Keywords
Autism spectrum disorders (ASD) are developmental disabilities characterized by difficulties in social communication, along with restricted interests or repetitive behaviors. The term includes the current Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (Text Revision) (DSM-IV) diagnoses of autism, Asperger syndrome, and pervasive developmental disorder not otherwise specified.
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The prevalence of ASD has increased steadily in the past several decades, partly because of the increasingly broad criteria for diagnosis, as well increased awareness by health care providers and by families, and earlier case finding. Current estimates are that 1 in approximately 110 children in the United States meet criteria for ASD,2
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with similar prevalence across different racial, ethnic, and socioeconomic groups,4
making intervention for this population an important and timely issue. The range of abilities of individuals within the autism spectrum is broad, ranging from individuals with co-occurring intellectual disability (ie, low-functioning autism) to those with milder symptoms who have average or higher intelligence (ie, high-functioning autism). What these diverse individuals have in common is a core deficit in the area of social skills.Social skills deficits in ASD
Difficulties with social skills and social interactions are a hallmark of ASD, although how these difficulties manifest differs from child to child and depends to some extent on age and functioning level of the child. Examples of social skills include making eye contact, initiating interactions with others, understanding and using nonverbal communication such as gestures and facial expressions, and maintaining reciprocal conversations. Young children with autism may show social skills delays in terms of limited eye contact, social smiling, joint attention, and pointing, whereas older children and adolescents may show difficulties maintaining conversations, taking another’s point of view, initiating social interactions, reading nonverbal body cues, and making and keeping friends.
Helping youth with ASD to improve their social skills is an important goal because this population reports having fewer friends, less satisfying friendships and relationships, and more feelings of loneliness than their typically developing peers, despite desiring more peer interactions and friendships.
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Furthermore, they report lower rates of self-esteem and higher rates of bullying and teasing than typically developing children and adolescents.6
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In addition, improving the social skills of youth with ASD is important because research has found that the social skills impairments in individuals with ASD contribute to underachievement at school and at work.8
Given the growing awareness of ASD, pediatricians are increasingly called on to assess children and adolescents for ASD and to guide families to the most appropriate services. This article describes some of the most frequently used social skill interventions and what is known about their effectiveness. It concludes with future directions and recommendations for pediatricians.
Social skills interventions
Many interventions have been designed to address the social skills deficits of children and adolescents with ASD. The types of appropriate social skills training vary with the age of the child or adolescent and functioning level. Typically, social skills interventions are facilitated by a therapist or teacher and may involve training peers, siblings, or parents to interact with youth with ASD in ways that increase their social skills, or may involve direct teaching of social skills to individuals with ASD. Social skills training may be individual or group based, may incorporate visuals such as videos or pictures, and usually takes place within school or clinic settings.
Although empirical support is still in the early stages, there is a growing body of evidence to support the effectiveness of different types of social skills training for youth with ASD.
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In particular, several types of social skills interventions are emerging as evidence based, including peer mentoring,10
social skills groups,11
and video modeling.12
Other types of social skills training, such as social stories, have shown preliminary evidence of efficacy13
but require additional research, whereas others, such as some of the commercially available social skills group curricula, are popular but have not yet undergone trials to measure effectiveness. Table 1 gives a description of these types of social skills training, as well as recommended resources for parents or practitioners who would like to learn more about implementing these interventions.Table 1Types of social skills training and recommended resources
| Types of Interventions | Recommended Resources |
|---|---|
| Peer mentoring | |
| Typically developing peers are trained to interact with children with ASD in ways that promote positive development of social skills, within a regular classroom setting | Peer Play and the Autism Spectrum: The Art of Guiding Children’s Socialization and Imagination by Wolfberg 42 is a manual for practitioners and caregivers that describes techniques for integrating play groups of typically developing peers and those with ASD |
| Social skills groups | |
| 4–5 students with ASD participate in lessons about various social skills topics, within school or clinic settings. Groups may also include typical peers as models/mentors | Social STAR: Peer Interaction Skills by Gajewski et al 24 Think Social! A Social Thinking Curriculum for School-Age Students by Winner 23 Navigating the Social World: A Curriculum for Individuals with Asperger’s Syndrome, High Functioning Autism, and Related Disorders by McAfee 25 These 3 curricula are designed to be presented in group format to school-aged children with ASD and include fun and interactive lessons about various social skills topics |
| Video modeling | |
| Children with ASD watch videos showing themselves or peers demonstrating specific social skills, and then practice the skills | Seeing is Believing: Video Self-Modeling for People with Autism and Other Developmental Disabilities by Buggey 43 describes how to create and use video self-modeling to teach social and other skills to individuals with ASD |
| Social stories | |
| Children with ASD read short stories written in the first person, in which they use an appropriate social skill | The New Social Stories Book by Gray describes how to write social stories and includes many examples that can be used as templates and individualized to specific children’s needs |
| Picture books | |
| Children with ASD look at photographic sequences of social skills to learn how and why to perform the skill | The Social Skills Picture Book: Teaching Communication, Play and Emotion by Baker 39 contains step-by-step comic-strip illustrations of children performing social skills, along with thought bubbles explaining how the children perform the skill, and why |
Peer Mentoring
Peer mentoring is a type of social skills intervention traditionally used with preschool-aged children within the regular classroom. In this model, typically developing peers are taught how to interact with children with autism to encourage the development of their social skills. In a peer-mentoring model, peers may be taught, for example, how to be a good buddy, which may include staying with an assigned child with ASD, playing with him or her, and talking with the child even if the child with ASD does not respond.
