what that means is – and this is a measure that uses what are called ‘standard scores’. Standard scores have a mean or an average of 100, and a standard deviation of 15, meaning 15 points above or below that mean is pretty significant. And here we see almost a 12-point standard score improvement from pre to post-test in the PEERS condition, with very little happening in that control condition. They also looked at social responsiveness in the study, using the Social Responsiveness Scale developed by John Constantino at Wash U, and here – this is an – what was once called an autism screening tool, I don’t know that it’s actually just for autistic youth, and we use it for lots of youth, but what they found here were changes that were medium to large effect sizes across the various studies. And you see in the bar graph here on the right that we see a full standard deviation typically in improved social responsiveness in the PEERS condition. This is a scale that uses T-scores. T-scores have a mean or an average of 50, and a standard deviation of ten, and here we’re seeing, again, almost a 12-point T-score improvement from pre to post-test in the PEERS condition, with very little happening in that wait list control condition. And then finally, in this meta-analysis they looked at social engagement, both according to teen report, as well as parent report. And so this is looking at the number of get-togethers in the previous month, that’s how we measure social engagement in our programmes. And here what you’re seeing is a little bit more variability, there’s anywhere from small to large effect sizes. Now, the large can go up to, like, 1.27, and really large effect sizes, and then there’s the smaller effect sizes. And what I found very interesting about this, and I’m not sure that it’s mentioned in the paper, but when I look at the studies that had the small effect sizes in social engagement, they are in cultures where there’s a lot of variability in social engagement. So, for example the Schum et al. paper took place in Hong Kong, and the Rabin paper took place in Israel, the Yoo paper took place in South Korea, and these are places where kids don’t have get-togethers as frequently as you might see in North America or other parts of the world. They’re just not as common, for kids to have those types of get-togethers. So it may not even be an ecologically valid assessment of social engagement in those parts of the world and I find that, kind of, interesting. But still we see small to large effect sizes across social engagement measures. And if you look at the bar graph on the right, this is a typical outcome in our programmes at UCLA. We typically will see that kids will have anywhere from four to five additional get-togethers in the previous month following PEERS in the treatment condition, with very little happening in the wait list control condition. So, the next study I wanted to share with you relates to in-person delivery of PEERS versus telehealth. So, you know, obviously, during the pandemic, you know, a lot of services, mental health services had to be moved, really, had to pivot to this remote delivery or telehealth delivery. And that really happened globally, and so there was very little research, prior to the pandemic, about the efficacy or the effectiveness of this telehealth delivery, and so we wanted to study that during the pandemic, and that’s what we did in this study. This was comparing in-person to telehealth and really the difference in structure was both programmes were 16 weeks in length. They were 90-minute weekly lessons, just the telehealth was conducted over Zoom. The content was very similar across the programmes, the only difference really was that we did add some modified or new content for online social skills. Most kids, during the pandemic, were socialising with their friends online, they couldn’t meet up in person, and so we had to add some new content about online social skills. In our in-person groups, we typically will do live roleplays, but in telehealth we were using the video roleplays that you just saw earlier. But we still do behaviour rehearsals and practice in the groups, but for telehealth that was in a Zoom breakout room, versus in-person that was live and in small groups. And then both groups included weekly homework assignments, the only difference was that in telehealth we added an assignment to have an in-group get-together. So, what that means is, is that historically in PEERS we had, sort of, a no-fraternisation policy during the group, meaning that group members were not supposed to socialise with each other outside of the group. We wanted them to learn how to make friends, you know, outside of our group, and then they could be friends after if they wanted to. During the pandemic though, we did add this additional assignment to have an in-group get-together where they were practicing some of those skills with another group member that we assigned them to, so that’s a little bit different. Alright, so the first thing we looked at in the study was, you know, was telehealth even efficacious, did it work? So, we just, kind of, looked at it on its own, from pre to post-test. This is looking at the Social Responsiveness Scale, and remember that because this is, sort of, an autism screener, if you will, higher scores indicate greater impairment in social responsiveness. And so you want the scores to go down, and we see from pre to post-test in the telehealth group that in fact we saw almost that full standard deviation change from pre to post-test. They went from, kind of, this upper moderate, almost severe type of symptoms related to poor social responsiveness to a more, kind of, mild range, at the moderate upper, like, limits. In terms of looking at social skills knowledge, we also saw a nice improvement from pre to post-test in the telehealth groups. Again, both of these findings are statistically significant. We looked at overall social skills on the Social Skills Improvement System, and there we see another ten-point standard score improvement from pre to post-test. Notice that when they came into our programme they were, kind of, in the below average range of social skills, and when they leave the programme, they’re, kind of, more in the average range. Again, really good outcomes for telehealth. This