Social Skills Interventions for Adolescents Diagnosed with High-Functioning Autism Spectrum Disorder
Social Skills Interventions for Adolescents Diagnosed with High-Functioning Autism Spectrum Disorder
Surprisingly, the possibility of a causal relationship between challenging behaviors, social abilities, and language deficits in children and adolescents with autism spectrum disorders had never been systematically studied. To remedy this lack of understanding Matson and colleagues (2013) examined the association between challenging behaviors and social competence in a large group of children (N = 109) between the ages of 3 and 16 years diagnosed with autism spectrum disorders, including Asperger's syndrome. The challenging behaviors examined included aggression, self-injury, eccentric, sexual, or escaping supervision (Matson, Hess, and Mahan, 2013). Verbal communication and social skills were tested using two validated instruments (Matson, Hess, and Mahan, 2013).
The findings of Matson and colleagues (2013) reveal that challenging behaviors had a strong moderating effect on social skills. The most predictable result was that children with few challenging behaviors and strong verbal skills had the strongest social skills (Matson, Hess, and Mahan, 2013). What was not expected, however, was that the worse a child was in terms of challenging behaviors the worse they did socially regardless of how strong their verbal skills were (Matson, Hess, and Mahan, 2013). In other words, verbal communication abilities had only a minimal impact on social skills compared to challenging behaviors. The logical conclusion drawn by the authors of this study was that social competency does not depend on verbal communication skills in children with autism spectrum disorders, but on the prevalence and severity of challenging behaviors that prevent successful social interactions (Matson, Hess, and Mahan, 2013).
Lerner and colleagues (2011) were interested in understanding the utility of a social skills intervention (SSI) that focus on improving social performance in children and adolescents with high-functioning autism spectrum disorders (HFASDs). They utilized a contemporary version of the Drama-based Social Pragmatic Intervention called Socio-Dramatic Affective-Relational Intervention (SDARI) (Lerner, Mikami, and Levine, 2011). A central component of SDARI is the use of games, including electronic, to motivate children to interact with peers and staff socially (Lerner, Mikami, and Levine, 2011). Role-playing, improvisation, and physical activities are some of the other tools employed (Lerner, Mikami, and Levine, 2011).
Lerner and colleagues (2011) enrolled 17 boys and girls between the ages of 11 and 17 for the study. The children were distributed between a treatment and non-treatment group in a non-random manner, largely controlled by enrollment opportunity and ability to pay (Lerner, Mikami, and Levine, 2011). The outcome measures were dependent on survey instruments the parents completed before and after the intervention, which assessed behavioral problems, social skills, non-verbal communication abilities, social responsiveness, and satisfaction with the intervention (Lerner, Mikami, and Levine, 2011). Survey instruments completed by the children assessed nonverbal accuracy and depression severity (Lerner, Mikami, and Levine, 2011).
The children enrolled in the treatment group participated in 145 hours of SDARI over 29 sessions, within a six-week program during the summer of 2007 (Lerner, Mikami, and Levine, 2011). The SDARI intervention staff was unaware of which children in their groups were enrolled in the study (Lerner, Mikami, and Levine, 2011). Evaluations took place every three-week for a total of seven times, with the SDARI sessions occurring in the middle of an 18-week study period; therefore, the study examined SDARI efficacy before and after sessions and the resiliency of any improvements over time.
Based on parent responses the only advantage that SDARI conferred was a significant increase in social assertion (Lerner, Mikami, and Levine, 2011). From the child's perspective, SDARI increased competence in judging the emotional content in adult voices (Lerner, Mikami, and Levine, 2011). These improvements persisted for at least six weeks following completion of the intervention (Lerner, Mikami, and Levine, 2011). These results suggest that SDARI is not an effective SSI, although there are methodological limitation to the study's design, such as the small sample size and the non-random distribution of the children.
Lerner and Makami (2012) conducted a preliminary randomized controlled trial (RCT) to compare the efficacy two SSIs for high-functioning peri-pubertal boys with autism spectrum disorders. The social knowledge SSI chosen for the study was Skillstreaming and its effectiveness was compared with that of the social performance SSI SDARI (Lerner and Makami, 2012). The outcome measures were instructor observed social behavior and skills, sociometrics reported by the children, and parent reported improvements observed at home (Lerner and Makami, 2012). The parents were blind to the treatment group (Lerner and Makami, 2012). The intervention involved a single 90 minute session per week after school for 4 weeks (Lerner and Makami, 2012).
