The efficacy of social skills treatment for children with Asperger Syndrome.
Children with Asperger Syndrome present with significant social skills deficits, which may contribute to clinical problems such as anxiety, depression, and/or other behavioral disorders. This article provides a description of the nature of Asperger Syndrome and provides possible treatment interventions, specifically focusing on the efficacy of social skills programs in clinic and school populations.
Asperger Syndrome (AS) is a chronic condition that affects an individual's social, emotional, and adaptive functioning. Treatment is complex and multifaceted, and may be long term. While the treatment of Asperger Syndrome can include individual and family psychotherapy, psychopharmacology, special education, occupational therapy, and speech and language therapy, the focus of this article is on group Social Skills Training.
Difficulties in social skill acquisition and generalization are often the most significant challenge for children with AS. Socialization deficits can result in significant hardships including an inability to meet the demands of everyday life and difficulty fulfilling vocational and social relationship aspirations (Klin & Volkmar, 2003). Failure to intervene could result in symptoms of depression, anxiety, or behavior disorders (Barnhill, 2001). Social skills treatment is a well documented important intervention for children with AS (Attwood, 1998; 2000; 2003; Bock, 2001; Klin, Sparrow, Marans, Carter, & Volkmar, 2000; Kransy, Williams, Provencal, & Ozonoff, 2003; Myles & Simpson, 2001; Myles, 2003), although little empirical evidence exists to support this premise (Greenway, 2000; Gresham, Sugai, & Horner, 2001).
For the few studies that do exist there has been some suggestion that social skills treatment is effective. However, problems exist in creating and evaluating treatment interventions that are reliably effective and valid. Inclusionary and exclusionary criteria for the disorder are difficult to establish. For example, there is little clinical consensus on the diagnostic criteria for AS, with the exception of nomenclature from the Diagnostic and Statistical Manual of Mental Disorders, text revision (DSM-IV-TR) (American Psychiatric Association, 2000), and on the nature of how, and if, these disorders differ from Autistic Disorder (AD). There are also problems inherent in studying this type of special population, particularly due to the small numbers of individuals affected, which creates statistical problems for any empirical study. Instruments to evaluate outcome, as it pertains to a child's social skill ability, are also difficult to utilize due to the low sensitivity of these instruments to detect change and the lack of specificity to the area of social skill that the treatment may be targeting. Determining which social skill area to be addressed can also be challenging, as each child's functioning will vary. This paper will review Asperger Disorder, its characteristics and assessment, as well as research on social skills treatment for children with AS. It will also provide recommendations for future research and study.
In 1944, Hans Asperger identified a small group of children, adolescents, and adults who exhibited social peculiarities and socially isolative behavior, while appearing cognitively and linguistically typical (as cited in Myles & Simpson, 2002). In particular, he described four boys, ages six to 11 who had impairments in nonverbal communication, comprehension of affect, and behavioral and conduct problems. Wing (1981) later coined the term "Asperger Syndrome," adding other dimensions to Asperger's original observations and proposing that formal diagnostic criteria be developed to support the increasing number of clinical accounts.
An increasing number of individuals have been diagnosed with AS (Ehlers & Gillberg, 1993). The mean age for a diagnosis of AS is approximately eight years old (Eisenmajer, Prior, Leekham, Wing, Gould, Welham, & Ong, 1996). Although the DSM-IV-TR (APA, 2000) does not provide reliable prevalence rates, AS has been estimated to occur in as many as 48 per 10,000 children. In 1989, Gillberg and Gillberg estimated prevalence rates to be about 10 to 26 per 10,000, based on a review of existing literature. In a later study, Ehlers and Gillberg (1993) noted that the prevalence might be higher, approximately 71 in 10,000 children (97 in 10,000 for boys and 44 in 10,000 for girls). Fombonne and Tidmarsh (2003), however, noted that the prevalence rate could be as low as 2 per 10,000, although they warned that few surveys of AS have been performed to date, and prevalence estimates can vary enormously, perhaps reflecting differences in methodology between studies and differing diagnostic criteria.
Characteristics of the Syndrome
Asperger Syndrome is currently understood as "a developmental disorder characterized by significant difficulties in social interaction and emotional relatedness and by unusual patterns of narrow interests and unique stereotyped behavior" (Church, Alisanski, & Amanullah, 2000, p. 12). The diagnosis of Asperger's Disorder was first added to the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, fourth edition (APA, 1994) as a Pervasive Developmental Disorder. The primary diagnostic criteria were listed as "severe and sustained impairment in social interaction and the development of restricted, repetitive patters of behavior interests and activities" (p. 75). Further criteria included significant impairment in nonverbal behaviors such as eye contact, facial expressions, body postures and social gestures; failure to develop appropriate peer relationships, lack of spontaneous seeking to share enjoyment and lack of social\emotional reciprocity (i.e., sharing interests, achievements, etc.). In addition, the following behaviors were noted: repetitive and stereotypical behaviors, restricted interests and activities, abnormal preoccupation with certain topics of interest, rigidity in rituals or routines, motor mannerisms (i.e., complex whole-body movements, or hand or finger flapping or twisting), and persistent preoccupation with parts of wholes). While there is not a clinically significant delay in language, there is a deficit in pragmatic language (the function or social use of language, used in conversation, turn-taking, etc.), as well as nonverbal communication (i.e., social interaction, gestures, facial expression, eye contact, and/or body posture) (APA, 1994, p. 77). These symptoms are consistent with diagnostic criteria presented in the most current version of the DSM-IV-TR (APA, 2000).
