Effective Social Skills Interventions for Adults with ASD: Critical Elements and Emerging Best Practices
Presented by Michael Murray, MD, Amanda Pearl, PhD, Andrea Layton, MA, BCBA, Susan Minnick, PsyD
June 12, 2014
Disclosures
• Research support:
• Pennsylvania Department of Public Welfare, Bureau of Autism Services
Educational Objectives • Understand the social functioning challenges faced by adults
with Autism Spectrum Disorders (ASD)
• Understand the current evidence base for social skills interventions
• Evaluate the appropriateness of social skills interventions for adults with ASD
• Use video modeling in social exposures for adults with ASD
ASD: The Core Deficits •Impaired Social Interactions
• Impaired Communication
• Restricted and Repetitive Patterns of Behavior
Social Success for Children • Centered around play routines
• Structured
• Rule based
• Embedded cues
• Relatively few skills to teach
Social Success for Teens • Centered around social communication (“hanging out”)
• Unstructured
• Contingency based
• Multiple, and at times, competing cues to interpret
• Need to establish capacity for social judgment
Social Success for Adults
• Still centered around social communication
• Unstructured
• Contingency based
• Multiple, and at times, competing cues to interpret
• Need to establish capacity for social judgment
• Additional social demands outside of educational environment including work and romantic relationships
Social Skills Deficits
• Theory of Mind
• Model of the capacity for empathy
• The ability to conceive that other people have their own ideas, thoughts and emotions
• Adults with ASD have reduced left prefrontal cortex activity when given theory of mind tasks on fMRI
Social Skills Deficits
• Central Coherence
• The ability to integrate individual elements of perception into an overall context of meaning (“the bigger picture”)
• Those who are affected tend to be detail oriented and have great difficulties capturing the overall context
Social Skills Deficits
• Executive Functions
• Planning and monitoring of one’s own actions
• Inhibiting impulses
• Focusing attention
• Flexible searching for problem solving strategies
• Maps to the prefrontal cortex
So what do these deficits look like in action?
Example #1: Pre-frontal cortex vulnerabilities
Lack of Social Fluency Example #2: Difficulty with social initiation and maintenance.
Social Fluency • Combination of accuracy and speed in executing social skills
• Allows individuals to function efficiently and effectively in a variety of social settings
• The basis for successful social transactions
Lack of Social Flexibility Example #3: The problem of social scripting
Social Flexibility
• Responding to changes in social contingencies
• Builds rapport, confidence, and trust
• Allows greater adaptability to new social environments
• Basis for positive peer interactions
Lack of Social Responsiveness Example #4: Misreading verbal and non-verbal cues
Social Responsiveness
• Readily reacting to verbal and non-verbal suggestions, influences, or efforts during a social interaction
• Basis for greater social intimacy within relationships
Social Skills:
Interpersonal responses with specific operational definitions that allow an individual to adapt to environmental demands through verbal and non-verbal communication
Not all social skills interventions are created equal…
• Social Skill vs.
• Communication Skill vs.
• Remediating Problem Behavior
• Eye contact
• Appropriate content of speech
• Appropriate speech intonation
• Number of words spoken
• Appropriate motor movements
• Verbal disruptions
• Leaving the group
“Social Skills” Targets:
• Turn taking
• Giving compliments
• Being a good sport
• Appropriate phone use
• Decreasing aggression
• Dating etiquette
• Conflict resolution
Established
• Social skills groups for school-aged children
• Video modeling for school-aged children
Establishing the evidence base…
Promising
• Parent training interventions for preschool-aged children
• Siblings as peer agents in school-aged children
• Peer training in school-aged training
• Visual supports for preschool and school aged children
Currently there is no established evidence base for social skills interventions for
adolescents and adults.
Essential ingredients in the SSG recipe
• Increase social initiations
• Use strategies to make the abstract concrete
• Provide structure and predictability
• Provide scaffolded language support
• Simplify language and group adults by language level
• Provide multiple and varied learning opportunities
• Include “other”- focused activities
• Increase social motivation
• Foster self-awareness and self-esteem
• Develop fun and nurturing environment
• Select relevant goals
• Such that issues most central to ASD are addressed
• Program in a sequential and progressive manner
Essential ingredients in the SSG recipe
• Improve social responding
• Include interaction with other people (as varied as possible!)
