Measuring the Social Support Network in Autistic Clients

Measuring the social support network in autistic clients: development and validation of the Network in Action-Interview

Rinske M. van den Heuvel; Leo Kannerhuis, Youz (Parnassia Group), Oosterbeek, Netherlands; Lectoraat Volwaardig Leven met Autisme, HAN University of Applied Sciences, Nijmegen, Netherlands; Department of Psychology, 3University of Amsterdam, Amsterdam, Netherlands

Hilde M. Geurts1; Leo Kannerhuis, Youz (Parnassia Group), Oosterbeek, Netherlands; Department of Psychology, 3University of Amsterdam, Amsterdam, Netherlands

Michel Wensing; General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg, Germany

Jan-Pieter Teunisse; Leo Kannerhuis, Youz (Parnassia Group), Oosterbeek, Netherlands; Lectoraat Volwaardig Leven met Autisme, HAN University of Applied Sciences, Nijmegen, Netherlands

Introduction: As social relationships are intertwined with mental health recovery, it is important to address a client’s social support network during mental health interventions. This seems even more important for autistic clients, because research suggests they have, on average, smaller networks and experience more loneliness than non-autistic individuals. Therefore, an interview assessing the social support network in relation to intervention goals was co-created together with stakeholders (autistic clients, mental healthcare professionals, and a mother of an autistic client). In addition, the psychometric properties and acceptability of this Network-in-Action-Interview (NiA-I) were studied as pre-registered (AsPredicted #59767).

Methods: The Nominal Group Technique was used to co-create the NiA-I with stakeholders, and it was administered to autistic clients (n = 44) recruited in a highly specialized mental health facility.

Results: Network-in-Action-Interview social support scores were significantly correlated with the Multidimensional Scale of Perceived Social Support, indicating sufficient convergent validity. Clients and professionals reported that the NiA-I provided the therapist with greater insight into the client’s social support network. Professionals reported that the NiA-I could be improved regarding administration duration.

Discussion: This cross-sectional study shows that the NiA-I is a solid and helpful tool for including the social network in clinical practice. Addressing and including a client’s social support network is important for recovery focused mental health treatment. The NiA-I can assist professionals in taking such actions.

autism, adults, mental healthcare, social network, social support

“A person’s social support network can either promote or hinder recovery from mental health problems…Regarding social support, autistic individuals appear more vulnerable. For example, autistic adults experience more loneliness and lower levels of social support compared to non-autistic individuals, with the latter being associated with lower quality of life. Moreover, wishes related to their social networks were reported by the majority of autistic adults recruited via a mental health facility. This strengthens the need to consider the social support network during mental health interventions in autistic individuals, a group known to have an elevated prevalence of mental health problems such as depression and anxiety disorders” (p. 1). 

“However, social network interventions are not a one-size-fits all solution, as everyone has different needs which differ along the journey of recovery. Using a social network mapping tool can assist the mental healthcare professional and the autistic individual in discovering collaboratively what could help the client regarding their network in several ways… We developed the Network in Action-Questionnaire (NiA-Q). This is a digital questionnaire assessing both functional (e.g., perceived social support and interpersonal distress) and structural aspects (e.g., network size) of the social support network. These aspects are assessed in relation to the individual’s treatment goals, so the information from the NiA-Q is directly applicable to the individual’s mental health intervention… In this study, we transformed the NiA-Q into an interview version, the Network in Action-Interview (NiA-I), in collaboration with stakeholders using a structural group technique. In addition, this study investigated (1) the first psychometric properties of the newly developed NiA-I; and (2) the acceptability of the instrument to autistic clients and professionals” (p. 2). 