There is a lack of consensus in the literature concerning language delays in Asperger Syndrome. Some authors report no history of language delay (Ghaziuddin & Mountain-Kimchi, 2004; Starr, Szatmari, Brysion & Zwaigenbaum, 2003), while Attwood (1998) suggests that about 50 percent of children with Asperger Syndrome are delayed in the development of speech, but do talk by age five. Starr and colleagues (2003) report that children with AS demonstrate difficulties in the areas of pragmatics (use of language in a social context), prosody (the melody of speech) and nonverbal communication. They may lack an understanding of idioms and display literal interpretations. They tend to use pedantic speech, idiosyncratic words, vocalization of thoughts, and have difficulties in auditory discrimination and verbal fluency. Their rate of speech may be unusual or may lack fluency, and there is often poor modulation of volume, although inflection and tone may not be as marked as in autism. Speech is often tangential and circumstantial, conveying a looseness of association and incoherence. Communication style is also characterized by marked verbosity. Cognitively, these individuals amass a large amount of factual information about a topic of interest. This interest can interfere with learning in general because it may absorb too much of the child's attention and motivation and impede the child's ability to engage in reciprocal social exchanges (Klin & Volkmar, 2003; Tantam, 1988).
Children with Asperger Syndrome also display motor clumsiness (Smith, 2000). Gillberg and Billstedt (2000) noted that motor disorders, specifically, Developmental Coordination Disorder (DCC), are relatively common in AS. These deficits include clumsiness and abnormal gait patterns (for example, they may not swing their arms when walking or running). They may also have difficulty in learning to ride a bike, in playing ball games, throwing, catching, and kicking (Attwood, 1998). Tantam also found deficiencies in the AS group on balance, copying a meaningless hand gesture, and flexing the terminal joining of a finger in imitating (Tantam, 1988). He also indicated that children with AS may also have poor fine motor skills, especially in tying shoelaces and handwriting (Tantam, 1988). However, Ghaziuddin, Tsai, and Ghaziuddin (1992) reported that the presence of poor coordination, may not be a differentiating factor between AS and HFA.
Individuals with Asperger Syndrome may also respond differently to sensory stimuli than do typical children (Gillberg & Billstedt, 2000). They may have a high pain threshold, but a low threshold for other sensory stimuli. For example, they may not be able to tolerate high pitched or complex sounds or sudden or unexpected noises and may be overly sensitive to certain fabrics, articles of clothing, food textures or tastes and odors (Dunn, Saiter, & Rinner, 2002).
Little is known about the cognitive abilities of students with AS (Myles & Simpson, 2002), although the DSM-IV-TR (APA, 2000) posits normal intellectual and language development as necessary for a diagnosis of AS. Individuals with Asperger Syndrome typically exhibit normal cognitive ability with performance on intelligence tests characterized by high verbal scores and lower nonverbal scores (Ehlers, Nyden, Gillberg, Dahlgren-Sandberg, Dahlgren, Hjelmquist, & Oden, 1997; Klin, Volkmar, Sparrow, Cichetti, & Rourke, 1995; Ghaziuddin & Mountain-Kimchi, 2004; Ozonoff, South, & Miller, 2000). However, Barnhill, Hagiwara, Myles, and Simpson's (2000) results were contradictory. They studied the cognitive profiles (most used the Wechsler Intelligence Scale for Children--Third Edition, 1991) of 37 children (ages 3 to 15 years) diagnosed with AS and found no significant difference between their Verbal and Performance IQ scores.
Barnhill et al. (2000) noted that there did not appear to be a distinctive cognitive profile for individuals with AS, but rather behavioral and academic characteristics served as better diagnostic indicators. Subjects obtained high scores on the Block Design (good nonverbal reasoning and visual-motor-spatial integration), Information (general knowledge and long-term recall), Similarities (verbal conceptualization), and Vocabulary (good range of knowledge or information and memory) subtests. Low scores were found on the Coding, Arithmetic (poor visual-motor coordination and distractibility, respectively), and Comprehension (poor social judgment) subtests. The low scores on Coding were attributed to distractibility, poor pencil control, disinterest, lethargy, excessive concern to detail, or visual memory difficulties. Barnhill et al. (2000) also found that average intellectual criteria, deemed necessary for a diagnosis of AS, according to the DSM-IV-TR, may not necessarily be true in all cases of individuals exhibiting similar symptoms. The academic profile of children with AS is highly variable.
Academically, children with AS or high functioning autism may have difficulties in reading, especially reading comprehension (Goldstein, Minshew & Seigel, 1994; O'Connor & Klein, 2004). However, some children may develop hyperlexia (Snowling & Frith, 1986), which is a highly developed word recognition, without accompanying reading comprehension abilities. This may be particularly evident in adolescents where the inferential demands may be greater than for younger students (Goldstein et al., 1994).
Individuals with AS have been identified as having difficulty with "theory of mind" tasks. That is, they lack an understanding and appreciation of the feelings, thoughts, needs, and intentions of others, how their behavior impacts others, and the meaning of reciprocity in relationships (Baron-Cohen, Leslie, & Frith, 1985). From about the age of four, typically developing children understand that other people have thoughts, knowledge, beliefs, and desires that influence and explain their behavior. Conversely, children with AS have difficulty conceptualizing and appreciating the thoughts and feelings of another person. This deficit has a major impact on the child's social reasoning skills and behavior. For example, they may struggle to determine whether someone's thoughts or actions are intentional or accidental (Attwood, 2000).
