This paper reviews empirical research on social skills interventions (SSIs) for children and adolescents diagnosed with high-functioning autism spectrum disorder (HFASD), including Asperger's syndrome. Drawing on multiple randomized controlled trials and preliminary studies, it examines the design, outcome measures, and findings of interventions such as the Socio-Dramatic Affective-Relational Intervention (SDARI), Skillstreaming, the PEERS program, and a school-based consultation model. The review evaluates the relative effectiveness of social knowledge versus social performance approaches and identifies methodological limitations — including small sample sizes and infrequent use of rigorous controls — that constrain definitive conclusions about SSI efficacy.
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 gap, 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, and eccentric, sexual, or supervision-escaping behaviors (Matson, Hess, and Mahan, 2013). Verbal communication and social skills were assessed 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 performed 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 was that social competency does not depend on verbal communication skills in children with autism spectrum disorders, but rather 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) focused 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 the Socio-Dramatic Affective-Relational Intervention (SDARI) (Lerner, Mikami, and Levine, 2011). A central component of SDARI is the use of games — including electronic games — to motivate children to interact socially with peers and staff (Lerner, Mikami, and Levine, 2011). Role-playing, improvisation, and physical activities are among 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 in 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). Outcome measures depended on survey instruments that parents completed before and after the intervention, assessing behavioral problems, social skills, nonverbal 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 summer program in 2007 (Lerner, Mikami, and Levine, 2011). The SDARI intervention staff were unaware of which children in their groups were enrolled in the study (Lerner, Mikami, and Levine, 2011). Evaluations took place every three weeks 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 both before and after sessions, as well as the durability of any improvements over time.
Based on parent responses, the only advantage conferred by SDARI was a significant increase in social assertion (Lerner, Mikami, and Levine, 2011). From the children's perspective, SDARI increased their 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 a broadly effective SSI, although there are methodological limitations to the study's design, including the small sample size and the non-random distribution of participants.
Lerner and Mikami (2012) conducted a preliminary randomized controlled trial (RCT) to compare the efficacy of 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 Mikami, 2012). Outcome measures included instructor-observed social behavior and skills, sociometrics reported by the children, and parent-reported improvements observed at home (Lerner and Mikami, 2012). Parents were blind to the treatment group assignment (Lerner and Mikami, 2012). The intervention involved a single 90-minute session per week after school over four weeks (Lerner and Mikami, 2012).
Social behavior patterns observed during the intervention sessions were reduced in the SDARI group compared to the Skillstreaming group (Lerner and Mikami, 2012). Positive interactions, such as sharing toys, occurred less frequently, but so did negative interactions (Lerner and Mikami, 2012). Low-level interactions, such as looking at the faces of other children, were similarly reduced over time (Lerner and Mikami, 2012). The children participating in both interventions became more popular with their peers over time, but the greatest improvement between the first and last intervention session was in the Skillstreaming group (Lerner and Mikami, 2012). Reciprocal friendships also improved over time, but no between-group difference was found (Lerner and Mikami, 2012). Staff reported that both groups improved their social skills over time; however, these improvements were not noticed by parents at home (Lerner and Mikami, 2012).
Lerner and Mikami (2012) conclude that both interventions — Skillstreaming and SDARI — are effective in improving the social skills of pre-adolescent boys with HFASD within a very short intervention period. Yet their findings suggest that Skillstreaming, as a social knowledge intervention, produced the best overall result. Although the number of subjects was small (just 13 boys between 9 and 13 years of age), the effect sizes easily reached statistical significance (Lerner and Mikami, 2012). When choosing between Skillstreaming and SDARI, Skillstreaming appears to be the better option 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 per week over five weeks during 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, children were randomized to either a treatment or wait-list group (Lopata et al., 2010). 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).
"RCT and replication confirm manualized SSI effectiveness"
"PEERS improves seven of eleven social outcome measures"
"School psychologist consultation yields modest social improvements"
"Methodological gaps limit definitive SSI efficacy conclusions"
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