“Throughout the study, a project group was involved consisting of two autistic clients, a mother of an autistic client, and five healthcare professionals from diverse backgrounds working in an autism mental healthcare center. They provided input during the development of the NiA-I, on recruitment strategies, and on content of the acceptability measures… All autistic clients and their therapists were recruited via a highly specialized autism mental health facility in the Netherlands. The client population is characterized by having co-occurring conditions besides a clinical diagnosis of an autism spectrum disorder (ASD), and they have often had previous treatment that was unsuccessful” (p. 2-3).

“The results indicate that the NiA-I is a sufficiently valid, reliable, and acceptable instrument to assess the social support network in clinical practice in autistic individuals. The results of acceptability ratings from clients and professionals showed that the NiA-I was considered relevant by the majority of both clients and therapists. Still, we have two suggestions to increase the usefulness of the NiA-I. First, it would be interesting to further explore the characteristics of clients for whom the NiA-I might be most beneficial, in order to better predict to whom and when this instrument is indicated. Second, the perceived usefulness for clients could be improved by adding a more comprehensive explanation of how the social support system can contribute to mental health recovery so that individuals could more easily relate the NiA-I outcomes to their own situation” (p. 6).

“The NiA-I provided the therapist with more insight into the client’s social support network, which is an important goal of the instrument. However, the acceptability ratings of professionals also indicated that the NiA-I could be improved regarding administration duration and how the interview fits within current clinical practice” (p. 6).

“The convergent validity analysis indicates that the NiA-I and MSPSS (Zimet et al., 1988) social support scores are sufficiently associated but do also differ. A first explanation is that the MSPSS might focus more on emotional aspects of social support than on concrete or informational support, as previously noted by others (Tracy and Whittaker, 1990), whereas the NiA-I explicitly asks about both emotional, informational, and practical support in relation to intervention goals” (p. 6).

Enhancing Client Insight: The NiA-I helps autistic clients gain a clearer understanding of their social network. By visualizing their relationships and support systems through sociograms and structured questions, clients are better able to articulate needs and identify patterns of support or hindrance in their lives.

Improving Clinical Relevance: Because the NiA-I assesses social support specifically in the context of intervention goals, it yields information that is directly applicable to treatment planning. This allows clinicians to tailor interventions more precisely and align them with clients' support structures.

Supporting Personalized Care: The tool enables a personalized, recovery-oriented approach to mental health care by factoring in each client’s unique social environment and treatment goals. This is especially important for autistic individuals, who often have specific preferences and needs related to social interactions

Fostering Network-Oriented Practice: NiA-I can serve as a foundation for network-inclusive practices, such as involving key support persons in treatment planning or forming resource groups. This supports a more systemic and empowering approach to care.

Practical Implementation in Routine Care: The NiA-I can be integrated into ongoing therapy with minimal additional training. Though time-intensive, therapists found it informative and useful, suggesting value in offering both full and shortened versions depending on clinical context.

“There are some limitations to keep in mind when interpreting the results of this study. First of all, this study included a relatively limited number of participants, so the psychometric properties of the NiA-I should also be evaluated in a larger sample. Future studies could assess other psychometric properties besides convergent validity and internal consistency. An interesting avenue for further research would be to explore predictive validity, for instance, by examining whether NiA-I scores are associated with recovery progress or perceived loneliness over time. A second limitation is that participants were not randomly selected, but were approached if their therapist expected a NiA-I to be relevant to them or if the client was interested in participating. This might have influenced the acceptability results. However, a nuance here is that a clinician in regular clinical practice will also first make a clinical judgment before administering the NiA-I to a client. 

Strengths of the study are that different types of stakeholders were involved in the development of the interview. Additionally, we used a structured group approach in the development process using NGT (Delbecq and Van de Ven, 1971), which encouraged all participants of the project group to give their input in an equal manner. To conclude, it is important to provide attention to social support and involve the social network during mental health interventions, especially in autistic clients given vulnerabilities in this area. The NiA-I provides a tool to practically implement this aim into the clinical working routine, resulting in greater understanding of wishes, needs and opportunities within the client’s social support network for both therapist and client” (p. 7).