The ability to develop and maintain interpersonal relationships is a cornerstone of successful child development and among the greatest challenges for children with autism spectrum disorders (ASD; Church, Alisanski, and Amanullah, 2000). Effective interpersonal relationship skills are important for social and familial functioning, academic performance, and workplace success. Children who experience significant difficulty in their interpersonal relationships are at risk for a variety of negative outcomes. In particular, these children are more likely to experience social isolation or rejection, academic underachievement, and mental health problems (Tantam, 2000; Welsh, Park, Widaman, and O’Neil, 2001). Additionally, the lack of social relationships constitutes a major risk factor for poor general health outcomes (House, Landis, and Umberson, 1988).
Improving children’s social skills is one of the most powerful predictors of a positive outcome for children with ASD (Painter, 2006). Children with adaptive social skills will be better equipped to successfully navigate the complex and dynamic world in which we live. Social skills training is an intervention aimed at fostering social skills by teaching specific skills (e.g., initiating conversation) or social problem solving (i.e. a framework to help make more independent and appropriate decisions in novel social situations) through the use of behavioral and social learning techniques (Cooper, Griffith & Filer, 1999).
Effective social skills training is predicated on accurately understanding and identifying the specific areas of need. Gresham and Elliott (1989) distinguished between skill deficits and performance deficits. A skill deficit occurs when a child lacks sufficient knowledge to execute a particular skill, while a performance deficit is when a child possesses knowledge of how to utilize a skill, but fails to perform the skills in a given situation (Gresham and Elliott, 1989). This distinction has important implications for how social skills interventions are conducted.
Addressing skill deficits requires teaching the child specific skills. Just as children are taught how to complete math problems, students with ASD require direct instruction on social skills development. But unlike teaching math, where two plus two always equals four, social skills instruction is more challenging due to the dynamic nature of social interactions. Promoting skill development requires a multi-component process, such as the “3-D model” (Asher, Gordon, Selbst, and Cooperberg, 2010). This model includes Discussing the steps to implement a skill, Demonstrating the skill for the child, and having the child Do the skill.
Performance deficits are addressed by increasing a child’s motivation to perform a desirable social skill. This is done through the use of consequence-based interventions, which are responses that occur following the exhibition of appropriate social skills. For example, positive reinforcement may include providing behavior specific praise (e.g., “I like the way you waited patiently to speak”) or administering a tangible reward (e.g., a small prize). Additionally, a child who appropriately initiates a conversation may receive the natural consequence of learning new information or making a new friend. A child may also receive a logical consequence, such as gaining access to a preferred activity that is closely related to the use of a desired social skill (e.g., complying with instructions to turn off the video game before dinner earns time to play the video game after dinner). As children with ASD often have a combination of skill and performance deficits, social skills training typically includes both promoting skill acquisition and enhancing skill performance.
An additional, and equally important, aim of social skills training is facilitating the generalization and maintenance of social skills. Social skills interventions often result in children exhibiting pro-social behaviors in a specific place (e.g., an office) for a limited period of time. The major challenge of social skills training is assisting children to consistently use their newly learned skills across different settings, with different people, and at different times (Gresham, 1998).
Social Skills Training in a Clinical Setting
Successful social skills training requires comprehensive intervention that includes skills training, increasing motivation, and generalization of skills to the real-world setting (Gresham, 1998). In clinical practice, these needs are met through the combination of group and/or individual therapy, communication with parents, and consultation with teachers. Specific treatment recommendations should be tailored to each child’s needs.
Social skills groups are a common intervention for children with ASD because they provide a forum for children to learn and practice specific social-behavioral skills with their peers in a controlled setting (Ozonoff, Dawson, and McPartland, 2002). While social skills curricula may vary, it is essential that programming be based on evidence-based strategies (e.g., Elias and Butler, 2005; McGinnis & Goldstein, 1997). Specific skills should be targeted each week and sessions should include discussions, skills demonstrations, and role plays during which feedback is provided. Adapted from previously published social skills group curricula, the groups at our practice include modules on emotion identification, empathy training, conversation and play skills, affect management, and social problem solving. The groups are one hour per session and occur once a week for 8 to 12 weeks, based on the local school schedules. Groups are comprised of four to eight children and are run by a licensed psychologist with extensive experience and training in social skills instruction and ASD.
While conducting social skills training within a group setting is most ideal for initial skill acquisition, our clinical experience suggests that this is not always possible. Some children may not yet possess the prerequisite language skills and/or behavioral abilities to gain full benefits from the group format. Logistically, other children may not be available to attend groups at the offered times due to personal scheduling conflicts. In these cases, children may benefit from social skills training delivered via structured individual therapy sessions.
In order to help children generalize learned social skills to their everyday environment, it is critical that clinicians engage parents and school personnel in the treatment process. In our experience, the clinician will often serve as a “point person,” taking on the responsibility to communicate with the parents and school staff to ensure interventions are applied consistently across settings. The use of written materials is one efficient and effective method to facilitate communication between all parties. For example, we communicate with parents by providing a weekly packet that includes a description of the target social skills being discussed during the session (including relevant visual aids), related readings, and a take home assignment. Parents are then encouraged to share this information with teachers or other relevant school personnel. At the conclusion of treatment, feedback about a child’s performance is shared with the parents and, with permission, school personnel. Working with a child over the course of several weeks allows a skilled clinician to identify a child’s social strengths and needs, as well as to determine behavioral strategies that have proven more and less effective in promoting the use of desired social skills.
Parents and teachers who are familiar with the contents discussed during group or individual sessions can provide ongoing coaching and feedback using a consistent model across settings while providing real-life opportunities for social practice with peers. A useful approach that parents and school personnel can utilize to foster social skill development is the “4 Ps” (Christophersen and Mortweet, 2003). These include pointing out to the children when others are using an appropriate skill, practicing the skills with their children, prompting the children to engage in specific skills, and praising the children for the exhibition of specific skills.
Children with ASD have persistent deficits in social communication and social interaction across multiple contexts. These difficulties affect nearly every aspect of these children’s lives and may have lifelong negative implications if they are not effectively treated. Teaching social skills requires systematic, comprehensive intervention and collaboration between the treating clinician, parents, and school personnel. Conducting social skills training based on behavioral principles in a clinical setting is one effective method to assist children with ASD to acquire and utilize pro-social behaviors in their daily lives. By addressing skill deficits, performance deficits, and generalization difficulties, treatment can help children develop critical skills in order to navigate the social world with more ease and success.
Dr. Flancbaum, Dr. Cooperberg, and Dr. Panter are licensed psychologists at Behavior Therapy Associates in Somerset, New Jersey. They provide a variety of services for children and adolescents with ASD and related disorders, including individual and group therapy, school-based consultation, and training workshops for professionals. For more information, see www.BehaviorTherapyAssociates.com. Correspondence can be directed to Meir.Flancbaum@gmail.com.
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