Effectiveness of Social Skill Interventions in children with ASD 1

Effectiveness of Social Skill Interventions in children with ASD

Alexa Holguin & Kenzie Smith

The University of Utah

Effectiveness of Social Skill Interventions in children with ASD 2

Introduction

Approximately 1 in 68 children are diagnosed with Autism Spectrum Disorder (ASD), which is a

127% increase from 2002 data (CDC, 2016). Social Skill interventions are paramount for this

demographic as ASD is characterized by deficits in verbal and nonverbal communication across multiple

contexts. Deficits can present as a lack of fluidity in conversation, failure to initiate or respond in social

settings, inability to maintain eye contact, lack of interest in making friends, and/or an inability to develop

and maintain meaningful relationships (DSM-V, 2013). The lack of effective and spontaneous interaction

with typically-developing peers hinders social participation, defined by the Occupational Therapy

Framework: Domain and Process (American Occupational Therapy Association, 2014) as the

“interweaving of occupations to support desired engagement in community and family activities as well

as those involving peers and friends” (p. S-45). Not only can inadequate social performance skills impact

friendship-making and peer acceptance, but it can also impede academic performance (Rankin, Weber,

Kang, & Lerner, 2016). According to (Wang, Ciu, and Parilla, (2010), there is a lack of empirical

evidence on current SST approaches including: video modeling, behavior modification peer mediation, Commented [AT2]: write out the first time you abbreviate

social story, joint-attention, and the buddy system. The purpose of this literature review is to examine the

effectiveness of social skill interventions on the development of social competency in children with

autism spectrum disorder. This study is important for occupational therapists because social skills

development in children with ASD is important for their occupational role development of peer, student,

friend, and occupational performance in social participation. Commented [AT3]: just a terrific intro
Effectiveness of Social Skill Interventions in children with ASD 3

Measures Commented [AT4]: this should be Methods

The following databases were searched: Ebsco Host, Eric, PsycInfo, and CINAHL for articles

about social skills training in children with autism spectrum disorder. To narrow our searches, we used

very specific key terms that included: (1) autism spectrum disorder, ASD, or autistic, (2) children, (3)

social skills training, intervention, (4) efficacy, effectiveness or improvement. With these key terms used

within our databases n=110 articles were found. Further inclusion/exclusion criteria were utilized. The

publish date was limited to 2007, and only full-text, peer-review articles were used. These limitations Commented [AT5]: just 2007?

narrowed the results to n=91. From these 91 articles, we selected a total of ten scholarly articles that met

the following criteria: (1) the DV’s included social skill perceptions or social skills mastery, and (2) Commented [AT6]: write out

studies had to use at least one type of social skills intervention. The quality of our articles was judged by

their level of evidence. Preferential selection was given to randomized control trials and meta-analyses,

because they are the hierarchy of evidence. The three randomized control trials had PEDRO scores Commented [AT7]: ? because they are at the top of the
hierarchy?
ranging from five to eight with ten being the highest possible score. Participants in these studies were

generally aware of their allocation and the therapists working with participants knew if they were in the

social skill building intervention or in the control group, which inevitably lowered the PEDRO rating.

Results

Video Modeling Interventions

Video modeling (VM) is a visual teaching method that consists of an individual observing

targeted, specific behaviors and then replicating the skills and or behaviors they watched in the video.

While social interaction is considered an overarching goal for children with ASD, (VM)VM helps reduce

the anxiety that surrounds person-to-person involvement in therapy, as well as providing a visual

representation that the participant can then replicate. Malmberg, Charlop, and Gershfeld (2015) conducted
Effectiveness of Social Skill Interventions in children with ASD 4

a case study to examine the effectiveness of video modeling (VM) in three children with ASD. Pre-

assessments were completed for each child’s individual behaviors to identify target outcomes that were

modelled in the videos and reassessed immediately after the VM. The results showed that all four children

improved on their targeted behaviors, and that these changes were maintained at the three-month follow-

up. A notable strength of this study was the inclusion of the follow up. The major limitation was the small

sample size used, which limits generalizability and does not allow for a great deal of assessment and

comparison among the participants.

