Using Behavioral Strategies to Improve
Social Skills in Children & Adolescents
   with Autism Spectrum Disorder




      ...
Overview
• Introduction & Overview of current research 
  in social skills training
• Intervention methods
• Behavioral Ba...
Criteria for ASD
• Impairment in socially reciprocal behavior

• Impairment in communication

• Restricted and repetitive ...
Subtypes



• Autism
• Asperger’s Disorder
• Childhood Disintegrative Disorder
• Rett’s Disorder 
• Pervasive Developmenta...
Social Skills Training for
children on the autism spectrum
Social Skills Groups: A Growing Trend
• Research and evidence‐based programs have not 
  caught up with the popularity and...
Social Skills Groups: A Growing Trend
• Pre‐planned lessons and social skills instruction 
  books are widely available an...
Growing too fast?
• No single approach will be successful with everyone, 
  especially in a group setting
• Parents and te...
Why so difficult?
• We need programs with empirical support for 
  efficacy
• Randomized clinical trials are difficult to ...
Social Delays: across the spectrum…
• Lack of interest in interaction

• Poor eye contact

• Little use of nonverbal commu...
Components of Successful Social
       Behavior: Varied & Complex
To name a few….

•   Imitation
•   Learning give and tak...
Within Autism….
• Children with ASD often miss out on the 
  incidental learning opportunities for these 
  social skills
...
How can we accommodate social behaviors and
 weaknesses unique to autism in a group setting?
• Incorporating ‘discussion’ ...
In Vivo Socialization
• It is not the activities alone that help 
  children learn social skills 
• It is the EXPERIENCE o...
Evidence-based Approaches to
  Social Skills Programming
Scripting and Fading
                    (McClannahan & Krantz, 2005)

• Construct scripts:
    • Choose phrases that gain...
Scripting Social Skills
• Provide explicit written script of interaction, e.g.,

    – Walk up to a classmate

    – Make ...
Scripting with Peer Training
Peers taught 5 facilitative skills w/o target child 
   present:

   1.   Look, wait, and lis...
Incidental Teaching
                            (McGee et al., 1999)

• Materials are controlled so that target 
  child m...
Peer Group Entry
               (Beilinson & Olswang, 2003)

• Lead Child is assigned a role to establish 
  group members...
Peer Group Entry

1.   Walk over to your friend.

2.   Watch your friend.

3. Get a toy like your friend is using.

4. Do ...
Buddy Time
                    (English et al., 1997)

•   20 min. period during school day
•   Each child assigned a budd...
Direct Instruction, con’t.
The “Conversation Can” (Brinton, Robinson & 
    Fujiki, 2005):

•   Brainstorm a list of topic...
Social Stories
                              (Gray, 2000)

• Descriptive sentences: statements of fact
    – Many children...
Example Social Story
Quirmbach, 2008 Review
• Reviewed 52 studies using Social Stories
• Studies aimed a variety of ages and ability levels
• A...
Comic Strip Conversations
• Use ‘think’ and ‘word’ bubble cartoons
• Provide a visual tool to show conversation and 
  thi...
Games Based on Special Interests
                      (Baker et al., 1998)


Develop social games based on special 
 inte...
Video Modeling
               (Nikopoulos & Keenan, 2003)


• Use commercial material such as My School Day
  (http://www....
Video Modeling
• View video, discuss reactions
• View video, attend to focused cue, discuss what 
  was noticed or what ch...
Social Cognitive Skills Training (Timler
                          et al., 2005)

Role play social scripts in peer group
 ...
Social Skills Groups
• Can use commercial curricula, such as
  • Navigating the Social World (McAfee, 2001)
  • Skillstrea...
Peer Support Networks
                       (Haring & Breen, 1992)


• Select 2‐5 peers to serve as social 
  support for...
Meta-analysis of Social Skills Interventions:
            Bellini et al., 2007
• Most effective when
  • Deficits of child...
Principles of Pragmatic Intervention
    Strategies: Involve the SLP



• SLPs have a legitimate role in assessing and 
  ...
Effective Techniques: Social Skills
                      Training
                         (Timler et al., 2007)
• Teache...
Treatment & Goal Planning