• Provide opportunities for programmed generalization and ongoing practice
• Skills should be applied outside the group setting
• Reduce interfering behaviors
• Reinforce positive behaviors
Essential ingredients in the SSG recipe
• Promote skill generalization
• Include peers
• Use multiple trainers
• Practice in naturalistic settings
Essential ingredients in the SSG recipe
Types of social skills groups • Applied Behavior Analysis (ABA)
• Cognitive Behavior Therapy (CBT)
• Social Stories (Gray)
• Comic Strip Conversations (Gray)
• Social Scripts
• Hidden Curriculum
• Video Modeling
What should social skills groups include? • There is no single best treatment for all individuals with an ASD,
but everyone agrees that intervention is essential
• Best method is to combine multiple approaches that fit the targeted group of individuals
• Ideal treatment coordinates interventionists and interventions that meet the specific needs of individual children
• Generalization of skills is essential
• Treatment plan and/or goals
Questions to ask regarding social skills programs
• How does treatment occur?
• Who implements the intervention?
• Where does the intervention occur?
• What does a session look like?
• Who usually is in a social skills group?
• How often does an intervention occur?
Questions to ask regarding social skills programs
• How is this treatment different from other social skills groups?
• Is there evidence that this treatment is effective?
• Are others involved (e.g., caregivers, siblings, peers)?
Example #1: Community Mental Health Clinic
• Therapist 1: “I’ve been doing a social skills group, would you like to help out for a few months as a co-therapist?”
• Therapist 2: “Sure! What are you working on?”
• Therapist 1: “Well, these guys have known each other for a while- we all just get together and see how things are going. Sometimes I’ll bring in an activity for us to do, like maybe playing charades. We have snacks- the guys love the food.”
Example #1: Community Mental Health Clinic
• Week-to-week activities with no overall goal
• What should we do this week?
• Does not build week-to-week on skills
• No outcomes or progress monitoring
• Often do not incorporate typical peers
• Billing issue
Example #2: School-based (College) Group
• “Small group counseling is needs based and consists of 4-5 students who meet weekly for about six weeks. Group members have an opportunity to learn from each other. They share ideas and give and receive feedback.”
Take Home Points
• GOOD NEWS: There are many social skills interventions out there, as well as interested professionals running these groups.
• BAD NEWS: There is limited research on the effectiveness of these interventions. Often times, little thought is given to efficacy and measuring outcome.
The Multi-Media Social Skills Project A Social Skills Intervention for Adults with Autism Spectrum Disorder
The Multi-Media Social Skills Project • The Multi-media Social Skills Project for Adolescents (ages 13- to
17-years-old) with ASD:
• 12-week program with 3 modules: 1. Social Approach
2. Social Maintenance
3. Specialized Social Relationships
• 90 minute skills building sessions followed by 90 minutes of peer generalization
• Weekly video modeling of social interactions, as well as intermittent self-video modeling of one-on-one conversation with a peer
The Multi-Media Social Skills Project • Results from the adolescent version found that following
participation in the group, adolescents with ASD:
• Displayed more eye contact and less silence during a conversation with a peer.
• Additionally, adolescents who were higher functioning and more anxious were found to show improvement in overall social responsiveness, social cognition, and social motivation following the group.
The Multi-Media Social Skills Project • Following success of the adolescent social skills project, the adult
(ages 18- to 35-years-old) was developed.
• 16-week program with 4 modules: 1. Basics of Social Relationships
2. Workplace Relationships
3. Barriers to Social Relationships
4. Dating
• 90 minute skills building sessions followed by 90 minutes of peer generalization
• Weekly video modeling of social interactions, as well as intermittent self-video modeling of one-on-one conversation with a peer
The Multi-Media Social Skills Project MODULE 1: Basics of Relationships
Skills Building (90 minutes with video modeling)
Generalization (90 minutes with same-age peers)
Week 1: Evaluating Social Relationships
• Evaluating interaction styles between people
• Being socially appropriate when interacting with others
• Determining degree of intimacy in relationships
• Board Games
• Apples to Apples • Cranium • Pictionary
• Outdoor Games • Cornhole • Frisbee • Ladder golf
• Arts and Crafts
Week 2: Establishing Social Contact
• Initiation of social contact • Choosing the right initiation skills
at the right time • Reading verbal and non-verbal
clues and adjusting behavior
Week 3: Conversation Skills • Maintaining conversation • Conversation transitions • Reading social feedback
• Trivia Night • Informational • Social
Week 4: Review of Module 1 • Fluency (review of Weeks 1 – 3) • One-on-0ne conversation with “tough” looking novel male peer
Video Modeling Examples
The Multi-Media Social Skills Project MODULE 2: Workplace Relationships
Skills Building (90 minutes with video modeling)
Generalization (90 minutes with same-age peers)
Week 5: Interview skills • Identifying appropriate jobs • Expressing interest in a position:
initiating professional conversations
• What to expect in a job interview
• Collecting applications at local retail stores/restaurants
• Building a LinkedIn profile
Week 6: Professional Communication Skills
• Navigating workplace relationships
• Workplace “small talk” • Giving and/or receiving criticism
• Completing applications for jobs • Mock interviews with group
leaders
Week 7: Interactions with the Public
• Maintaining workplace relationships
• When can workplace relationships become friendships?