A video modeling approach was also used in (Charlop, Dennis, Carpenter, & and Greenberg’s ,

(2016) study to observe the effects of a (VM) approach on verbal responses, tone modulation, facial

expressions, and gestures. For this intervention, three children ages seven 7 to eleven 11 were recruited

from a behavior therapy program to watch individualized videos modeling targeted behaviors in response

to selected stimuli. Social behaviors in response to these stimuli were subsequently recorded during

baseline, generalization probes, and peer probes. Results indicated that all three children reached the

criteria for social expressive behavior acquisition by demonstration of all four target responses seven out

of nine times during two consecutive trials. The strengths of this study included high generalization and

procedural reliability. The videos were tailored towards the interests and familiarity of each child and the

results were rated twice by different observers. Limitations included the small sample size and lack of

baseline peer probe data for two of the children. This study shows promising results for (VM) as an

approach to teach multiple social behaviors during a reinforcing activity that children enjoy.

Typically developing peer mediated SST interventions Commented [AT8]: use caps and lower case

Kamps et al. (2015) conducted a randomized control trial to determine the efficacy of a peer-

mediated intervention (PMI) on social communication competency, social behavior, and social adaption

for young children with ASD. Participants were randomly allocated into the control condition, receiving

traditional IEP services, or into a 30-minute weekly SST intervention facilitated by therapists and four to
Effectiveness of Social Skill Interventions in children with ASD 5

six typically developing peers. During the SST intervention participants were taught how to initiate and

maintain a fluid conversation with their peers during group play. Social initiations and responses for both

groups were collected and coded every trimester from kindergarten to first grade using social probes,

video-taped peer playtimes, and naturally occurring peer interactions. Results showed the experimental

group displayed significant improvements in communicative initiations, growth in social adaption, and

improvement in teacher rated social behavior, but no significant differences in responses or total

communicative acts. Although this study had high intervention fidelity, prolonged engagement, and high

generalizability, the maturation of the sample size and dosage of the intervention could have off-set

between- group results.

McMahon, Vismara, and Solomon (2012) conducted a similar study examining effects of social

skills group training on children with ASD using social role-modelling through typically developing

peers. Participants of both groups were assigned to a nineteen19-week SST intervention with typically

developing peers or into a control condition excluding typical peers. The sessions were based on a Social

Adjustment Enhancement curriculum that included different weekly activities focusing on various social

skills and interactions. Assessors observed these sessions to monitor participant interaction and social

initiations. The results of this study showed that there were significantly greater interactions with peers

from beginning to end of therapy, and the group with typically developing peers resulted in even greater

increases in social participation and engagement due to the visual representation of their social behaviors.

The greatest strength of this study was the inclusion of typically developing peers. The notable limitation

was that the improvement in social competency could not be directly correlated with the intervention as

there were other factors such as comfort level with other peers that could have led to the observable

improvements in participant’s social behavior.

Effectiveness of Social Skill Interventions in children with ASD 6

Group Therapy Based Interventions

(Deckers, Muris, Roelofs, & and Arntz , (2016) administered a group SST intervention to

improve social skill attainment and reduce perceived levels of loneliness in children with ASD. For this

study fifty-two52 participants were randomly selected to be in the experimental condition, receiving

outpatient social skills training, or to be in the waitlist control group. During the intervention, participants

discussed social skills and reenacted social situations with their peers. The experimental group improved

significantly in social skill behaviors, but significant reductions in perceived loneliness were not

observed; this finding suggests emotional changes likely require more time and social immersion than

observable behavioral changes. Comorbidities, theory of mind, and level of desire of social interaction

were also found to have no statistical impact on social skill development, which is reassuring for this

demographic. Strengths of this study included an 88% participation rate and high generalizability as it

was conducted in an outpatient center group therapy setting and incorporated parental involvement in SST

with participants in their natural social environments. Limitations of this study included the time

constraints imposed by the student’s academic calendar.

Similarly, DeRosier, Swick, Davis, McMillen, and Matthews (2011) examined the effectiveness

of an SST program in fifty-five55 children ages 8-12 with (HFASD). Participants were randomly Commented [AT9]: is this the first time you abbreviated? If
so, write it out the first time
allocated to the experimental group, receiving fifteen 15 weeks of SST covering autism specific deficits

such as communication, collaboration, and friendship skills with parental involvement, or into the control

group, receiving a generic SST without parental inclusion. Results from child and parent reported data

found significant gains in social skills mastery including: social awareness, motivation for social

interaction, and reduction of autistic mannerisms in the experimental group compared to the control

group. Parental participation is likely to have enhanced treatment outcomes. Although the researchers

were limited by homogeneity of the sample representing predominantly white, middle-class males, this
Effectiveness of Social Skill Interventions in children with ASD 7

study had many strengths including: random assignment, large sample size, prolonged engagement, and

high fidelity. Overall, this study supports the use of group based interventions in children with HFSAD.