• Group leaders should learn what behaviors are of 
  most concern to parents and teachers an...
Steps for evaluating social behavior in
   preparation for goal planning
1. Observe the child
2. Identify positive pro soc...
Treatment and Goal Planning: your
            contribution
• Note positive and negative behaviors displayed
• Note strengt...
Preparation
• These observations and notes can be 
  formally organized into a functional 
  assessment of behavior
• Whic...
Sample Treatment Plan
                  Reinforcement/                  Competing             Strategies for prevention/
P...
Friends Group



Visual schedule   1.
                       Greeting



for group         2.
                       Rules...
Peer Tutors as Social Models
• Boys & Girls
• No clinical concerns or outstanding 
  behavior issues
• Natural ‘helpers’
•...
Peer tutor worksheet, example

               Children with Autism Spectrum Disorders can:

• Have trouble understanding l...
Things to remember:
               Advocate for your child
• Consider your child’s learning style
• Provide input regardin...
Critical Components
 Activities designed
to learn and practice                        Pare
                               ...
Important to consider
   • Children can be agents of change for each 
     other
   • Children with autism can actively 
 ...
Thank you!
• A special acknowledgement to Kathy Koenig and the clinicians and
  investigators at the Yale Child Study Cent...
To Medicate Or Not Autism Spectrum Handout [Compatibility Mode]
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To Medicate Or Not Autism Spectrum Handout [Compatibility Mode]