• Focus group with marketing/PR professional
Week 8: Review of Module 2 • Fluency (review of Weeks 5 – 7) • Interview with HR staff
Video Modeling Examples
The Multi-Media Social Skills Project MODULE 3: Barriers to Social Relationships
Skills Building (90 minutes with video modeling)
Generalization (90 minutes with same-age peers)
Week 9: Overcoming anxiety • Identifying anxiety • Skills for coping with anxiety
• Behavioral techniques
• Group dinner with peers at a local restaurant
Week 10: Conflict resolution • Identifying when others may be trying to take advantage
• Ways to cope with frustration • Being assertive
• Group was given gift cards for local restaurants ($15 for Red Robin; $10 Wendy’s) and had to decide:
• Who received which card • Who they went to dinner
with
Week 11: Self-advocacy and self-disclosure
• Legal rights • When and where may it be
appropriate to discuss a disability?
• One-on-one dinner with a peer at a local restaurant
Week 12: Review of Module 3 • Fluency (review of Weeks 9 – 11) • One-on-0ne conversation with “argumentative” confederate
Video Modeling Examples
The Multi-Media Social Skills Project Module 4: Dating Skills Building
(90 minutes with video modeling) Generalization
(90 minutes with same-age peers)
Week 13: Setting appropriate expectations and recognizing interest
• How to recognize romantic interest
• How to express romantic interest • Safety: does he/she mean no or
are they playing hard to get?
• Adam: Part I
Week 14: Relationship maintenance
• Romantic vs. platonic relationship maintenance
• How to maintain a romantic relationship
• Changes in romantic relationships over time
• Adam: Part II
Week 15: Sexuality • Review of safety • What are typical/atypical sexual
behaviors? • Definition of stalking
• FAQ session with novel peers matched to gender/sexual orientation
Week 16: Review of Module 4 • Fluency (review of Weeks 13 – 15) • One-on-0ne conversation with confederate pulling for empathetic support
Video Modeling Examples
Outcome Measures
• Behavioral Observations
• ASD Symptoms
• Social Responsiveness Scale, Second Edition (SRS 2)
• Social Skills Inventory (SSIN)
• Adult Autism Spectrum Quotient (AQ)
• Empathy Quotient (EQ)
• Broadband Psychopathology
• Adult Behavior Checklist (ABCL); Adult Self-Report (ASR)
• Social and Emotional Loneliness Scale for Adults (SELSA)
• Social Phobia Inventory (SPIN)
Current Pilot Data
• Completed:
• 2 groups of 4 – 6 adults
• In progress:
• 2 groups of 4 – 6 adults
• 91% male/9% female
• Mean age: 22.04 years (18 – 35)
• Mean Verbal IQ: 89.17 (70 – 129)
• Mean SRS 2 (parent): 68.5 (moderate ASD symptoms)
• Groups were sorted based on age, SRS 2, and Verbal IQ scores
Qualitative Results: 1st 2 cohorts
• Focus groups resulted in 2 articles being published in a newsletter
• 40% of individuals were hired as volunteer, were given a paid position, or were promoted following the group
• 1 individual indicated he will be pursuing positions as a self-advocate
• Quotes:
• “I love communicating now.”
• “No one had even asked me for my opinion before.”
Future Directions
• Current 2 cohorts will finish in late summer/early fall of 2014
• 4 more cohorts will be completed prior to early summer 2015 in the Central region (Harrisburg/Hershey area)
• Additional cohorts to be run in the Eastern and Western region of the state in July 2015 – June 2016
• This will include the training of several therapists to run the groups in each region
• Examine results and disseminate to stakeholders
• Determine for whom this intervention works
• Adapt manual for individuals who have more severe ASD symptoms and/or comorbid Intellectual Disability
ASERT is funded by the Bureau of Autism Services, PA Department of Public Welfare
Website: www.PAautism.org Email: [email protected]