Mathews, Erkfritz-Gay, Knight, Lancaster, and Kupzyk (2012), conducted a comparable study to

test the effects of social skills training (SST) on eighteen 18 children with autism spectrum disorder Commented [AT10]: once you abbreviate, you keep
abbreviating
(ASD), to examine the changes in social competence and their peer relationships. Group interventions

with social skills training were used in this study to enhance the social interaction and improve school

behavior adjustments. The weekly sessions are categorized into various themes such as group interaction

and conversation, forming bonds, interactive group process, anxiety management, and significant losses

and transitions. Parents of each child completed the Social Competence/Social Skill Development Scale

(SCDS) that provided a broad measure of social competency and social skill development for their

children. Results from this group-based SST intervention comparing pretest and posttest assessments,

showed an overall increase in both parent and teacher ratings. The posttest results showed that there was

an increase in social engagement, group interaction, and improvement in managing social anxieties,

exhibiting a positive correlation between group SST and social competency in children with autism

spectrum disorder. This was an extremely valuable study that held several strengths, the greatest being the

numerous measures that were used to determine the increase in social competency in the participants. The

limitations of this study came from the lack of measure of the direct observable behaviors.

Soorya, Siper, Beck, Soffes, Halpern, Gorenstein, and Wang (2015) administered a study to Commented [AT11]: incorrect APA citation

examine the efficacy of a targeted social skills training group in school-aged children with autism

spectrum disorder (ASD). Soorya et al. (2015) used group training in this study to facilitate greater social

contact amongst the participants while targeting ASD-specific social behavioral impairments. Children in

this study participated in a randomized control trial to examine the efficacy of NETT (Nonverbal

communication, Emotion recognition, and Theory of mind Training) relative to a facilitated play group.
Effectiveness of Social Skill Interventions in children with ASD 8

Treatment outcomes included social behavior and social cognition measured by neuropsychological

assessments conducted by blinded raters. Each group was subject to identical treatment that included

child therapy groups, as well as concurrent parent groups. Child therapy groups included a 15-minute

free-play/snack time, 60-minute instruction, and 15-minute wrap-up/circle time over the course of twelve

sessions. The results of this study showed that there was an overall positive effect on social skills training

groups on pro-social behavior in school aged children with ASD. The NETT resulted in significant

improvements on the social behavior composite compared to the active control condition. A strength of

this study, was the maintenance of learned behaviors that was observed at the three-month follow up. A

limitation of this study was the use of care-giver self-reports, as it susceptible to response bias. Commented [AT12]: I know you struggled with making
these concise, and I just wanted to let you know that I think
you did a really nice job editing these summaries.
Discussion

Over the course of this literature review, it is clear there is a great deal of variety within the

integration of social skills training (SST) in children with autism spectrum disorder (ASD). To narrow our

study, we evaluated the incorporation of SST in video modeling, peer-mediated, and group SST. To

further understand the current research that is available on social skills training, specific terms were used

to obtain relevant information. Of the ninety-one91 articles found through our database search with

exclusionary measures included, ten were selected for review and eight were used within this systematic

review. Three of the eight articles reviewed were level I randomized control trials. The remaining articles

ranged from level II-level V. The lack of level I evidence found is congruent with the overarching need

for more rigorous studies to be conducted on the subject. While the use of social skills training was

supported across the eight articles examined, there were certain limitations apparent in several of the

studies. In video modeling, for instance, it is challenging to perform these studies with large groups of

participants due to the time, resources and individual attention required; This this resulted in very small

sample sizes across studies.