  1. 1. Using Behavioral Strategies to Improve Social Skills in Children & Adolescents with Autism Spectrum Disorder Moira Lewis, M.S. CCC-SLP Health Education Workshop Summer 2010
  2. 2. Overview • Introduction & Overview of current research  in social skills training • Intervention methods • Behavioral Basis for group interventions • Peer tutor information • Questions & Answers
  3. 3. Criteria for ASD • Impairment in socially reciprocal behavior • Impairment in communication • Restricted and repetitive behaviors and/or  interests
  4. 4. Subtypes • Autism • Asperger’s Disorder • Childhood Disintegrative Disorder • Rett’s Disorder  • Pervasive Developmental Disorder ‐‐ not otherwise  specified 
  5. 5. Social Skills Training for children on the autism spectrum
  6. 6. Social Skills Groups: A Growing Trend • Research and evidence‐based programs have not  caught up with the popularity and number of  social skills groups, clinics, and materials at this  point in time • We know there is a need for both intervention and  additional evidence • Children and adolescents with ASD do desire  and  deserve friendships and long lasting relationships • Do we know what works best?
  7. 7. Social Skills Groups: A Growing Trend • Pre‐planned lessons and social skills instruction  books are widely available and used, and continue  to be published • Are worksheets and pre planned lessons  addressing individual skills from week to week the  most effective way to teach? • What is a more effective way for children to learn & practice Consider this: • Allow individual needs of the children to dictate the  lessons and activities
  8. 8. Growing too fast? • No single approach will be successful with everyone,  especially in a group setting • Parents and teachers are eager to find an effective way to  improve a child’s ability to interact and lead to successful  relationships • Providers have been pushed to employ multiple methods  to address social skills intervention • A majority have not been empirically tested • Good news: research is being conducted as we speak • Bad news: Difficult area of research to implement well.
  9. 9. Why so difficult? • We need programs with empirical support for  efficacy • Randomized clinical trials are difficult to do  especially in school and clinical settings • We need social outcome measures to assess subtle  changes/improvement in social skills and  behavior • Most social skill programs rely on curriculum that  is anecdotally based, not systematically tested • Future directions currently being ‘tested’
  10. 10. Social Delays: across the spectrum… • Lack of interest in interaction • Poor eye contact • Little use of nonverbal communicative means • Lack of social or emotional reciprocity  • Deviant or absent language • In those with speech, inability to sustain a conversation • Cognitive impairment  
  11. 11. Components of Successful Social Behavior: Varied & Complex To name a few…. • Imitation • Learning give and take • Perspective taking • Regulating reactions • Opportunities for interactions over time • ‘Personal History’ • Verbal and nonverbal communication • Understanding non literal language and sarcasm • Problem solve simple conflicts with peers
  12. 12. Within Autism…. • Children with ASD often miss out on the  incidental learning opportunities for these  social skills • Decreased levels of motivation and interest  in others • Difficulty interpreting subtle social cues • Interactions and social rules constantly  change • Varied learning styles
  13. 13. How can we accommodate social behaviors and weaknesses unique to autism in a group setting? • Incorporating ‘discussion’ of social skills among  learners is not likely to always be successful • Verbal learning=often a weakness of children with  ASD • Most children require a great deal of practice,  repetition, and reinforcement to be able to : • Learn a skill + apply it flexibly • Being told what to do in a social situation vs.  applying or performing the behavior flexibly in the  correct setting • Real interaction is CRITICAL
  14. 14. In Vivo Socialization • It is not the activities alone that help  children learn social skills  • It is the EXPERIENCE of carrying out the  activity, with facilitation from adults and  with peers • Acceptance and responsiveness should be  consistently promoted so that members  come to feel they ‘belong’ • May promote self esteem, a sense of  accomplishment, a sense of friendship, a  motivation to pursue successful peer  relationships
  15. 15. Evidence-based Approaches to Social Skills Programming
  16. 16. Scripting and Fading (McClannahan & Krantz, 2005) • Construct scripts: • Choose phrases that gain access to favorite objects  and activities (“Tickle me!”) • Select scripts that contain different words • Use fully grammatical forms • Make scripts age‐appropriate • Start w/ 1‐2 scripts, increase as  mastered • Record scripts • Use model to introduce use of scripts • Teach script sequence • Increase number of scripts used • Fade portions of scripts
  17. 17. Scripting Social Skills • Provide explicit written script of interaction, e.g., – Walk up to a classmate – Make eye contact – Say, “Hi ____________” • Practice script w/ clinician • Practice w/ peer • Script Fading: Cut off increasingly large parts of script,  until client can do the scene independently
  18. 18. Scripting with Peer Training Peers taught 5 facilitative skills w/o target child  present: 1. Look, wait, and listen 2. Answer questions 3. Start talking 4. Say something nice 5. Keep talking Target children given written scripts for social  interaction  (“Can I play checkers with you?”)