Individuals with AS may find themselves socially isolated, although they are not usually withdrawn in the presence of other people. They may approach others in an inappropriate or eccentric fashion, initiating long-winded and pedantic conversations about their favorite topics (i.e., trains, math, dinosaurs, etc.) with little regard for the other person's interest. They are unable to move past these awkward approaches and may appear insensitive to others' feelings, intentions, and nonverbal communication. They may be able to describe correctly, in a cognitive and formal fashion, other people's (or their own) emotions; however, they are unable to act on this knowledge in an intuitive and spontaneous manner (Klin & Volmar, 2003).
Most individuals with AS have an awareness of being "different" from others. Self-esteem problems are common, particularly among adolescents with AS (Myles & Simpson, 2002). As children move into adolescence and then young adulthood, they may experience increasingly more stress as conflict with social norms becomes more complex. They may become more vulnerable to anxiety and/or depression (Barnhill, 2001). Barnhill found that social failure was positively correlated with depression. The greater the depression, the more that students with AS attributed their social problems to their ability and effort. Family tension may also contribute to emotional problems for an individual in the autism spectrum (Tantam, 2000).
Individuals with AS may express their distress in various ways (Kim, Szatmari, Bryson, Streiner, & Wilson, 2000). They may have a strong awareness of their need for contact with others or a desire for closeness. Nevertheless, they may cope with environmental stress by withdrawing or isolating themselves from other people, even family members. Other individuals with AS might not be affected by their isolative tendencies and prefer to maintain distance. Likewise, the same emotional difficulties, which could result in depression in one AS individual, may lead to frustration and antisocial behavior in another. One factor that may mediate this expression of distress is the degree of empathy a person with AS experiences with others. Anxiety disorders are a particularly common expression of distress, which may be more apparent by observation of their external behaviors (i.e., rituals) than by self-report. However, a diagnosis of anxiety can be critical since long-standing anxiety can lead to depression and possibly suicidal ideation (Tantam, 2000). Behavioral problems may become more evident as feelings of stress mount and the child with AS experiences an increasing lack of control. He or she may see the world as threatening and unpredictable (Myles & Simpson, 2002) and react in aggressive ways. Some researchers have stressed that social deficits and increasing behavioral problems could contribute to psychological problems for children with AS (Green, Gilchrist, Burton, & Cox, 2000; Tonge, Brereton, Gray, & Einfeld, 1999).
There is currently no consensus regarding the types of assessment instruments that should be used to diagnose Asperger Syndrome. Freeman, Cronin and Candela (2002) suggested that a comprehensive assessment for AS should include an interview with the primary caretaker for the purposes of obtaining a comprehensive developmental history (including pregnancy, neonatal, and postnatal history, medical history, history of medications, family history of developmental disorders and psychiatric illnesses, and family and psychosocial factors). An interview with the child should also be conducted to determine the level of the child's communication, academic, social skills, and adaptive functioning.
Observation is another important component in making an accurate diagnosis, which might be conducted in natural (home and/or school) and/or artificial settings (structured child and/or parent interview). Cognitive testing might be important for intervention purposes. Adaptive behavior is an additional area of interest, as children with AS tend to possess a limited range of daily living skills (Szatmari et al., 1995). Communication assessment should examine nonverbal forms of communication, non-literal language, pragmatics, perseveration, metalinguistics, reciprocity, and rules of conversation (Klin & Volkmar, 2003). It may also be important to assess for issues of attention and hyperactivity (Klin et al., 2000).
When diagnosing AS, utilizing a screening questionnaire that assesses for typical characteristics may be important. Many have argued against the utility of such instruments, as they closely follow the DSM-IV-TR (2000) criteria, rather than resembling Asperger's original case observations (Gillberg & Gillberg, 1989; Szatmari et al., 1989). Currently, there are several rating forms that a clinician can use to assess for characteristics of AS, as they relate to DSM-IV-TR (APA, 2000) criteria and diagnosis. The Autism Spectrum Screening Questionnaire (ASSQ, Ehlers, Gillberg, & Wing 1999) assesses for social interaction, communication problems, restricted and repetitive behavior, and motor clumsiness. Ehlers et al. (1999) reported that the ASSQ is a reliable and valid parent and teacher screening tool used for assessing characteristics of high-functioning autism spectrum disorders.
The Asperger Syndrome Diagnostic Interview (ASDI) (Gillberg, Gillberg, Rastam, & Wentz, 2001) is another screening instrument based on Gillberg and Gillberg's (1989) criteria that closely resembles Asperger's original observations. The ASDI is not intended for use in making a diagnosis of AS in accordance with the DSM-IV-TR (APA, 2000). The ASDI measures six areas: Social, Interests, Routines, Verbal and Speech, Non-verbal Communication, and Motor and appears to have acceptable reliability and validity (Gillberg et al., 2001).
The Asperger Diagnostic Interview (LeCouteur, Rutter, Lord, Rios, Robertson, Holdgrafer, & McLennan, 1989) measures six areas: Social, Interests, Routines, Verbal and Speech, Non-verbal Communication, and Motor and appears to have acceptable reliability and validity. The Autism Diagnostic Interview Revised (Lord, Rutter & Le Couteur, 1994) is a semi-structured, investigator-based 90-minute interview for caregivers of children and adults with a possible pervasive developmental disorder. The interview is appropriate for children with mental ages from about 18 months into adulthood and linked to ICD-10 and DSM-IV criteria.
