Every child on the autism spectrum is unique, with different strengths and needs at different ages. It is the family's challenge to cobble together an individualized treatment plan based on a wide variety of options, from speech and language therapy to applied behavior analysis, from medication to special diets.1 One intervention many families consider is social skills training. A lack of intuitive social ability is a hallmark of autism. Social skills training is aimed at addressing the challenges that result, and often plays a central role in treatment plans. But what does "social skills training" mean? What is it intended to achieve? And what research has been done so far to demonstrate whether it works?
The issue of social impairment is complex. Even those who deal with autism spectrum disorders (ASDs) every day can find it difficult to explain these social deficits to someone unfamiliar with them. Often people are not consciously aware of their own ability to instantly process social cues, interpret people's intentions, or choose responses, let alone able to picture what it would be like to live without this ability. To imagine another disability, such as blindness, might be easier. We can put ourselves, at least to some degree, in the shoes of a person who has lost his or her sight. But a social disability?
What if we had to learn social rules that everyone else seemed to already know? What if we had to work at understanding complex emotions, in others and ourselves? What if even this understanding didn't help us to know what to do when we felt empathetic, embarrassed, or jealous? What if we had to struggle to figure out what another person knew, or felt, or thought, and how he or she might behave as a result? What if, no matter how much of this social dance we learned, it just kept getting more complex with every passing year?
This is what it is like to be socially blind. This is what it is like to have an ASD. Recognizing that, how do parents, teachers, and clinicians help? One way is through social skills training.
THE COMPLEXITIES OF THE SOCIAL SELF
A catchall phrase for social skills training might be "teaching a person how to navigate social reality" -- a goal so complex and multifaceted it is truly mind-boggling.
Given our limited knowledge of the field of social development in general, and of how this developmental process goes awry in autism in particular, researchers can find themselves on the outside of autism looking in. One of the starting points has been to build a list of external signs that help characterize the social impairment of ASD: poor eye contact 2 ; a lack of interest in initiating social interactions 3 ; a lack of understanding of emotions and how they are expressed 4 ; and a literal interpretation of nonliteral language, such as figures of speech, metaphors, and sarcasm. 5
One logical approach to treatment might be to break down social skills into their components and then teach these basic skills in a stepwise fashion. However, looks can be deceiving and what at first appears to be a "basic skill" can turn out to be incredibly convoluted, making it difficult for a caregiver to teach and for a person on the spectrum to apply to new situations. Take the social skill of "greeting" others. As Myles and Simpson (2001) 6 explain:
"A greeting...is a social skill that is thought to be simple. However, further analysis shows this skill, which most take for granted, to be extremely complex. How a child greets a friend in the classroom differs from the type of greeting that would be used if the two met at the local mall. The greeting used the first time the child sees a friend differs from the greeting exchanged when they see each other 30 minutes later. Further, words and actions for greetings differ, depending on whether the child is greeting a teacher or a peer.... [G]reetings are complex, as are most social skills."
These skills build upon prerequisite skills, many of them beginning in infancy. 7 A child with ASD may need social skills training throughout childhood and into adulthood, layer by layer, with basic skills leading to higher-level skills, which in turn branch out into the most complex skills required of adults living and working in the community. Clearly, social skills training needs will vary at different developmental stages. A 4-year-old with ASD may need to learn basic social rules such as sharing toys, for example. However, years later he or she may be more concerned with fitting in with friends, getting a first date, or developing a sexual relationship.
One thing is certain. Social skills are crucial to success in the classroom, the workplace, and the community. They also are essential to interpersonal success -- to friendship and romance. This means they matter not just in terms of achievement, but also in terms of mental health. In contrast to the stereotype that people with ASDs lack the desire for person-to-person connection, many children and adolescents on the spectrum long for social acceptance and social interaction with others. High-functioning individuals with ASD may express loneliness as early as elementary school, with their sense of isolation often intensifying during adolescence. 8,9
Intervention is definitely necessary...but do we know how to do it?
SMORGASBORD OF 'SOCIAL SKILLS' TREATMENTS
Despite the enormous difficulty involved, clinicians, teachers, and others "in the trenches" have developed techniques aimed at improving the social understanding and functioning of individuals with ASD. Before discussing these, however, we should mention a treatment that can be an important precursor to programs, tools, and techniques thought of as "social skills training": early intensive behavioral interventions.