  19. 19. Incidental Teaching (McGee et al., 1999) • Materials are controlled so that target  child must interact to obtain needed  objects and complete favored activities • Interactions are ‘engineered,’: • Child is assigned to complete puzzle • Peer holds all puzzle pieces and is told to  hold them until asked • Child must ask for each piece to complete  task Creating communication temptations and  barriers.
  20. 20. Peer Group Entry (Beilinson & Olswang, 2003) • Lead Child is assigned a role to establish  group membership • Child is prompted to initiate interactions • Child is given highly valued objects,  game, or ‘prop’ • Target child is taught five‐step sequence  for entering group, using Visual Schedule
  21. 21. Peer Group Entry 1. Walk over to your friend. 2. Watch your friend. 3. Get a toy like your friend is using. 4. Do the same thing as your friend. 5. Tell an idea.
  22. 22. Buddy Time (English et al., 1997) • 20 min. period during school day • Each child assigned a buddy • Buddies rotate • Class or peers are taught ‘buddy’ rules sequentially • Both buddies receive reward if follow rules for entire  buddy period: 1. STAY 2. PLAY 3. TALK: say name, talk about the play, respond to partner, repeat then say more about it, ask a Question
  23. 23. Direct Instruction, con’t. The “Conversation Can” (Brinton, Robinson &  Fujiki, 2005): • Brainstorm a list of topics classmates might want to discuss • Write each on a slip of paper • Put slips in can • Take turns pulling out a topic • Start conversation: – Think first: What should I say – Say two things about the topic – Ask interlocutor a question about the topic – Listen while interlocutor answers
  24. 24. Social Stories (Gray, 2000) • Descriptive sentences: statements of fact – Many children play on the playground during recess. • Perspective sentences: refer to internal states – Some children like to make a lot of noise. • Affirmative sentences: express a common value – One child goes down the slide at a time. – This is a safe thing to do. • Control sentences: identify personal strategies – When I have to wait my turn on the slide, I can count the people in front of me to make the time go faster. • Cooperative sentences: what others can do to help. – The teacher can help me if I feel impatient. She can talk to me while I wait.
  25. 25. Example Social Story
  26. 26. Quirmbach, 2008 Review • Reviewed 52 studies using Social Stories • Studies aimed a variety of ages and ability levels • ALL used case study methodology • 60% reported positive outcomes – On a range of behaviors – Most target reducing inappropriate behaviors • Data on increasing pro‐social behaviors is less abundant
  27. 27. Comic Strip Conversations • Use ‘think’ and ‘word’ bubble cartoons • Provide a visual tool to show conversation and  thinking Sam doesn’t know  Sam, I saw a  as much as I do  cowcatcher on an old‐ about trains. I will  fashioned train  find out if he knows  yesterday. Do you  what the  know what that is? cowcatcher does  before I tell him  about the one I saw
  28. 28. Games Based on Special Interests (Baker et al., 1998) Develop social games based on special  interests of target child • Involve target child in development of materials and rules • Have target child teach game to peer • Set up special opportunities to play game • Take turns choosing games to play during interactive game  time • Use favorite games as a method of developing an  interaction‐ naturally motivating!
  29. 29. Video Modeling (Nikopoulos & Keenan, 2003) • Use commercial material such as My School Day (http://www.modelmekids.com/) • Video tape peers conducting interactions such as  greeting, negotiating, etc. • Use video clips from TV shows to exemplify  interactions (may use negative interaction) • Rehearse with written scripts first • Verbal rehearsal
  30. 30. Video Modeling • View video, discuss reactions • View video, attend to focused cue, discuss what  was noticed or what changed • Re‐enact scene on video with clinician • Re‐enact with peer • DESCRIBE VERBALLY  while watching • Improvise similar situation
  31. 31. Social Cognitive Skills Training (Timler et al., 2005) Role play social scripts in peer group • Situation paragraph read to group • 4‐5 situations/ 2 hour session • 6 weeks of 2 sessions/week Guide role play to identify what they know about situation  from their own and other’s perspective (thinking about  thinking) Ask Questions, identify a range of response strategies by  • selecting goal,  • stating alternative strategies to reach goal • Evaluating consequences after response
  32. 32. Social Skills Groups • Can use commercial curricula, such as • Navigating the Social World (McAfee, 2001) • Skillstreaming the Adolescent (Goldstein &  McGinnis, 2000) • Provide consistent group structure • Check‐in, greet • Review last meeting’s skill • Introduce new skill • Model and role play new skill • Snack, social time • Activity that allows real‐life practice of new skill • Summary
  33. 33. Peer Support Networks (Haring & Breen, 1992) • Select 2‐5 peers to serve as social  support for student with ASD • Assign each support peer a 20 minute period/day to  structure activities for student with ASD, e.g.: – Lunch: use Prompt and Praise to engage with others  at table – Recess: teacher or clinician creates scripts for  entering games; peer support and target student  practice in private, then on playground
  34. 34. Meta-analysis of Social Skills Interventions: Bellini et al., 2007 • Most effective when • Deficits of child are systematically matched to  intervention strategy • Ex.: If child lacks skills to enter peer group, teach  those; if child can enter but cannot participate and  maintain participation, teach those skills • Targeting social‐cognitive skills; use meta‐ linguistic and meta‐cognitive strategies • Done in classroom settings • As opposed to settings contrived for the purpose
