Should I shake her hand or give her a hug?

The most complicated part of any person's day can be dealing with social situations. Different environments or relationships bring a variety of rules and actions.

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  Should I shake her hand or give her a hug?
  
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  Can I tell that joke here?
  
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  Why can't we play a different game?
  

Rachel, a high school junior with Asperger Syndrome, is called to her resource teacher's classroom. Mrs. Boyd tells her to sit down and asks her about a conversation Rachel had with Miss Reed earlier that day. Rachel tells Mrs. Boyd that she had watched a makeover show on television over the weekend and that she thought about Miss Reed as she watched the show. Rachel said she couldn't wait for Monday so she could tell Miss Reed what clothes to wear so she wouldn't look so fat and not to put on so much blusher and especially not to line her lips with that dark lip liner pencil. Mrs. Boyd asked Rachel how she thought Miss Reed felt about the discussion. Rachel said Miss Reed cried like the lady on the show did when she was so happy she looked better. Mrs. Boyd realized she had to work with Rachel about the different things crying can mean and on what she could tell other people about their appearances. Mrs. Boyd also needed to tell Miss Reed about Asperger Syndrome and social misunderstandings.

What makes "social" difficult for persons with ASD? Social interactions involve verbal and non-verbal communication, personal space, humor, topic flow, and many other facets that are usually deficit areas for people on the spectrum. In The Oasis Guide to Asperger Syndrome (2001), the authors state that up to 90% of communication is nonverbal and only 10% is the spoken words. If most of a person's attention is on the spoken word, it is easier to see how conversations with others can be misunderstood by those on the spectrum, and then add to that a possible sensory overload and anxiety to make social really hard. This module will further explain how social competence and social skills are exhibited in persons with ASD and what supports can increase positive interactions.

Pre-Assessment

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Pre-Assessment

What is the primary purpose of social skills assessment?

Select an answer for question 564

Why is it important to interview the child or adolescent himself if possible?

Select an answer for question 565

Which of the following best represent criteria for quality social objectives?

Select an answer for question 566

What is a skill acquisition deficit?

Select an answer for question 567

What is a performance deficit?

Select an answer for question 568

Why is it important to determine whether an area of challenge is due to a skill acquisition deficit or a performance deficit?

Select an answer for question 569

Which of these statements best describes priming?

Select an answer for question 570

Which of the following strategies can be used to prime social cognitions and behaviors?

Select an answer for question 571

What is generalization?

Select an answer for question 572

What is meant by the term social accommodation?

Select an answer for question 573

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According to the Diagnostic and Statistical Manual of Mental Disorders - Fourth Edition (American Psychiatric Association, 2000), essential diagnostic criteria in the social domain include "(a) marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction; (b) failure to develop peer relationships appropriate to developmental level; (c) a lack of spontaneous seeking to share enjoyment, interests, or achievements with other people; and (d) lack of social and emotional reciprocity" (p. 75).

Social skill deficits may be separated into four broad categories of social functioning: nonverbal communication, social initiation, social reciprocity, and social cognition. Each category will be discussed on the following pages.

Nonverbal Communication

Successful social skills require the ability to read and understand the nonverbal cues of others and to clearly express thoughts, feelings, and intentions through facial expressions, gestures, and body language. In many ways, nonverbal communication is more meaningful than verbal communication. Difficulty reading body language or nonverbal cues of others is a common problem for individuals with ASD. Some fail to look for nonverbal cues and are virtually oblivious to nonverbal communication. Others may look for nonverbal cues, but interpret them incorrectly or fail to understand the intended message. Understanding nonverbal communication requires that we recognize the body language of others and infer the meaning of the nonverbal communication. This is done by integrating all the available nonverbal and contextual cues in the environment.

George is between classes at college, so he decides to go to the student center. He sits at a table with a group of girls and says hi. Before the girls can respond, George starts talking about how cool fire engines are and how many fire stations are in their city and how many different kinds of trucks each station has and how many fires there were in the last year. The girls are looking at each other and some are giggling. One girl tries to interrupt George, but he keeps on talking. The girls start getting up and walking away. George is confused about what is happening. He feels very upset. He talks to his parents that night about the girls and the talking and the walking away. His parents remind him of the service his college offers to help him learn about social situations, conversations, and reading nonverbal signs. George says he might stop in to see the coordinator tomorrow.

Difficulties with initiating interactions are common among individuals with ASD (Hauck, Fein, Waterhouse, & Feinstein, 1995). Many children fall into one of two initiation categories: those who rarely initiate interactions with others, and those who initiate frequently, but inappropriately. Children in the first category often demonstrate fear, anxiety, or apathy regarding social interactions. It was once believed that the vast majority of children on the autism spectrum fit into this category. In fact, many social skill interventions have been designed with the express goal of increasing social initiations. However, in recent years an increasing number of children have been found to fit within the latter category. These children initiate interactions frequently, but their initiations are often ill timed and ill conceived. For example, they may interrupt or talk over someone. They may ask repetitive questions or questions that only pertain to their own interests or they may talk with others in settings that require silence, such as a library or church. For these children, the goal of social skills training is not to get them to initiate more frequently but to get them to initiate more appropriately.