Early intensive behavioral treatments, such as applied behavior analysis (ABA), are often used with young affected children to help put development, especially social and language/communication development, back on track. They are based on the psychobiological notion that brain structure and experience are interconnected, especially during infancy and early childhood. 10,11
If something fundamental goes awry in the autistic brain, and so interferes with early social interaction and experience, the reverse also will be true. That is, the continuing development of the "experience-expectant" brain will be negatively affected when crucial social experiences do not occur. 12 Neurological development, already gone wrong, will be even further derailed when an infant on the autism spectrum fails to focus on human faces and voices 13 or to seek out his or her parent's gaze. 14 Both the "give" and the "take" of parent-infant interaction will not occur as they were meant to, and so the brain -- wired and waiting for certain input -- will suffer from never having received it.
In Early Behavioral Intervention, Brain Plasticity, and the Prevention of Autism Spectrum Disorder, Geraldine Dawson describes how early intensive behavioral treatments can help "guide brain and behavioral development back toward a normal pathway." 15 For example, if a toddler with autism is completely uninterested in social interaction, preferring to look at inanimate objects rather than people, ABA can help that toddler learn to find pleasure or reward in gazing at a human face. The more social interaction becomes valued, the more eye gaze, joint attention, and other fundamental social skills can be nurtured, encouraged, and built upon, opening the way for various types of social skills training.
The sheer number of social skills interventions and programs offered in schools and clinics is daunting, but here we will introduce a few of the better-known strategies.
Social Stories™ and Comic Strip Conversations. These resources use stories and drawings to build social understanding.
Social Stories are brief, personal stories written for children to help them understand social situations. 16,17,18 The story describes the situation, with the child's and others' feelings and/or thoughts as key elements. Possible social responses may be included, in a positive way, to help the child understand a social situation or cope with a stressful encounter. Say a child with ASD was invited to a classmate's birthday party. At the party, he or she walked over and opened one of the birthday girl's presents, and negative consequences ensued. Following the party, the parent and child could write a Social Story. The story could describe the setting, describe the characters watching the child with ASD tear the paper off the birthday girl's present, and explain what the birthday girl may have been thinking, what the other children attending may have been thinking, and what the child with autism remembers thinking. In the end, the story could relate options for socially desirable behavior in the situation. The aim is to increase insight and help guide future behavior.
Comic Strip Conversations involve "drawing" conversations to help the child learn the social rules that others learn more naturally. Bubbles representing a conversation can bump into or overlap one another to illustrate "interrupting" and "thought" bubbles can show others' thoughts during conversation. For example, a child with ASD who takes offense at a peer's comment, "You can't catch me!" can be shown that the peer may not have been rejecting, but trying to start a fun game of chase.
Hidden Curriculum. These strategies involve directly teaching "unspoken" social rules.
The "hidden curriculum" refers to a set of social rules or guidelines that most people understand intuitively. 19 These are the rules that everybody seems to pick up naturally, that everybody just knows. However, individuals with ASD do not pick up these rules naturally, and these rules need to be taught directly to them. A child who does not intuit or know these rules is at risk for social isolation.
For example, most older children know the signs which signal that someone has claimed a seat in the classroom. But an older child with ASD is likely to overlook the signs: a jacket slung over the back of the chair or a book positioned in the seat. The repercussions of "stealing" someone else's seat are likely to leave the child with ASD mystified and rejected.
In the book The Hidden Curriculum, 20 the authors outline possible teaching strategies and list numerous unwritten social rules ranging from the somewhat simple, such as only the birthday girl or boy opens the presents, to the more subtle, such as just because a person is nice to you one time doesn't mean he or she is your "best friend."
Social scripts. 21 This strategy involves teaching "scripts" for common social situations.
In a social scripts intervention, sometimes used to assist individuals with ASD to initiate social contact and conversation, the child learns a scripted question or phrase such as, "Did you like playing on the swing today?" The child initially uses a support, such as a reminder card with the script available to read, and then is gradually weaned from this support until he or she can use the question or phrase spontaneously. 22
Computers and other technology. These interventions involve using videos, software, or virtual-reality programs to teach complex social skills, such as recognition of emotions in facial expressions and tone of voice.