The Asperger Syndrome Diagnostic Scale (ASDS) (Myles, Jones-Bock, & Simpson, 2001) has been used as a diagnostic tool to assess for characteristics of AS based on the DSM-IV-TR (APA, 2000) criteria for children ages 5 to 18 years. The ASDS which targets five specific areas of behavior (cognitive, maladaptive, language, social, and sensorimotor) is a 50 item yes or no questionnaire which takes approximately 10 to 15 minutes to complete. The ASDS yields an AS Quotient which indicates the likelihood that an individual qualifies for a diagnosis of AS.
The Autism Diagnostic Observation Schedule (ADOS) (Lord, Rutter, DiLavore, & Risi, 1999) is a semi-structured naturalistic assessment of communication, social interaction and play designed for individuals suspected of having autism or other pervasive developmental disorders. The ADOS takes about 30 minutes to administer and by using the ADOS, psychologists can observe the child participating in various activities, for example, observing how a young child requests that the examiner continue blowing up a balloon and rate their performance.
Measures of social perception are becoming of increasing interest to researchers investigating reliable and valid intervention strategies for children diagnosed with AS (Ozonoff & Miller, 1995). Despite the need for standardized, reliable and valid measures to assess for verbal and non-verbal social skills, only a few of these instruments exist (Gresham, 1981; Koning & Magill-Evans, 2001). The Social Skills Rating System (SSRS) (Gresham & Elliot, 1990) takes approximately 10 minutes to complete and can be filled out by the student, parent, and/or teacher. It is designed to evaluate skills such as empathy, self-control, cooperation, and assertiveness. The student forms yield three social skills subscale scores, including Cooperation, Assertive, and Empathy. The parent and teacher forms yield four social skills subscale scores (Cooperation, Assertive, Responsibility, and Self-Control), in addition to two problem behavior subscale scores (Internalizing and Externalizing).
Diagnostic Considerations: Distinction between Autism and Asperger Syndrome
There is intense debate surrounding the classification of the characteristics associated with AS, as being similar, if not the same condition as high functioning autism (HFA) with varying characteristics (Bowman, 1988); or as part of the autism spectrum disorders (Freeman, Cronin, & Candela, 2002; Meyer & Minshew, 2002); or as a separate and distinct diagnosis (Klin, Sparrow, Marans, Carter, & Volkmar, 2000; Ozonoff, Rogers, & Pennington, 1991).
Bowman (1988) conducted a case study with a family of four boys, all diagnosed with characteristics of autistic-like disorders and concluded that the variation between the two conditions (AS and AD) could best be explained on the basis of severity within the same disorder. Kim, Szatmari, Bryson, Streiner, and Wilson (2000) noted that although there are differences at any point in time between AS and HFA, children with autism who develop good language skills, eventually come to resemble older AS children. Thus, children with autistic symptoms should be diagnosed with the same disorder.
Others argue that AS should be conceptualized as part of a spectrum of autistic disorders or as existing on an autistic continuum. In a review of several studies which evaluated the diagnostic dilemma of AS and AD, Eisenmajer et al. (1996) found few clinical differences existed between HFA and AD as defined by clinical practitioners, with the exception that AS children sought friendships more than the AD children. Eisenmajer et al. concluded that AS exists on a continuum with AD and is not a separate disorder.
Szatmari, Archer, Fisman, Streiner, and Wilson (1995) found that children (4-6 years of age) with AS and AD differed on social deficit measures and in the types of repetitive and stereotypic behaviors exhibited. While the groups differed on measures of adaptive behavior in socialization, but no differences were found on measures of nonverbal cognition.
Ozonoff, South, and Miller (2000, using the DSM-IV (APA, 1994) criteria found few group differences in current presentation and cognitive functioning between AS and AD, but several differences in early history. Children with AS showed better imaginative play and creative abilities than children with HFA, and children with AS also demonstrated more circumscribed interests. Differences in historical variables were found which emphasized early language development, behavior problems in pre-school years, DSM-IV lifetime symptomatology, and greater use of special education services in the HFA group than the AS group.
McLaughlin-Cheng (1998) conducted a meta-analysis of children, adolescents, and adults between the ages of 5 and 23 years of age with diagnoses of Asperger's Syndrome (AS), Autism (AD), and High Functioning Autism (HFA) in order to determine if differences existed in levels of cognitive functioning and/or adaptive behavior. Results indicated that children and adolescents with AS performed better overall than those with AD or HFA on cognitive and adaptive behavioral measures. Meyer and Minshew (2002) debated earlier conclusions that individuals with AS performed better cognitively, stating that AS and HFA are nearly indistinguishable on cognitive measures, but that children with AS seem to perform better on tasks which require use of theory of mind and abstract reasoning.
Starr, Szatmari, Bryson, and Zwaigenbaum (2003) compared the two-year outcome of 58 children, ages 6 to 8 years old, who were diagnosed with AS and AD using the Autism Diagnostic Interview (ADI) (LeCouteur, Rutter, Lord, Rios, Robertson, Holdgrafer, & McLennan, 1989). The AD group experienced a greater decrease in communication symptom severity over time relative to the AS group, and there was a trend for the AS group to show a greater increase in social symptoms. Children with AS showed a greater increase in symptoms of impairment in social reciprocity than did children with AD. The magnitude of the differences observed between the two groups seen at inception was maintained two years later. Starr et al. (2003) concluded that different outcomes follow different trajectories over time, supporting their premise that symptoms and level of functioning represent independent phenotypes in PDD.