is looking at that same measure, but according to problem behaviours, which also significantly decreased in the telehealth group. And then, finally, we looked at social engagement, so the number of get-togethers that teens were reporting. On average, they were reporting having about five additional get-togethers in the previous month, and also parents were reporting a similar trend, about five additional get-togethers in the previous month. So, telehealth is looking good, right? Everything is coming out statistically significant, so the next question is well, how does telehealth compare to in-person delivery of PEERS? Alright, so the blue line here is the telehealth group, and the yellow line is the in-person group, and you can see that they’re perfectly in line with one another. This is the Social Responsiveness Scale, and we’re seeing really dramatic decreases in symptoms related to poor social responsiveness from pre to post-test. So, both looking quite good, and no significant differences between those outcomes. This is looking at the social skills knowledge of teens pre and post-PEERS for both telehealth and in-person, and again, perfectly in line. They are able to learn the skills at the same rate, whether it be remote delivery or in-person. This next graph represents social skills on the Social Skills Improvement System, and again, you can see that both groups are improving at similar rates, and they are not statistically significantly different. Same with problem behaviour, seeing the same types of decreases in those areas, nothing statistically significant across telehealth or in-person delivery. And then finally, this is looking at social engagement and the number of get-togethers in the previous month, and you’re seeing that telehealth appears to be outperforming in-person. But we have to remember too that we had that additional in-group get-together, remember, where we’re assigning group members to hang out socially online to practice some of the skills for our telehealth groups. And so they were going to have an additional potentially for get-togethers a month with those in-group get-togethers, and that’s reflected here. But they’re still not statistically significant between telehealth and in-person and I think if you were to remove those get-togethers that were in-group get-togethers, that you would see some similar results across the groups. Same thing with parents, parents were also reporting significant improvements across telehealth and in-person. Again, telehealth appears to be outperforming a bit, but again, that’s because of those in-group get-togethers, but there are no statistically significant differences across the groups. They’re both doing quite well. Alright, so, wrapping things up I did want to share with you some of the new directions that we’re taking this work, and also some resources. And so, we – during the pandemic we were quite fortunate that we were able to continue our research, and were conducting three randomised controlled trials simultaneously in our PEERS clinic at UCLA. One was focused on PEERS for Careers, which is a college-to-career transition programme for autistic adults. It’s a 20-week programme that teaches the soft skills related to finding, obtaining and maintaining employment. And what we were looking at in this study was the impact of this peer-mediated career coaching. So, half of our sample was randomly assigned to receive a career coach, which was an undergraduate or graduate student interested in providing career coaching to neurodivergent adults. We trained them in how to do that, but everybody received the intervention, and this was all conducted over Zoom during the pandemic. And so, we are in the process of writing up the results from this study, but we did actually complete the study with over 100 adults on the autism spectrum. I’m very excited to be sharing that in the very near future. We also have PEERS for Dating, which is what it sounds like, it’s a programme helping autistic adults learn to develop and maintain romantic relationships. It’s a 16-week curriculum, and it’s peer-mediated, again, where peers are acting as dating coaches, and again, the variable that we’re looking at here is what is the impact of that peer coaching, essentially? So, half of the group is randomly assigned to receive a dating coach, the other half is not, but everybody receives the intervention. This was also conducted over telehealth via Zoom during the pandemic, and we are now just in our final weeks of our very last cohort where we enrolled over 100 adults on the autism spectrum. Finally, a third randomised controlled trial that we’ve been conducting during the pandemic and beyond is PEERS L-Dopa. So this is a clinical trial for autistic teens and adults that is using the drug L-Dopa in conjunction with the PEERS intervention. So, L – you may be familiar with the drug L-Dopa, it’s used for Parkinson’s patients, and it increases the amount of dopamine in the brain. So, dopamine is this naturally occurring, you know, substance in the brain that’s very much related to feelings of reward and pleasure. And so the idea here was if we could increase the amount of dopamine in the brain, in conjunction with social skills interventions, could we actually make socialisation more rewarding? And so, we’re comparing L-Dopa to a placebo. And so, more to come on that, but I think a, kind of, interesting study as well. In terms of clinical services that we provide at the UCLA PEERS clinic, we have ongoing groups for adults. We offer both in-person options and telehealth options, throughout the year, as a clinical service. People come and receive the intervention through their insurance or, you know, through managed healthcare. We also have programmes for adolescents, all of these programmes are either parent or caregiver-assisted, but again, we have in-person and remote options. We also have educational groups that are open worldwide. We discovered, during the pandemic, that there were a lot of people that wanted to come to our programmes at UCLA and telehealth made that option a possibility for people wherever they were on the planet. But this programme is offered more as an educational class because it’s not something that you could do through managed healthcare across borders in that way. And so, we