Social behavior patterns observed during the intervention sessions were reduced in the SDARI group compared to the Skillstreaming group (Lerner and Makami, 2012). Positive interactions, such as sharing toys, occurred less frequently, but so did negative interactions (Lerner and Makami, 2012). Low-level interactions, such as looking at the faces of other children, were similarly reduced over time (Lerner and Makami, 2012). The children participating in both interventions became more popular with their peers over time, but the greatest improvement between the end of the first and last intervention session was in the Skillstreaming group (Lerner and Makami, 2012). Reciprocal friendships also improved over time, but no between group difference was found (Lerner and Makami, 2012). Staff also reported that both groups improved their social skills over time; however, these improvements were not noticed by parents at home (Lerner and Makami, 2012).
Lerner and Makami (2012) conclude that both interventions, Skillstreaming and SDARI, are effective in improving the social skills of pre-adolescent boys having HFASD within a very short intervention period. Yet, the findings of Lerner and Makami (2012) suggest that the Skillstreaming intervention, which is a social knowledge intervention, produced the best result. Although the number of subjects in the study was small, just 13 boys between 9 and 13 years of age, the effect sizes easily reached statistical significance (Lerner and Makami, 2012). When given a choice between Skillstreaming and SDARI, Skillstreaming seems the best choice for HFASD boys transitioning through puberty.
Lopata and colleagues (2010) also conducted an RCT to compare the efficacy of a manualized SSI when treating 36 HFASD children between the ages of 7 and 12. The intervention was adapted from Skillstreaming and involved five daily 70-minute sessions for a period of 5 weeks over the summer (Lopata et al., 2010). Each session began with 20 minutes of intensive instruction incorporating the following steps: defining the skill, modeling the skill, establishing the skill needed for a particular child, selecting the role-player, choreographing the role-play, giving feedback, and assigning homework (Lopata et al., 2010). The instruction session was followed by a 50-minute therapeutic session structured so that children were encouraged to practice learned skills with peers (Lopata et al., 2010).
At the beginning of the study the children were randomized to either a treatment or wait-list group (Lopata et al., 2010). The outcome measures included survey instruments designed to assess social skill competency, severity of autism spectrum features, parent and teacher evaluations of social skills and withdrawal, social knowledge, nonverbal accuracy, spoken language competency, intelligence, and intervention satisfaction questionnaires designed by the researchers for parents, children, and intervention staff (Lopata et al., 2010).
All outcome measure except for two revealed significant improvements in children within the treatment group (Lopata et al., 2010). The two exceptions were the BASC-2-TRS social skills and non-verbal accuracy, which revealed a non-significant trend favoring the treatment group (Lopata et al., 2010). The satisfaction surveys revealed high levels of satisfaction among all three groups (Lopata et al., 2010). Overall, the social features associated with HFASD children were significantly reduced and the level of social functioning increased (Lopata et al., 2010). The greatest improvement was observed for social skill knowledge and idiom comprehension (Lopata et al., 2010).
The limitations of the RCT conducted by Lopata and colleagues (2010) were addressed in a replication RCT conducted two years later. The main limitations cited by the authors was the lack of a confirmation of diagnosis using a gold standard and a long-term assessment of the durability of the changes over time (Thomeer et al., 2012). Thomeer and colleagues (2012) enrolled 35 children between the ages of 7 and 12 years. The enrolled children were diagnosed with high-functioning autism, Asperger's syndrome, or pervasive developmental disorder -- not otherwise specified (PDD-NOS) and therefore fit within the HFASD classification (Thomeer et al., 2012). The children were randomized to a treatment or wait-list group and the same outcome measures utilized (Thomeer et al., 2012).
Based on parent, child, and staff ratings the treatment group experienced significant improvements by the end of the intervention compared to wait-listed children, with a few exceptions (Thomeer et al., 2012). Withdrawal symptoms based on parent ratings failed to reach significance, but trended in a direction that favored the treatment group (Thomeer et al., 2012). Child ratings for non-verbal accuracy (child faces) had the same outcome (Thomeer et al., 2012). All staff ratings reached…
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