Howlin (2003) compared 34 adults with autism and 42 with AS, matched for age and nonverbal IQ, with the ADI-R (Lord, Rutter, & LeCouteur, 1994) and found early childhood differences. For children with AS, first concerns included general behavioral problems, ritualistic and stereotyped behavior/interests, and motor delays/difficulties, whereas the autism group displayed early social difficulties and motor delays as prominent concerns. Early differences appeared to diminish over time; even motor clumsiness did not appear to be significantly different between the groups. She concluded that there appears to be no consistent evidence that there are any major differences in rates of social, emotional, and psychiatric problems, current symptomatology, motor clumsiness or neurological profiles between the two groups. She did acknowledge that when children are matched on Full Scale IQ, the AS groups have better developed verbal skills and significant differences in academic attainment; although, cognitively, both groups were similar in functioning.
Still, theorists remain who propose a distinct diagnosis of AS, as separate from HFA and AD. Differentiation appears to be important as targets for intervention become narrower, and diagnosis can have implications for availability of services. Klin and Volmar (2000) support the viewpoint that AS and HFA should be distinct and separate diagnoses based on specific clinical characteristics, which include social, cognitive, and adaptive functioning. Tonge, Brereton, Gray, and Einfeld, (1999) found that children and adolescents with AS presented with higher rates of psychopathology than those with HFA, were more disruptive, antisocial, and anxious, and had more problems with social relationships. But while clear distinctions between AS and AD are still debatable, it is important to delineate some differences for the purpose of effective intervention planning.
Social Skills Training
Social skills represent a complex area within human behavior (Myles & Simpson, 2001; Myles, 2003). Social interactions can be confusing and sometimes painful for children whose rigid adherence to social conventions is positively reinforced in some settings, but punished in others (Myles & Simpson, 2002). Children and adolescents who are deficient in social skills and who are poorly accepted by peers have a high incidence of school maladjustment, delinquency, child psychopathology, and adult mental health difficulties (Gresham, 1981). Attwood (2003) speculated about the potential negative consequences that might result for a child who fails to develop peer relationships. Further, the lack of close friends could be a contributing factor in childhood depression (Barnhill, 2001). Thus, the relevance of social skills training becomes important for the individual's adjustment (Ciechalski & Schmidt, 1995; Ruberman, 2002).
In a survey of mothers of children with AS, 78 percent rated social skills training for their children as extremely important (Little, 2003). Gresham, Sugai, and Horner (2001) noted a lack of empirical evidence for the use of social skills training as an effective intervention strategy, particularly for students with high-incidence disabilities, such as learning disabilities, mental retardation, emotional disturbance, or ADHD. Hwang and Hughes (2000) found that social interactive strategies had the potential for increasing social and communicative skills in children with autism. Children with AS are typically unable to participate fully in age-appropriate relations due to their lack of understanding of social skills (Bock, 2001), thus intervention should focus on strengthening the "ability to negotiate the verbal social world" (Landa, 2000, p. 146). Rogers (2000) noted that social skills training involving peer participation might be effective.
Gresham (1988) stated that individuals who are highly socially competent are able to meet the demands of everyday functioning. They possess appropriate peer reinforcement behaviors, communication skills, problem-solving skills, and social self-efficacy and can develop such adaptive behaviors as independent functioning, self-direction, personal responsibility, and functional academic skills. Children and adolescents with social skill deficits and poor acceptance from peers, have a high incidence of school maladjustment, delinquency, child psychopathology, and adult mental health difficulties.
Gresham (1988) delineated four reasons for social skills problems: skill deficits, performance deficits, self-control skill deficits, and self-control performance deficits. Children with social skill deficits do not have the necessary skill in their repertoire, or they may omit the critical steps needed to perform the behavioral sequence or do not perform the behavior with appropriate frequency or intensity (performance deficit). Self-control deficits apply to individuals who have not learned a particular social skill because of some type of interfering response (cognitive-verbal, physiological/emotional, and/or overt/motoric). Children with self-control performance deficits have the specific social skills within their repertoire, but do not perform these skills at acceptable levels due to problems in antecedent and/or consequent/control (i.e., a child with impulsivity) (Gresham, 1988). AS children could easily fall into any one of the categories of self-control deficiencies as interfering behaviors may be high (i.e., selective attention, anxiety, etc.). Skill (not knowing the skill) and performance (knowing the skill but not successfully performing it) deficits can also be observed.
Gresham (1988) conceptualized social skill training as a four-step process. Teaching social skills involves promoting skill acquisition, enhancing skill performance, removing interfering behaviors, and facilitating generalization. Within the realm of promoting the skill, the individual learns appropriate social behavior via modeling, coaching, and instructions/explanations. He stated that enhancing skill performance involves behavioral rehearsal, reinforcement based techniques, peer initiation strategies, and cooperative learning strategies. Removing the interfering behavior may involve a response-cost system, group contingencies, differential reinforcement, or self-instructional procedures. Facilitating generalization can involve utilizing natural community-based reinforcements, diverse training opportunities, or incorporating functioning mediators (i.e., social stimuli).
Attwood (2000) suggested that social skills training might target the identification of specific emotions, the contexts in which they might be appropriate, and modulation skills to help manage the intensity of the emotions. AS individuals tend to use imitation and modeling to camouflage their difficulties with social integration. They might need help in clarifying why certain behaviors are expected in varying contexts. Once these "codes of conduct" are explained, however, the child often rigidly enforces them. Over time, the child with AS can learn the codes of social conduct by intellectual analysis, rather than by natural intuition (Attwood, 1998).