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This model is especially appropriate now that many children with ASD participate in general education classrooms alongside typically developing peers. Furthermore, merely participating in an inclusive classroom setting is not sufficient to increase social interactions and improve social skills for children with autism15
because, without intervention, typically developing children choose to play with other typically developing peers rather than with children with autism.16
However, with training, typically developing children are able and willing to interact with children with ASD. Training typical peers and siblings to model and reinforce appropriate social skills for preschool children with ASD within an inclusive classroom setting has been shown to be one of the most effective strategies for increasing the early social communication skills of preschool children with ASD, and children with ASD seem to generalize and maintain the gains over time and across other settings and children.10
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Pivotal Response Training (PRT) is a behaviorally-based intervention for children with autism.
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One application of PRT is as a peer-delivered model to teach social reinforcement (eg, paying attention to the child with ASD), to follow the lead of the child with ASD (eg, allowing the child with ASD choose the activity to play), and to model appropriate social behaviors such as turn taking and conversation. Although much training is required, this model is found to be effective when implemented.3
Peer-mediated PRT has also been used with school-aged children. For example, one study found that using peer-mediated PRT techniques with elementary school–aged children with ASD resulted in an increase in social skills including initiations and turn taking.20
Social Skills Groups
One of the most commonly used interventions for school-aged children and adolescents on the autism spectrum is social skills groups. In a traditional social skills group, approximately 4 or 5 children with ASD participate in social skills lessons taught by a teacher or therapist. These groups usually meet at the child’s school along with other classmates, or in an outpatient clinic setting with other youth with ASD from the broader community. Session topics might include greeting others, being friendly, joining or initiating play with others, reading nonverbal cues, and starting and maintaining conversations. See Table 2 for examples of topics taught in social skills groups for school-aged children and adolescents with ASD.
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Table 2Examples of lesson topics for social skills groups
| Elementary School Age Group 22 | Adolescent Social Skills Group 21 |
|---|---|
| Getting to know someone Body talk (nonverbals) Dealing with emotions Conversation Making impressions Teasing vs humor Friendship tips | Meeting new people/asking questions Using body talk Using body signals to express and understand emotions Being positive Keeping the conversation going/active listening Teen obstacles Sharing opinions |
Several commercially available curricula for social skills groups for youth with ASD have enjoyed a great deal of clinical success, although their effectiveness has not yet been fully evaluated through research. Some of these programs include Winner’s
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Think Social!, Gajewski and colleagues’24
Social STAR, and McAfee’s25
Navigating the Social World. These curricula are created for teachers and therapists to deliver within schools or clinics to school-age students with ASD or related difficulties in social skills. They include fun and interactive lessons on topics such as greeting others, starting and ending a conversation, being a friend, dealing with teasing, recognizing emotions, asking for help, giving and receiving compliments, and reading other people’s body cues.In addition to lesson-based groups such as those described earlier, social skills groups can also be activity based to foster social interactions between members. One such social skills group model that has shown effectiveness was one in which elementary school–aged children were split into groups of 3 for Lego therapy; 1 child in each group was designated the engineer, supplier, and builder, and had to work together to build different Lego projects while following certain rules such as working together, being polite, and sharing. Results showed improvements in social skills compared with a more traditional lesson-based social skills group.