John, a six foot ninth grader with ASD, is on a community trip to the local mall. He has a picture schedule to follow and a photo shopping list for one store. He appears happy to be at the mall; he is smiling, laughing, and making what the staff recognize as happy noises. To regulate his sensory system, John needs a lot of large muscle input. Before he left for the trip, he walked several laps with a weighted backpack and jumped on a mini-trampoline. John's class is walking down the hall when he suddenly runs ahead, leaping and landing with loud footsteps near a group of mall employees. One girl yells and a man moves out of the way as John stops right next to them. John's teacher approaches the group and explains John is trying to say hi. The teacher hands the group cards that have a definition of autism and a website they can visit to learn more (John's parents agreed to the card being handed out on community trips if needed to educate others). John's teacher reminds him about "space" as he puts his arm out to demonstrate how much space to leave between yourself and someone else. John needs further instruction on how to initiate greetings with strangers.

Social reciprocity refers to the give-and-take of social interactions. Successful social interactions involve a mutual, back-and-forth exchange between two or more individuals. Many individuals with ASD engage in one-sided interactions in which they are either doing all the talking or fail to respond to the social initiations of others and to build on conversations with others. Individuals with ASD may continually derail conversations by changing the subject to fit their self-interests. They may also fail to respond to the initiations of others.

Jamie, an eleventh grade student with high functioning autism, was eating her lunch in the cafeteria when a classmate, Amy, sat down across from her. Jamie and Amy greeted each other and were eating their lunches. Amy asked Jamie if she had any plans for the weekend. Jamie answered for the next ten minutes straight about everything she was doing over the weekend, including an elaboration about going to a museum to see a glass exhibit which happens to be her current special interest area. Amy tried to comment on Jamie's plans and tell about what she would be doing for the weekend, but Jamie never stopped talking to give her a turn.

Several social skill difficulties exhibited by children and adolescents with ASD may be attributed to the manner in which they process social information, or social cognition (Baron-Cohen, 1989). Social cognition involves understanding the thoughts, intentions, motives, and behaviors of ourselves and others (Flavell, Miller, & Miller, 1993). As such, it impacts the success of social functioning. Knowing and understanding social norms, customs, and values is essential to healthy social interactions and is influenced by our social cognition (Resnick, Levine, & Teasley, 1991). Within the social-cognitive domain, three processes are particularly important in social functioning: knowledge (know-how), perspective taking, and self-awareness. Individuals with ASD often experience difficulties in all these areas.

Rose, a fifth grade student with ASD, has trouble waiting in the lunch line. As her classroom gets ready for lunch, she always wants to be first in line. When the class gets to the cafeteria, Rose yells and pushes in past anyone else who is waiting. Rose is not following spoken directions from her teacher, the cafeteria workers, or other students. To try to help, Rose's teacher makes a photo of each student and puts them in order on a Velcro board. She teaches the students to line up in the order of the photo board. (The pictures get changed periodically so each student can be the leader.) In the hallway by the cafeteria, Rose's teacher places contact paper handprints on the wall. Each student places their hand on the handprint to wait until they are told to go in and get their food. Rose learns to take her place in line at the classroom and to wait with her hand on the wall for lunch. It works so well, the cafeteria workers add enough handprints so all students can use the system as they wait for lunch. This system helped Rose understand the social norms of waiting in line and taking turns as the leader.

Darrell is sitting at the lunch table with his seventh grade classmates. He is talking and laughing with them. One of his classmates tells him if he stands on the table and yells out a swear word that everyone will think he is funny and will want to be his friend. Darrell jumps up on the cafeteria table and yells a swear word. His classmates are laughing! Darrell thinks, "My friend was right, this is funny." He yells another swear word as the principal walks up to the table and says to follow him to his office. Darrell tries to high five his classmates as he gets down, but they turn their backs to him and stop laughing. The principal asks Darrell to explain what was going on, so Darrell tells him everything. The principal calls the speech and language therapist to the office and asks him to do some cartooning with Darrell to help him understand what happened and maybe write a Social Story TM about the situation. Darrell sees two of his classmates in the office as he leaves. They sarcastically say, "Thanks a lot Darrell." Darrell answers, "You're welcome." The speech therapist notices the exchange and decides he will have many things to review with Darrell about his classmates and how to recognize friends.

Social skill deficits are often seen from a skill acquisition/performance deficit model.

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  A skill acquisition deficit refers to the absence of a skill or behavior. For example, a young child may not know how to effectively join in activities with peers. If we want this child to join in activities with peers, we need to teach her the skills to do so.
  

It's recess time and a group of kindergarten students are playing Duck, Duck, Goose. Joette, a student with Asperger Syndrome, is watching the game. A teacher notices Joette watching and takes her over near the students. She whispers to Joette to ask if they will let her join in the game. The other students welcome her. Joette sits down to play and the teacher walks away. When the kids say, "Duck" and tap Joette on the head, she is really upset she is not the goose. Finally, she is tapped as the goose. Joette doesn't understand the game and runs around the whole playground instead of just the circle. When the tapper catches Joette and touches her, Joette says the child hit her and runs to the teacher. The teacher tells the tapper she knows he just touched her, but to Joette it felt like a hit. Both the tapper and Joette settle down. The teacher then has Joette watch the game as she explains it to her. Joette tries again. She plays it the right way and the kids tap her very lightly.