Howlin and Yates (1993) recommended specific techniques such as role-playing, team activities, structured games and analysis of videotaped social behavior. Social skill group goals might include increasing self-awareness; developing strategies to compensate for social deficits, improving conversational skills, and encouraging independent living skills (Howlin & Yates, 1993). Barnhill (2001) suggested that the optimal means for learning social skills involves modeling, role-play, and feedback. Gutstein and Sheely (2002) emphasized social and emotional development concepts such as collaboration, perspective taking, and conversation strategies. Falk-Ross, Iverson and Gilbert (2004) suggested teaching pragmatic language using card games. In this way the children can learn to initiate conversation, respond, take turns, and remain on topic. Body language, facial cues, gestures and voice tone can also be practiced using this technique.
Children with AS struggle to decipher nonverbal behavior accurately in a social context (Attwood, 1998; Davies, Bishop, Manstead, & Tantam, 1994). Duke, Nowicki, and Martin (1996) suggested that social success is greatly influenced by the ability to interpret nonverbal behavior. Nonverbal behavior involves a proscribed set of unwritten rules that must be flexible enough to use in any given situation. Since they are not written down or formalized, they must be inferred in order to achieve social acceptance. Some nonverbal behaviors may be part of a child's behavioral repertoire that has developed from birth (Duke et al., 1996), while other skills must be acquired and generalized. These skills can include knowledge of paralanguage, facial expressions, postures and gestures, interpersonal distance and touch (boundaries), rhythm and time, and "objectics" (personal style and hygiene that is similar to the generally accepted peer group). Duke et al. (1996) proposed a school-based curriculum to teach nonverbal behaviors in areas of paralanguage (aspects of sound that communicate emotion), facial expression, space and touch, gestures and posture, rhythm and time, and personal hygiene.
Myles and Simpson (2001) also acknowledged the importance of self-esteem building as the child with AS may be highly aware that they may look, act, feel, and in some ways, are different from other people. They suggested self-esteem strategies to include placing the child in the role of helper, focusing on what the child is doing right (using reframing), finding out what the child does well and helping him or her do more of it, and complimenting the child and teaching him or her to compliment themselves.
Kransy, Williams, Provencal, and Ozonoff (2003) designed a PROGRESS curriculum (Program for Remediating and Expanding Social Skills), which emphasized the following goals: basic interactional skills, conversational skills, play and friendship skills, emotion processing skills, and social problem solving. These were further broken down into Nonverbal behaviors (eye contact, social distance, voice volume, and facial expression); Conversation (how to initiate, maintain and end a conversation; turn taking in conversations, making comments, asking questions, etc.); Friendship and Relationship skills (qualities of being a good friend, greeting others, responding to greetings, joining groups, sharing, compromising and following group rules); Understanding thoughts and feelings of self and others (perspective taking, empathy, etc.); and finally, Problem Solving (what to do when you are teased or excluded, etc.). They also described techniques such as making the abstract concrete by explicitly operationalizing the new skill and teaching children to differentiate this behavior or skill from other behaviors using visually-based instruction, a high level of structure and predictability, providing special attention in transitions, using scaffolded language support, providing multiple and varied learning opportunities, providing other focused activities, fostering self-awareness and self-esteem, selecting relevant goals, sequencing skills in a progressive manner and providing opportunities for generalization and ongoing practice (p. 111).
Bock (2001) described a group strategy to assist individuals with AS in their social and behavioral learning by coaching them to attend to relevant social cues, processing these cues, pondering their relevance and meaning, and selecting an appropriate response during novel social interactions (thereby increasing generalization). Bock called this the SODA strategy (Stop, Observe, Deliberate, and Act), which serves as an ongoing cueing system and helps students to develop an organizational schema for the setting within which social interaction will occur. Questions such as: "What is the room arrangement? What is the activity schedule or routine? Where should I go to observe?" are used as prompts. The "Observe" component helps students note social cues used by people in this setting. Questions include, "What are people doing or saying? What is the length of a typical conversation? What do people do after they've visited?" At the "Deliberate" component, students are cued to consider what they might say or do and how others would perceive them. Questions include, "What would I like to do or say? How will I know when others would like to visit, linger, or would prefer to end the conversation?" The "Act" component then helps students interact with others by prompting them (in vivo) to approach a person with whom they would like to visit, say "Hello, how are you?" listen to the person and ask related questions, and look for cues that this person would like to visit longer or would like to end the conversation.
Myles and Simpson (2001) and Myles (2003) reviewed several social skill strategies that might be effective for children and adolescents with AS. They noted that for individuals who do not develop adequate social skills, the impact might range from not being able to develop and keep friendships, to being ridiculed by peers to not being able to keep a job due to a lack of understanding of the environmental culture. Myles and Simpson (2001) noted that one important area in social skills treatment is the "hidden curriculum," or the "dos" and "don'ts" of everyday behavior. In school, children with AS need to be aware of teachers' expectations, teacher-pleasing (and displeasing) behavior, which students to interact with and those to stay away from, and behaviors that attract positive and negative attention. Temple Grandin, an adult with AS, developed her own set of rules to guide her social interactions and behavior in society (as cited in Myles and Simpson, 2001). Her rule system consists of "Really Bad Things, Courtesy Rules, Illegal But Not Bad, and Sins of the System" (p. 281). Myles and Simpson (2001) proposed a systematic approach to developing an individual's "hidden curriculum" which involves six steps: 1) provision of a rationale for the relevancy of developing this type of approach; 2) presentation of what the student needs to know; 3) development of a model of appropriate social behavior; 4) verification of learning behavior (i.e., via teacher monitoring); 5) evaluation by the teacher and the student in order to gauge which behaviors have been learned and which have not (or need work on); and 6) generalization via opportunities to practice this strategy in the community.