Taking into consideration roughly half of participants with ASD have comorbidities such as

anxiety, which can hinder large sample sizes. Our sample sizes ranged from three to sixty-nine69.
Effectiveness of Social Skill Interventions in children with ASD 9

Commented [AT13]: indent if it’s a new paragraph

Regarding occupational therapy practice (OT), these studies showed the importance of social skills

training integration into OT treatment for children with ASD. The benefits for OT integration of SST

include development of peer, student, teacher, and friend roles, as well as increased competency of

occupational performance in social participation. Our studies included several randomized control trials,

all of which supported the use of social skills training for children with ASD. Across our eight articles,

there were none that exacerbated social skill deficits within participants, nor was there any danger or

harm associated with the various studies. Based on these findings, social skills training in children with

autism spectrum disorder would be given a Class I, Level A rating from the American Heart Association.

However,
Commented [AT14]: ?
It is important to note that while our studies did not show conflicting results from SST, more advanced

studies need to be performed to support the implementation of this therapy in occupational therapy and

other health settings. Further studies would need to be conducted to determine which of the SST

approaches yield the greatest benefit in children with ASD in overcoming social deficits.
Effectiveness of Social Skill Interventions in children with ASD 10

References

American Occupational Therapy Association. (2014). Occupational therapy practice

framework: Domain and process. American Journal of Occupational Therapy,

68(Suppl. 1), S 45. doi:10.5014/ajot.2014.682006

Charlop, M. H., Dennis, C., Carpenter, M. H., & Greenberg, A. L. (2010). Teaching socially expressive

behaviors to children with autism through video modeling. Education and Treatment of Children,

33(3), 371–393.

Centers of Disease and Control. (2016). Data & statistics. Retrieved from

https://www.cdc.gov/ncbddd/autism/data.html

Deckers, A., Muris, P., Roelofs, J., & Arntz, A. (2016). A group-administered social skills training for 8-

to 12-year-old, high-functioning children with autism spectrum disorders: An evaluation of its

effectiveness in a naturalistic outpatient treatment setting. Journal of Autism and Developmental

Disorders, 46(11), 3493-3504

DeRosier, M., Swick, D., Davis, N., McMillen, J., & Matthews, R. (2011). The efficacy of a social skills

group intervention for improving social behaviors in children with high functioning autism

spectrum disorders. Journal of Autism and Developmental Disorders, 41(8), 1033-1043. Commented [AT15]: no extra space

DSM-5 Diagnostic Criteria (2013). Retrieved April 08, 2017, from

https://www.autismspeaks.org/what-autism/diagnosis/dsm-5-diagnostic-criteria
Effectiveness of Social Skill Interventions in children with ASD 11

Kamps, D., Thiemann-Bourque, K., Heitzman-Powell, L., Schwartz, I., Rosenberg, N., et al. (2015). A Commented [AT16]: incorrect APA reference

comprehensive peer network intervention to improve social communication of children with

autism spectrum disorders: A randomized trial in kindergarten and first grade. Journal of Autism

and Developmental Disorders, 45(6), 1809-1824.

Malmberg, D. B., Charlop, M. H., & Gershfeld, S. J. (2015). A Two experiment treatment comparison

study: Teaching social skills to children with autism spectrum disorder. Journal of Developmental

and Physical Disabilities, 27(3), 375-392.doi:10.1007/s10882-015-9420-x.

Mathews, T., Erkfritz-Gay, K., Knight, J., Lancaster, B., Kupzyk, H. (2012). The effects of social skills

training on children with autism spectrum disorders and disruptive behavior disorders. Children's

Health Care. Vol. 42 Issue 4, p311- 332. 22p. doi: 10.1080/02739615.2013.842458. Commented [AT17]: incorrect APA style

McMahon, C. M., Vismara, L. A., & Solomon, M. (2012). Measuring changes in social behavior during a

social skills intervention for higher-functioning children and adolescents with autism spectrum

disorder. Journal of Autism and Developmental Disorders, 43(8), 1843-1856.doi

10.1007/s10803-012-1733-3.

Soorya, L. V., Siper, P. M., Beck, T., Soffes, S., Halpern, D., Gorenstein, M., & Wang, A. T. (2015).

Randomized comparative trial of a social cognitive skills group for children with Autism

spectrum disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 54(3),

208-217.doi: 10.1016/j.jaac.2014.12.005.

Wang, S., Cui, Y., & Parrila, R. (2011). Examining the effectiveness of peer-mediated and video-

modeling social skills interventions for children with autism spectrum disorders: A meta-analysis

in single-case research using HLM. Research in Autism Spectrum Disorders, 5(1), 562–569. Commented [AT18]: ital
Effectiveness of Social Skill Interventions in children with ASD 12