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This concept could be applied to other social skills groups with themes such as cooking, in which students might be split into groups of 3, with recipes being chosen and explained by the teacher or therapist, and each group having a head chef, sous chef, and ingredient gatherer.Several recent summary papers and meta-analyses on social skills groups for school-aged youth with ASD have found emerging evidence of effectiveness, although it is unclear how well participants generalize the new skills and maintain them over time.
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Several factors have been identified that may improve the effects, generalization, and maintenance of social skills groups. These factors include having at least 30 hours of group time, implementing the group within the natural setting (ie, the child’s classroom, rather than a pullout model), matching the strategies and skills taught to the individual participants’ specific social skills difficulties, and ensuring implementation fidelity of the interventions.29
Another factor that may aide in the generalization and maintenance of the skills learned in social skills groups is the inclusion of opportunities to interact with typical peers who are trained to promote and encourage social skills of peers with ASD.
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Some newer models of social skills groups that are currently undergoing randomized, controlled trials are those that include typical peers from the child’s school and take place within the classroom setting. In this model, typically developing peers with strong social skills and interest in helping peers with social challenges volunteer to serve as peer mentors in the group and receive training before participation. See Box 1 for an example of peer training information used in a social skills group model; the efficacy of this information is currently being investigated in a multisite research project.21
Preliminary evidence is showing that this may be an effective strategy.Box 1
Example of peer mentor training information for adolescent social skills groups
- 10.Be as concrete as possible. Explain sarcasm, double meanings in jokes, and idioms.
- 9.Remember that facial expressions and body language cues may not work. Be direct.
- 8.Avoid verbal overload. Be clear and use short sentences. These students often struggle to find the main point.
- 7.If a student does something that hurts your feelings, say “When you did ___, it made me feel ___. Next time, can you please try ___.”
- 6.Planning activities may be particularly difficult for students in this group because making changes from daily routines can be a challenge. Reminders and preparation for the activity are helpful.
- 5.If students insist that they are correct and get into repetitive verbal arguments, have them write down the statement.
- 4.Be aware that these students may be sensitive to noises, smells, sights, or other senses that can make it virtually impossible to concentrate on anything else.
- 3.Do not take anything personally. Sometimes they may say things that are inappropriate; help to guide them towards an understanding of why it hurts your feelings. Perspective taking is hard for these students and they need practice.
- 2.Involve the students as much as possible, cueing them what to say if they seem at a loss during group activities or conversations (both inside and outside the group).
- 1.Most of all: have fun!! You will learn as much from these students as they will learn from you.
10 tips for working with students in the group
Another component that has recently begun to be incorporated into social skills groups is mindfulness and relaxation training. Mindfulness refers to the practice of being aware of and focusing on the present moment and is taught using meditation exercises.
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Mindfulness training is used in dialectical behavior therapy33
to treat individuals with borderline personality disorder, and it has also been used successfully to treat other conditions, including anxiety and chronic pain.32
Previous research has shown the effectiveness of mindfulness practices on reducing anxiety and improving social skills in other populations, including individuals with learning disabilities.34
In social skills groups for ASD, mindfulness may help group members focus on the group and lessen distractions from the school day. See Box 2 for an example of a mindfulness exercise that may be used at the start of an adolescent social skills group.Box 2
A mindfulness exercise for a social skills group
“Imagine yourself sitting inside an invisible egg. There is an invisible eggshell, a big circle all around you, front, back, up, down, and sideways. Close your eyes and stay very still. Relax into the quiet, not moving. Just rest there in the peaceful stillness, imagining yourself completely at ease. Expand into this space, as far as your mind can go, including the whole universe.” (Ring a bell.) “Now, see if you can hear the sound of the bell all the way to the end.” (Pause until the sound stops. Ring the bell at intervals of 30–60 seconds, over a period of ∼4–5 minutes).
Video Modeling
Video modeling is a type of social skills intervention in which children with ASD watch video demonstrations of themselves or other children successfully performing appropriate social skills, and then imitate the skills modeled in the video. Research has widely supported video modeling as an effective intervention for children and adolescents with ASD to learn many types of skills, including social skills.
