Social skills deficits are considered to be one of the critical diagnostic impairments that define autism and Asperger Syndrome, so it is perhaps not surprising that both school personnel and clinicians in the community frequently recommend that a child or adolescent on the autism spectrum should be enrolled in social skills groups. The intention of such groups is to improve the development of these skills that often are so compromised. Yet just how much research evidence exists supporting the effectiveness of social skills groups as they are currently being delivered? The goals of this review are to summarize what the research tells us regarding efficacy of group social skills development models and to suggest to families what they should require from those delivering this kind of service.
Social skills are critical to successful adult outcome, from having rewarding personal relationships to academic and vocational accomplishment to overall mental health and quality of life. When considering these issues for the individual with an autism spectrum disorder we must be cognizant of the developmental nature of these conditions. Individuals on the autism spectrum have underlying brain differences that affect how they experience the world. In turn, experiences in life have direct consequences on ongoing brain development. So the outcome of any child’s development is the sum total of underlying assets and deficits and the life experiences that continuously shape all of us and directly impact brain development. That is why early intervention is such a powerful tool. It actually shapes brain development during critical periods and individual outcome can be profoundly affected by having or not having these kinds of experiences.
Those of us who work intensively with children with autism continually witness how autism unfolds and how the lack of certain experiences contributes to the ultimate outcome of each one of them. For example, it is not uncommon for parents to tell us that their child has never had a friend. While this is painful in and of itself, the developmental ramifications are significant. Peer interactions are necessary to develop the skills for maintaining conversation, taking perspective, playing appropriately, controlling emotional expression, negotiating conflict, and experiencing intimacy. Without these experiences in childhood, establishing a positive adulthood is very difficult. So, the child with the developmental differences of autism suffers the additional burden of limited experience in critical areas, resulting in what we so often see in young adults as inability to establish relationships or maintain a job and personal independence. Therefore it is no wonder that so many clinicians and educational professionals try to provide development in the area of social skills. We all know it is critical for successful adulthood. But is what is being typically provided in schools and clinics effective in improving essential social skills?
Very recently, four significant reviews of social skills interventions have been published (White et al., 2007; Rao et al., 2008; Matson et al., 2007; Bellini et al., 2007.) They provide guidelines for assessing social skills groups as they have been implemented and give us important standards for assessing whether critical qualities exist in what is being currently offered.
White, Keonig & Scahill describe their concern with social skills development as being based on findings that social skills deficits do not remit but become more devastating with age as the social milieu becomes more complex; that children in inclusive settings are often more rejected and isolated, yet are not given the skills to succeed; and that social skills deficits contribute to academic and occupational underachievement and later mood and anxiety problems. Given these outcomes, high quality social skills interventions are crucial. Fourteen studies were identified that addressed group intervention for children and adolescents identified as having an autism spectrum disorder (ASD.) All studies had very small sample sizes (ten or less.) Only two studies utilized a manualized approach specifically developed for individuals with an ASD while others used techniques developed for other populations. Others simply described their approaches in greater or lesser detail. Only five studies included a comparison group and none used randomized assignment to treatment group. None of the studies could be considered an effectiveness study, that is, one that examines the generalizability of gains to other settings. White et al. concluded that the state of research about social skills groups is still in its infancy. However, they identified some promising strategies, based on what was demonstrated in the studies, that should be considered in future program development. These include stimulating social motivation, rewarding social initiation, reinforcing appropriate social responding, treating interfering behaviors, and providing opportunities for skill generalization. Their strongest recommendation was that we need to develop and validate manualized social skills curricula to be utilized in schools and community-based groups.
Rao, Beidel & Murray reviewed papers evaluating social skills training programs for youth with Asperger Syndrome or high functioning autism to assess their efficacy and make recommendations for future research directions. They examined ten studies of high functioning children on the autism spectrum as such students are more likely to be in inclusion settings where the social demands are more intense. They found that current research is lacking in the following areas: establishing a common definition of what comprises social skills; conducting research that includes having control groups to compare outcomes and having blind observers to evaluate results; generalizing techniques to other settings; and conducting long term follow-up to determine if an intervention had any effects on eventual outcome. They recommended that future studies utilize manualized treatments specific to particular social deficits (e.g. simple interaction versus relationship development,) that more rigorous research designs be employed to assess effectiveness, and that generalization beyond the office be specifically implemented and measured. As in the previous review, these authors noted that the feasibility of improving social development through group instruction has been demonstrated, but the specific methods need further research.