Videos can be used in any number of ways, such as having a child watch him- or herself performing a social task or role-playing a social situation and then analyzing what went right and what went wrong. They can be especially helpful for teaching children with ASD how to interpret body language because the action can be stopped or slowed down on the video and discussed. A child who has learned the component skills of greeting visitors may be helped by a video showing how all the component skills come together to form the integrated behavior in an actual social situation. 23,24,25,26
Researchers in the United Kingdom have developed an animated series, The Transporters, which aims to teach reading of facial emotions to preschoolers with autism, while a computer program entitled Mind Reading: The Interactive Guide to Emotions is geared toward children who can use the computer effectively. 27 (See IAN's Transported to a World of Emotion.)
Meanwhile, researchers in Alabama have successfully demonstratated that a computer-based social skills program called FaceSayhelps children with both low and high functioning autism improve their ability to recognize emotions and to interact socially. It also helps children with high functioning autism to recognize faces. (In this program, "avatars," which are animated photos of real people, interact with the children as they play skills-focused games.)28 Similarly, researchers in Texas have experimented with using virtual reality to set up practice social interactions for high-functioning individuals on the autism spectrum. 29 Even socially interactive robots are being designed. 30
Social skills groups. These groups offer an opportunity for individuals with ASDs to practice social skills with each other and/or typical peers on a regular basis.
Some social skills groups consist solely of children with ASD while other groups have a mix of participants, children with ASD along with typically developing children. Often these groups use a variety of techniques and tools, including those discussed in this article.
The good news: There are many social skills interventions to try.
The bad news: Research on these treatments and their effectiveness has so far been limited.
SOCIAL SKILLS TRAINING: LIMITED RESEARCH
Social skills training is often overlooked by those measuring use of autism treatments, but we do have some evidence that these treatments are quite common. Green and colleagues identified Social Stories as the fifth most frequently used autism treatment in their Internet survey of parents of children on the spectrum.31 The IAN Research survey, also conducted via the Internet, found that 14% of participating families were using social skills groups as part of their child's current treatment plan. This increased to more than 20% for 8- to 12-year-olds and to more than 25% for children with Asperger's syndrome. (Look for the Interactive Autism Network's upcoming report to read more about what families participating in the IAN Research Project report about their experience of social skills groups.)
Clearly, social interventions are widely used, especially for children who are older and/or higher functioning.
Unfortunately, we are only beginning to investigate whether social skills training is effective. Evaluating social skills programs, like evaluating other psychosocial, behavioral, and educational treatments carried out in clinics and schools, presents different (and perhaps more complex) challenges than evaluating a medication. Still, such evaluation is crucial, considering that core features of autism are currently treated with only psychosocial, behavioral, and educational interventions, not with medical or biological ones. 32
So far, much of the research on social skills training has been based on the observations of clinicians, educators, or other practitioners who implemented a specific social skills intervention with a small number of children, later evaluating whether it seemed to improve skills. Several researchers have reviewed collections of such studies in order to identify common problems or limitations, point out promising strategies, and make recommendations for future research. 33,34,35,36
Unfortunately, when social skills programs have been examined as a whole, evaluation of their usefulness has not always been encouraging. After reviewing 55 research studies on school-based social skills programs for youth with ASD, for example, researchers at Indiana University found such programs to be only minimally effective. 37 "The results of the meta-analysis are certainly hard to swallow," the lead researcher, Scott Bellini, said, "but they do shed some light on factors that lead to more beneficial social outcomes for children with autism." 38 The team identified some major problems with existing programs, including low dosage -- the children did not receive many hours of social skills training. (Considering the intensity recommended for ABA and similar early interventions, it may be that social skills training needs to be much more intensive than it is now.) Another issue identified was the need to provide the intervention in the child's natural setting, meaning the classroom, rather than in a "pull-out" setting; treatment in naturalistic settings appeared to be more effective. Also mentioned was the need to ensure that a program, once planned, was carried out as intended. If this did not occur, a poor outcome might be the result of poor implementation, not poor design.