The use of social stories can be an effective method of providing guidance and direction to promote social awareness, self-calming, and self-management when responding to social situations (Gray, 2000). The individual stories contain four sentence types: 1) descriptive--information about the setting, subjects, and actions; 2) directive--statements about the appropriate behavioral response; 3) perspective--sentences describing the feelings and reactions of others in the targeted situations; and 4) control--analogies of similar actions. Attwood (2000) noted that the social story is written with the intention of providing information about what people are doing, thinking or feeling, the sequence of events, identifying significant social cues and their meaning, and providing a script of what to do or say. Social stories provide a "visitor's guide" of this culture by explaining social conventions and their rationale.
Gray (1994) also proposed the concept of cartooning, which involves the use of visual symbols. The purpose of cartooning is to enhance the processing abilities and understanding of the environment in individuals with autism. Comic strip conversations have been used as an effective way to illustrate and interpret social situations. Attwood (1998) noted that comic strip conversations "allow children to analyze and understand the range of messages and meanings that are part of natural conversation and play" (p. 72). Attwood (2000) further noted that comic strip conversations provide a means of visually illustrating communication that occurs in conversation. Attwood commented that this type of tool could be useful for clinicians when analyzing a child's motives if a specific incident has caused considerable distress as well as in illustrating what types of alternative responses the child could make.
Efficacy of social skills treatment
There is little research detailing the efficacy of social skills training (SST) specifically for individuals diagnosed with AS or HFA (Greenway, 2000). Mesibov (1984) was the first to evaluate the efficacy of a social skills group for adolescents and adults with AS. The group goals included targeting interpersonal skills, enhancing self-esteem, and promoting positive peer experience. Techniques included modeling, coaching and role-play. While qualitative measures (participants, families' and staff members' impressions) were promising, no objective pre-post assessment was conducted. Williams (1995) investigated a four-year long program that emphasized perspective taking, conversation, voice tone, flexibility and listening. Qualitative data suggested some progress was made in friendship, but perspective taking ability did not show a commensurate rate of progress. Statistically significant improvement was demonstrated in talking with peers, initiating conversations with staff, using appropriate facial expressions and fluency of speech.
Marriage, Gordon, and Brand (1995) investigated the effects of a short-term social skills group for children with AS. Techniques included role-playing, video-taping, prompting with card, viewing movies, and playing games. Parent ratings showed little post improvement, but qualitative ratings were noted in self-confidence and social skill acquisition.
Ozonoff and Miller (1995) looked at the progress of five adolescent boys who participated in a four and a half month training program. Improvement was noted in perspective taking versus the no treatment control group, but post treatment ratings did not show generalization.
Howlin and Yates (1999) evaluated the effectiveness of social skills groups for adults diagnosed with AS. The researchers found that during the group experience, participants showed a good understanding of social rules and a degree of awareness of other people's feelings and emotions, though they noted problems with contextual changes and generalization. Other changes included changes in job status and living situations.
Hwang and Hughes (2000) found that social skills training resulted in some immediate gains in social and affective behaviors, nonverbal and verbal communication, eye contact, joint attention, and imitative play. Gutstein and Whitney (2002) pointed out, however, that these gains were not maintained over time, nor were they generalizable to other settings. Gutstein and Whitney emphasized that if long-term gains were to be made, then social skills training for children with AS must be based on the intrinsic enjoyment of experience-sharing encounters. Goals of intervention must include not only scripted social survival skills, but should also incorporate social referencing and coordination of actions, perceptions, feelings, and ideas with social partners.
Barnhill, Tapscott-Cook, Tebbenkamp, and Myles (2002) conducted a study to investigate the effectiveness of social skills intervention targeting nonverbal communication for adolescents with AS utilizing the Diagnostic Analysis of Nonverbal Accuracy (DANVA2) (Nowicki & Duke, 1997) as a pre- and post assessment measure of nonverbal social perception. Barnhill et al. (2002) found that even though their intervention strategy (nonverbal skills training) lacked statistical significance; they felt that two positive outcomes emerged. One was that some social relationships were developed and maintained across the 8-week treatment segment and beyond. Fifty percent of the participants (N=8) continued to contact each other several months after the treatment ended. The second noteworthy outcome was that participants were able read the nonverbal communication of others following the intervention (i.e., facial expression or deciphering paralanguage) in a natural community setting.
Bauminger (2002) evaluated the efficacy of a 7-month, cognitive behavioral intervention program designed to enhance the social competence of high-functioning children with autism, ages 8-17. Parents and teachers were actively involved in the process. Children demonstrated improvement in the areas of social cognition/problem solving, emotional understanding, and social interaction; more specifically, speech initiation/contact with a peer and eye contact. Bauminger (2002) acknowledged that generalizability was difficult to determine and that there was the absence of a control group to rule out naturalistic changes that could occur due to maturity or by nature of receiving more individualized attention.
Kransy, Willliams, Provencal, and Ozonoff (2003) reviewed five studies that measured the effectiveness of social skills training with children with autism. They reported significant improvement in social skills, positive peer experiences, and enhanced self-esteem post-treatment.
Barry, Klinger, Lee, Palardy, Gilmore, and Bodin (2003) also noted that little research has been conducted to determine the efficacy of social skills treatment for children with high-functioning autism. Barry et al. (2003) developed an 8-week group intervention designed to provide social skills instruction to specific to social rules and scripts. The researchers noted that the intervention was effective in improving social behavior, specifically, greetings, play, initiating social contact, and conversation skills. However, they noted that skills improved as they were being taught but did not endure in other settings, and skills not addressed as part of the intervention remained the same.