Matson, Matson & Rivet examined a wide range of social skills interventions for children with ASDs of all functioning levels. In their review of seventy-nine treatment studies, they generated specific recommendations of what is required for the field to move forward toward more validated and specific social skills treatments. They suggest:
- Parent training models to improve generalization and to make intervention available for younger children
- Programs that address interfering behaviors or co-morbid disorders (such as severe anxiety)
- Interventions for children under six years of age whose brains have greater plasticity and who should be developing skills they can practice throughout elementary school
- Need-specific programs that can differentiate between those who need very basic versus more advanced skill development
- Consistent use of measurements in existing school and community social skills programs to assess if participants are meeting their specified goals
Bellini, Peters, Benner & Hope reviewed social skills interventions being delivered in school settings. As social skills development is almost universally stated as a goal for special education students with ASDs, this is a particularly critical area to examine. A meta-analysis of fifty-five single-subject design studies was conducted to formulate some generalizations about treatment effectiveness of programs as they are currently being delivered in schools and to specify what approaches seem to offer the best potential. Bellini et al. reiterate that there is only minimal evidence that social skills training programs are effective for children in general, let alone for those for whom social deficit is the defining attribute.
The most important conclusions of this review were that social skills interventions in schools, as they are being reported in the literature, have low to questionable treatment and generalization effects and moderate maintenance effects. That implies that most treatments were not particularly effective in changing social behavior or affecting any changes that generalize across settings, but that any changes that occurred were somewhat maintained. The studies were then assessed by approach with the general findings that interventions need to be more intensively implemented, that they should occur in context rather than in an office, that the strategy should match the specific skill deficit, and that validated treatments should be implemented by clinicians trained in the specific intervention to insure effectiveness. The findings of this analysis were discouraging and implied that much of what is now being done for students with ASDs in schools may be rather ineffective.
Given the limited research evidence for the effectiveness of group social skills interventions, what are responsible recommendations? For community-based interventions, parents should ask the following questions:
- Is there a manualized, evidence-based curriculum or a well-designed, explicit program with specific goals?
- Do the proposed group members have similar needs that are being addressed specifically?
- Do the target behaviors being addressed make sense for each member?
- Is generalization to real-life settings being designed as an integral part of the program?
As children with ASDs typically lack good generalization skills, it is necessary to provide more specific opportunities for practice in realistic settings. This can be implemented through parent involvement with each session’s lesson, rehearsal and reinforcement homework for members, and prescribed member interaction between sessions. Interventions can also take place in actual life locations. Of importance, as well, is the therapist’s orientation to achieving measurable goals. Does the group leader:
- Assess each member’s needs before inclusion in the group?
- Have plans for assessing effectiveness?
- Consider the family’s specific desires for skill acquisition?
- Assess satisfaction with the service at the conclusion?
In-school services also need to be examined. Families should request that:
- Services be very specifically described on the student’s individualized educational plan
- Those delivering the services have knowledge about both social skill development and the specifics of delivering such services to children on the autism spectrum
- Services be of sufficient intensity to be effective
- School personnel are utilizing evidence-base practices
- Interventions are being delivered in authentic locations such as playgrounds, classrooms, and lunchrooms, rather than only professional offices.
Sometimes parents do not feel sufficiently knowledgeable or empowered to request the services their child truly needs to promote the best outcome. It is important for parents to be wise consumers by:
- Requesting specific plans and generalization strategies
- Learning how to reinforce social skills through play dates and get-togethers
- Helping their child maximize strengths and interests in social settings
- Negotiating with school treatment teams to implement a true social skills program that is individually designed and data-driven
Meanwhile, professionals who specialize in autism and Asperger Syndrome can help families gain awareness of the current state of knowledge; understand what they as parents can specifically accomplish with their children; and know what critical questions to ask of anyone currently providing social skills intervention in schools or community. Together, parents and professionals should continue to advocate for more treatment-based research on social skills development now.