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Skills learned through video modeling tend to be maintained over time and generalized to other people and settings.12
Video modeling seems to be most effective when it is combined with other interventions to teach social skills.36
Social Stories and Picture Books
Social stories are brief, individualized stories written to teach a social skill or behavior, or about a concept or event. Specific procedures for creating social stories are described by Gray and involve a parent or teacher writing a short story about the child with ASD, in the first person, about a skill, activity, or event, and lets the child know what, when, where, and why the situation, skill, or event will happen, along with the expected behavior or response of the child with ASD. For example, a parent or teacher may write a social story about a specific social skill such as greeting others, joining an activity, or giving a compliment. A social story about greeting others may describe the child going up to another child, saying hello, and asking how the other child is doing, and would explain why the child does this and the result. Studies have found some evidence of effectiveness for social stories when used as part of a more comprehensive social skills program.
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In a similar way to social stories, picture books can be used to teach social skills. Baker’s
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Social Skills Picture Book is an example of a picture book that is used for this purpose. This book has a collection of comic-strip photographs of children demonstrating various social skills and explaining why they are using those skills. Each set of pictures breaks up the social skill into several different components and the pictures are narrated using thought bubbles to show what the people depicted are thinking and feeling to make the social skills explicit.Access to services
Recognition of the disorder and accurate diagnoses are the first steps in the provision of appropriate services. The resources available to children and adolescents with ASD are increasing, but parents often struggle with access to effective services. Information regarding social skill training services is available through local and national organizations, with the Internet being one of the most effective ways to access information about specific opportunities in the child’s community. For example, pediatricians or parents may visit the Web site for the national advocacy group Autism Speaks (www.autismspeaks.org) and search for local social skills training opportunities under the Family Services tab. In addition, many large cities have Web sites designed to provide information about accessing local services. For instance, in the Seattle (WA) area, the Web site of the Asperger Support Network (www.seattleaspergers.org) provides information about social skills training opportunities in the area. The interventions described on these Web sites are typically social skills groups provided by speech therapists, occupational therapists, Board-certified Behavior Analysts, or mental health therapists in the area. In addition, many different social skills curricula can be found by searching online book retailers, as well as through local libraries and bookstores.
Another good way to access services is through the schools of children and adolescent with ASD. As schools are becoming more familiar with the needs of this population, they are more commonly offering social skills groups for these children through their individualized education programs (IEPs). Parents and pediatricians may request social skills groups as a part of the IEP for any child on the autism spectrum if this is not already being provided. As with all school-based services provided through an IEP, this service is free of charge to parents and is considered part of the child’s education.
Future directions
There are many different strategies to teach social skills to youth with ASD, and social skills training is an important component of intervention for this population. As a result of several recent calls for more multisite, randomized, controlled trials to determine the essential ingredients of effective programs,
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additional research is being conducted on manualized interventions and the literature body is expected to increase substantially in the next decade. Currently, specific research questions include pinpointing what works for which types of children and adolescents with ASD and designing effective programs that can be implemented at schools across the country.We expect that social skills interventions will continue to improve and that including typical peers in social skills training will become standard in most interventions to increase the generalization of skills. We also believe that mindfulness training will be an important component of social skills training for adolescents with ASD. As is the case across interventions for ASD and other developmental disabilities, interventions will be most effective when they are tailored to the specific needs of the children receiving the training.
Summary, clinical implications, and recommendations for pediatricians
Social skills deficits are a core feature of ASD and are amenable to treatment. Evidence is emerging for the effectiveness of social skills training for youth with ASD, with treatment options including social skills groups at school or in the community, peer training or mentoring, social stories, and video modeling. We recommend that social skills training should be included as a part of any comprehensive intervention program for youth with ASD.
Given the increasing prevalence of ASD, it is likely the pediatricians will encounter youth with ASD in their practices. Pediatricians are strongly encouraged to recommend social skills training as a part of routine care for this population. Pediatricians should consider asking parents of children with ASD about their children’s intervention programs (eg, speech therapy, occupational therapy, social skills training) and should recommend social skills training to those who are not already receiving it. Pediatricians may encourage parents to ask (and advocate, when needed) for these groups at their schools (typically through their child’s IEP), outpatient mental health centers, or developmental disability clinics, as well as through their speech and occupational therapists. Pediatricians may also recommend to parents and teachers the social skills training resources listed in Table 1.
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Footnotes
The authors have nothing to disclose.
Identification
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© 2012 Elsevier Inc. Published by Elsevier Inc. All rights reserved.