Carter, Meckes, Pritchard, Swensen, Wittman, and Velde (2004) designed and implemented an after-school program for children (ages 8 to 15) with Asperger's Syndrome. The six session program included such topics as getting to know each other, conversation starters, defining friendship, celebrating with friends, trust and saying good bye for the elementary aged group and more advanced topics for the adolescent group including what is friendship, forming friendship relations, volunteering, maintaining a friendship and saying good-bye. Verbal feedback was obtained from younger students and written from older. Parents responded to an e-mail survey. Group satisfaction was the primary information solicited and the feedback they received from both parents and youth was positive.
Elder, Caterino, and Virden (2004) evaluated the efficacy of social skills treatment for children with AS. Eight children (7 boys and 1 girl) participated in an accelerated 8- day summer session social skills group. The social skills treatment curriculum consisted of the following core concepts: recognizing and expressing emotions in self and others, physical versus mental feelings, stress and relaxation, initiating conversations, using nonverbal conversations skills, maintaining conversation, and bullying and teasing. Parents and children rated skill level pre and post treatment. Variables measured included social skills, problem behaviors, and parental stress utilizing the Social Skills Rating System (SSRS) (Gresham & Elliott, 1990), the Parenting Stress Index (PSI) (Abidin, 1995), and the Clue Breakers Survey (unpublished), an instrument designed specifically for this study. The PSI indicated that parenting stress significantly decreased post-treatment. Positive trends included less problem behavior and overall family stress, increased recognition and expression of emotion in self and others, improved knowledge of physical versus mental feelings, improved stress and relaxation skills, improved ability to initiate and maintain conversations and nonverbal communication, and better conflict resolution.
Gresham et al. (2001) emphasized that a persistent problem with much of the SST literature is the inability of the researchers to demonstrate consistent and durable gains in social skills across settings as well as maintenance over time. Gresham et al. (2001) noted that SST could produce significant and seemingly insignificant effects on social competence functioning. Another possible reason for the weak effects of SST involves the assessment instruments used to evaluate pre- and post functioning. Gresham et al. (2001) found that in some studies the assessment instruments used were not closely related to the variables being measured. Furthermore, a number of studies appeared to use assessment instruments that lacked validity and reliability or even used "home-made" measures (Greenway, 2000; Gresham et al., 2001). Finally, one of the strongest areas of weakness appeared to be related to failure to demonstrate sufficient generalization and maintenance of the learned social skills (Gresham et al., 2001; Howlin & Yates, 1999; Hwang & Hughes, 2000). Greenway (2000) noted that the lack of success of SST might also be influenced by a lack of precision in targeting small aspects of social skills and a lack of opportunity to practice new skills.
Caldarella and Merrella's (1997) meta-analysis of social skills domains noted that the following components are most often emphasized in successful social skills programs: peer relations, self-management, compliance, assertiveness, and academics. Gresham, Sugai and Horner's (2001) meta-analysis of social skills groups for students with or at risk for high-incidence disabilities found that effective SST strategies generally incorporated modeling, coaching and reinforcement and tended to utilize cognitive-behavioral procedures, as well as specific intervention strategies.
The socialization deficits of AS can also result in significant stress and conflict in families of individuals with AS due to the individual's difficulties in meeting the demands of everyday life and their problems with educational, vocational, and social relationships (Klin & Volkmar, 2003; Lainhart, 1999; Little, 2002). While presently support groups for parents of AS exist, as well as internet chat rooms, researchers (Sofronoff & Farbotko, 2002) have also suggested that parents participate in parent management training (PMT), aimed at promoting parenting skills and strengthening family functioning. Relational Developmental Intervention (Gutstein & Sheely, 2002) provides for intensive parental involvement through seminars and continued internet support. However, there are not many programs currently in existence for parents and families of children with AS. Programs that allow parents to participate in social skills groups, either with their child, or in separate but simultaneous groups, should be explored. These programs may vary in the participation of parents; for example, parents could participate in a partnership with their child or be silent observers seated in the outer perimeter of the group. Programs for siblings might also be developed. As always, further research needs to be conducted to evaluate the effectiveness of such parent and family programs.
In addition, significant challenges exist in the classroom setting for teachers who shoulder the responsibility of educating children with AS whose challenges might include narrow interests, selectiveattention, and abnormal social interactions (Myles & Simpson, 2002). Since schools are the most natural environments for children, social skills training programs should also be established in educational settings (Carter et al., 2004). School programs also provide for exposure to competent peer models and allow for more intense and longer programs (Gresham, 2001). In this way, fluency as well as acquisition and performance can be developed. Greater practice should also allow for generalizability to multiple settings and long-term maintenance. In addition, schools and families need to work together to teach and reinforce the same social skills, using similar techniques whenever possible. Ultimately, more research is needed in examining the efficacy of social skills groups for children with HFA or AS, particularly for school-age children.
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Lisa M. Elder
Argosy University, Phoenix
Linda C. Caterino
Arizona State University, Tempe
Melmed Center, Scottsdale Arizona
Melmed Center, Scottsdale, Arizona
Gina De Simone
Argosy University, Phoenix
Correspondence to Linda Caterino, Ph.D, Training Director, School Psychology Program, Division of Psychology in Education, Arizona State University, Tempe, AZ 85287; e-mail: email@example.com.