have an online social skills class for making and keeping friends, and also for dating, both open to adolescents and also to adults. And, you know, even though a lot of our research has focused on neurodivergent youth, all of these programmes are really open to anybody who wants to learn the skills, so we have a lot of people with ADHD, depression, anxiety, maybe no diagnosis at all, they just want to learn the skills, like everybody else. And so, again, it’s really not specific to autistic youth. Finally, we also have PEERS for Preschoolers, so this is a programme for kids four to six years of age, focusing on making and keeping friends, and so we have in-person options, as well as telehealth options that are parent-only. And so, in the parent-only option children are not attending the Zoom classes, but parents are learning how to be good social coaches to their kids, to improve their ability to make and keep friends. Now, I wanted to share with you some other resources that we have at UCLA. We conduct weekend boot camps. These are two-day intensive topical boot camps that teach a lot of the skills we teach in our clinical programme. So, we have a conversation boot camp, a friendship boot camp, we have a bully-proofing boot camp, a dating boot camp, and an online dating boot camp, and these are open to both adults, to children, teens, and – as well as professionals and parents. And so, they’re offered five times a year at UCLA, in-person, they meet on a Saturday and a Sunday from 900am to 300pm, this is, sort of, a different delivery option for families that maybe can’t commit to one of our longer 16-week programmes. And we’re currently submitting a grant to test and compare our tele – our – sorry, our in-person delivery of PEERS to these weekend workshops, if you will, to see if there’s any difference in outcomes. We also have a PEERS Virtual Boot Camp, so this is available through a YouTube channel that never expires. There are 35 pre-recorded episodes that cover all of the skills that we teach in PEERS in Adolescents and in our Young Adult programme, and in this way families can, kind of, go at their own pace and review the material again, but again, it’s offered over a YouTube channel that never expires. We also have a number of free resources through the UCLA PEERS clinic, this is one of them. This is our roleplay video library that we created with over 100 roleplay videos, like the ones that you just saw in this presentation, that anyone can access. And you can just use this QR code or go to the UCLA PEERS clinic website and find this in the resources page, but we want to make that resource available to anyone interested. Additionally, we also have a free PEERS app. This is an app that you can find in either the Apple Store, I guess is what you call it, right, for iOS devices, and the App Store, and also for Android devices. But basically this app works as, kind of, like a videogame where you go through these different levels and the first level is on conversational skills and it teaches all the skills that we teach in our curriculum with roleplay videos to accompany the lesson. And then, at the end of the lesson, there’s a little quiz that you take, and then there’s some suggested homework assignments to practice the skills, and then you can advance to the next level. And so there are 16 levels in this app and they focus on things like making and keeping friends, and also, there’s a little bit of content on dating etiquette as well. So this, again, is a free resource. We also have a book that I wrote called The Science of Making Friends, which is really meant for families who maybe can’t access a PEERS programme, or maybe just want to learn a little bit more about the skills that we teach, without going through an actual group, and so each chapter represents a different set of skills that we teach in PEERS. There’s parent sections that are, kind of, narrative and provide social coaching tips. There’s also teen and young adult chapter summaries that are, you know, a little bit more kid-friendly, if you will, and there’s even a DVD companion that goes with this with roleplay videos and lots of chapter exercises to practice the skills. Finally, if you haven’t checked out this series on Netflix, Love on the Spectrum, this is a series that started in Australia and it’s expanded to the US now. I think they just won three Emmys for the US series, but the very first season of Love on the Spectrum in Australia features a PEERS dating boot camp that I conducted in Sydney, Australia, with some of the cast members. So, if you want to see more about our boot camps, and in particular the dating boot camp, this is a great resource, and also, just a very lovely show that might interest you. Finally, we also have regular trainings that we conduct over Zoom at UCLA. These are offered five times a year, and so we have these three-day certified teleconferences in April and in November every year for our Teen parent-assisted programme. We also do twice a year, three-day certified trainings for the PEERS for Young Adults programme, and that’s always held in September and in February, and then every June, we do certified training in our school-based curriculum for adolescents. So if you want more information about that, definitely check out our website to get more information. Meanwhile, I just want to end with thanking this amazing team that I have the honour and the privilege to work with at UCLA. It’s – you know, I feel very lucky to be able to represent our programme in talks like this but, you know, it’s a huge collaborative effort, and so these are some of the people that are responsible for the work that we do. Lots of brilliant Research Assistants, amazing administrative support, and lots of research collaborators, and also very generous funders that we’re very grateful to. So, I will leave you with our contact information. This is – our social media handle is @UCLAPEERS, you can find us on Facebook, Twitter and Instagram. Always check out our website as well if you want more information, or if you’d like to contact us via email, you’re also welcome to do that. But once again I want to thank the Association for Child and Adolescent Mental Health for the opportunity to present to you today, and I wish you all the very best of luck. Thank you.