  35. 35. Principles of Pragmatic Intervention Strategies: Involve the SLP • SLPs have a legitimate role in assessing and  developing social/pragmatic skills • Students with ASD will not acquire social skills  from exposure; they require mediated experiences • Verbal, written and graphic supports are effective • Peer involvement is an essential element – Peers need training, but it is not extensive
  36. 36. Effective Techniques: Social Skills Training (Timler et al., 2007) • Teacher Redirects • Prompting children to play with one another • Rephrasing or restating one child’s statement for  another • Praising children for playing together • Direct instruction in social language • Modeling and practice with explicit cues • Role play with prompting • Corrective feedback • Authentic contexts (peer involvement) • Self‐monitoring for older students
  37. 37. Treatment & Goal Planning • Group leaders should learn what behaviors are of  most concern to parents and teachers and note  what behaviors the child exhibits that indicate  poor social understanding and interaction • Initial observation is critical • Standard assessments can also be incorporated
  38. 38. Steps for evaluating social behavior in preparation for goal planning 1. Observe the child 2. Identify positive pro social behaviors, strengths,  weaknesses, and problem behaviors 3. Conduct a functional analysis of the behavior 4. Hypothesize about what motivates the behavior 5. Observe each child’s approach to the group as a whole‐ do they assume a certain role? Are they ambivalent about  joining? Provocative? Are they completely silent? Do they  take on a clowning role? Are they less mature or more  mature than other group members? 6. Target goals for change‐ ( Aim to )Eliminate problem  behaviors and teach/practice/develop new, pro‐social  behaviors
  39. 39. Treatment and Goal Planning: your contribution • Note positive and negative behaviors displayed • Note strengths, weaknesses, interests, and  communicate about favorite games and activities • Document, for negative behaviors: the setting,  events, antecedents, consequences, possible  motivating factors
  40. 40. Preparation • These observations and notes can be  formally organized into a functional  assessment of behavior • Which is then used to develop and guide a  treatment plan • Refer to Applied Behavior Analysis for a detailed discussion  of functional behavior assessment.
  41. 41. Sample Treatment Plan Reinforcement/ Competing Strategies for prevention/ Prosocial teaching strategies behaviors* replacement behaviors target behaviors (example) 1. Joining 1a. Special star chart with 1a. Insisting on 1a. Ignoring stars for joining in each drawing activities with activity, a lot of praising, 1b. Insisting on 1b. Asking peers if they are Peers 1b. Working in dyads, showing others how interested conversation games good he is at art 2. Becoming 2a. Stars for being okay with 2a. Rigid about the 1a. Ignoring/redirecting changes agenda 1b. Asking peer tutors for Flexible and feedback “Do you want to plans & rules 2b. Games on flexibility have a friend who tells you negative things about you all the time?” 3. Monitor 3a. Stars for ‘Body Still 3a.Flapping habit 3a. Hand signal from group 3b. Encouraging him to 3b. Gets very close as a reminder body monitor peers who are still to peers to speak 3b. Encourage peer tutor to position/ notice the behavior space
  42. 42. Friends Group Visual schedule 1. Greeting for group 2. Rules! therapy 3. Planet Game sessions 4. Snack 5. Quiz Show 6. Closing
  43. 43. Peer Tutors as Social Models • Boys & Girls • No clinical concerns or outstanding  behavior issues • Natural ‘helpers’ • Recruited from other classrooms • Given a general overview and specific  instructions for tutoring, prompting,  or modeling each week
  44. 44. Peer tutor worksheet, example Children with Autism Spectrum Disorders can: • Have trouble understanding language, especially if sentences are complicated Keep language simple • Have trouble understanding things they can’t see, like ‘yesterday’ or ‘next  week’ Use pictures to teach things that are hard to think about abstractly • Have difficulty knowing whether their voice is too loud or too soft Tell the child directly that they are speaking too loudly or too softly • Have trouble with touching other children when they should keep their  hands to themselves  Tell the child the rule “keep your hands on your own body”
  45. 45. Things to remember: Advocate for your child • Consider your child’s learning style • Provide input regarding social ‘successes and messes’ outside of  school • Recruit and incorporate typical peers and buddies‐ use other kids  as a resource • Ask about generalization of skills and communication across  teachers and settings (i.e. classroom, playground,  paraprofessionals,etc.) • Social Skills instruction can be kept simple • Average standardized testing can be deceiving • Support can always be ‘backed off’ • Avoid “cookbook” techniques • Always ask!
  46. 46. Critical Components Activities designed to learn and practice Pare Part nt appropriate  icipa tion Interaction Typically  Developing  Peers Functional  assessment of behavior Group therapy  experience: focus on  process 
  47. 47. Important to consider • Children can be agents of change for each  other • Children with autism can actively  experience interactions through games and  activities that are socially motivating • ….While receiving continual reinforcement  for appropriate behavior • If the children enjoy interacting with each  other = a positive experience = reinforcing  in its own right
  48. 48. Thank you! • A special acknowledgement to Kathy Koenig and the clinicians and investigators at the Yale Child Study Center, and their work thus far  with the Social Skills Development Program Questions?

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