A common problem with social skills research itself was lack of a common definition of what the treatment was actually targeting.Which social skills, defined and characterized how? Measured how? Matched to which children, with what level of ability and what needs? Sample sizes were often very small, and those evaluating effectiveness were not "blinded" to prevent their biases and hopes from influencing their assessment of the program's worth. Few used comparison groups so that researchers could distinguish improvement due to an intervention versus improvement due to simple growth and maturation. Few followed up, in the short or long term, to see if any skills gained were retained. 39
On the more positive side, researchers looking at social skills efforts so far have been able to identify some elements that seem to contribute to a worthwhile social skills program. Based on their review of five studies, for example, Krasny and colleagues offered the following "essential ingredients" for social skills programs: 40
- Make the abstract concrete
- Provide structure and predictability
- Provide scaffolded language support (simplify language and group children by language level)
- Provide multiple and varied learning opportunities
- Include "other"-focused activities (with children always working in pairs or groups, and with cooperation and partnership encouraged)
- Foster self-awareness and self-esteem
- Select relevant goals (such that issues most central to ASD are addressed)
- Program in a sequential and progressive manner
- Provide opportunities for programmed generalization and ongoing practice (so skills are applied outside group setting)
Similarly, Williams White and her team, having reviewed 14 studies, identified a number of "promising strategies": 41
- Increase social motivation (foster self-awareness and self-esteem; develop a fun and nurturing environment)
- Increase social initiations (use strategies such as making social rules concrete, for example, "stay one arm's length away from the other person")
- Improve appropriate social responding (use modeling and role-playing to teach skills)
- Reduce interfering behaviors (reinforce positive behaviors by, for example, maintaining behavior charts and reinforcing desired behavior with stars)
- Promote skill generalization by orchestrating peer involvement, using multiple trainers, involving parents in training, providing opportunities to practice skills in naturalistic settings, and assigning "homework" -- having children practice between sessions
Some common themes appear to be emerging. One of these is the need to foster self-awareness and self-esteem as part of a social skills intervention, because these are so linked with social motivation and social awareness, not to mention mental health.
Another key issue is the need for these interventions to require interacting with other people, and as many varied people as possible. One-on-one direct teaching or therapy can be an important part of social skills training, but to truly practice a social skill requires creating a social situation, or making use of a preexisting one.
Also noted is the need to focus on making sure skills are generalized, that is, used in other contexts. Individuals on the autism spectrum tend to become "stuck," learning a skill in a certain setting and then not perceiving its relevance out of that context. Making sure new social skills are practiced and used far beyond the clinic or school setting is crucial to a social skills training program's success.
WHERE DO WE GO FROM HERE?
Acknowledging that social skills research is still in its infancy, researchers have begun to make recommendations for next steps. Some useful techniques and tools have been created; now they need to be refined. In addition, the development of manuals detailing how a specific social skills program is to be carried out, and how teachers, therapists, parents, and clinicians are to be trained, is essential. Unlike a medication, which you just give on a prescribed basis, a psychosocial intervention requires a program that can be communicated to those who will provide it, and that can be implemented again and again in the same way.
As programs become better defined and tested on a small, pilot scale, randomized controlled trials (RCTs) will become possible. RCTs are the gold standard for research, allowing comparison of a specific intervention to a different intervention or to no intervention at all. (For a discussion on the topic of RCTs, see IAN's Gold Standard of Evidence: The Randomized Controlled Trial [RCT].)
For example, researchers might take 100 children ranging from ages 8 to 10 with high-functioning autism or Asperger's syndrome, randomly assigning them to the regular school program or to that plus a new social skills training group that is going to meet daily for a number of weeks or months. The teachers or therapists leading the groups would be trained to carry out the social skills program precisely as set forth in a manual (such that personal variations of the program did not interfere with the research). Before the trial began, the research team would decide how to measure the outcome based on the program's goals. Outcome measures might include the number of social initiations a child makes, the number of conversations in which a child is able to take conversational turns (instead of launching into a too-long monologue), or measures of loneliness, maladaptive behavior, or life satisfaction. At the end of the program, it should be clear whether children who received the new program did better than those who did not. Once a program is proven effective, the next challenge will be to move it into the wider community, and to make sure it can be implemented just as effectively in regular public schools or local clinics where there is no research team to oversee it. 42,43
The research community, for its part, is very much aware of what next steps are required. There is reason to hope that there will come a time when we will have a much better sense of which specific social skills program, implemented in what way, will be most beneficial for which individuals on the spectrum. For now, parents, teachers, and therapists rely on the knowledge and programs that have been developed "in the trenches," hoping what they are doing is the most effective strategy, and that they will soon have more guidance to go on.