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  A performance deficit refers to a skill or behavior that is present but not demonstrated or performed. To use the earlier example, a child may have the skill (or ability) to join in an activity but for some reason fails to do so. In this case, if we want the child to participate, we would not need to teach her to do so (since she already has the skill). Instead, we would need to address the factor that is impeding performance of the skill, such as lack of motivation, anxiety, or sensory sensitivities.
  

Ben can dance! He loves music and loves to move to it. Ben's friends want him to come to the school dance on Friday, but he isn't sure about going to the dance. It's in the gym and there will be really loud, loud music and strobe lights in the large, dark room. Other people might bump into him while they are all dancing. His friends tell him he can wear his ear buds from his music device to lessen the noise and that they will help keep other kids from bumping into him. They tell him he'll look cool if he wears his sunglasses to the dance so the strobe lights won't be so bright. Ben tells them he'll think about it. He isn't sure his sensory system is up to that much action.

A skill acquisition/performance deficit model guides the selection of intervention strategies. Most intervention strategies are better suited for either skill acquisition or performance deficits. The selected intervention should match the type of deficit present (Gresham, Sugai, & Horner, 2001). That is, you would not want to deliver a performance enhancement strategy if the child was mainly experiencing a skill acquisition deficit. It is important to note that these two categories are not mutually exclusive. Some strategies are capable of both teaching a new skill and enhancing the performance of existing skills (e.g., video modeling, Social Stories^TM, prompting, self-monitoring).

Assessment of Social Skills

The first step in social skills training programs should consist of conducting a thorough evaluation of the child's current level of social functioning (Bellini, 2006). The purpose of the social skills assessment is to identify skills that will be the direct target of the intervention and to monitor the outcomes of the social skills program. The evaluation details both the strengths and needs of the individual related to social functioning. The assessment often involves a combination of observation (both naturalistic and structured), interview (e.g., parents, teachers, playground supervisors), and social skill rating forms (parent, teacher, and self-reports). Social skills assessment involves the direct assessment of social skills (via systematic observation) and the evaluation of social competence (via interview and rating scales). Information gathered from the assessment allows us to develop quality IEP and treatment objectives.

Purpose of Social Skills Assessment

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  To identify skills to teach
  
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  To monitor progress
  

Miki, a kindergartener with autism, has significant expressive communication deficits and exhibits severe aggressive behavior with peers. She is primarily echolalic and seldom uses her language spontaneously with classmates and teachers. Miki is extremely fearful of social situations and often avoids social interactions. Consequently, Miki spends the vast majority of her playground time by herself with little peer interaction. When peers initiate, Miki often responds with physical aggression. A social skills assessment was conducted. Staff observed Miki on the playground, in the cafeteria, and during gym class. The psychologist on the team also completed a rating scale with Miki's parents. The team concluded that she has significant skill deficits in responding to the initiations with peers. It was hypothesized that Miki was engaging in aggressive behaviors because of her difficulties with social responsiveness. Social skills programming was implemented to teach Miki how to effectively initiate and respond to the initiations of peers.

Direct observation of social behaviors should follow the interviews and administration of rating scales. Two traditional methods of observation may be used to assess the social functioning of children with ASD, naturalistic and structured. The purpose of both is to observe the child's social performance across settings, persons, and social contexts. Naturalistic observation involves observing and recording the child's behavior in real-life social settings, such as the school playground and cafeteria, or in various social settings at or near the child's home. Structured observations involve observing social behavior in a structured play group or structured social group. The child with ASD is grouped with one or two non-disabled peers in a setting that is rich in social opportunities (games, toys, and other age-appropriate play objects).

Evaluations of social competence are typically conducted through the use of interviews or rating scales. Interviews are a valuable method for obtaining information regarding social functioning in a relatively short time by allowing us to collect and synthesize information from a variety of respondents, representing a wide range of settings. That is, they allow the evaluator to make decisions regarding the direction and focus of the program.

Rating scales are indirect assessment tools that provide information across a variety of functioning areas. These measures range from informal checklists to standardized rating scales and may be administered to parents, teachers, and the child. Rating scales can measure social functioning, anxiety, self-concept and self-esteem, and behavioral functioning. A major advantage of rating scales is their ability to quickly and efficiently obtain large quantities of information regarding social behavior from a variety of sources and across a variety of settings.

Social Validity

Social validity refers to the social significance of the treatment objectives, the social significance of the intervention strategies, and the social importance of the intervention results (Gresham & Lambros, 1998). It involves ensuring that the consumers believe that the selected treatment objectives are indeed important for the child to achieve. Social validity influences treatment fidelity; that is, to the degree to which the intervention was implemented as intended. The measurement of treatment fidelity, in part, allows us to determine whether an ineffectual intervention is due to an ineffective intervention strategy or to poor implementation.

Mrs. Cohn, a seventh grade science teacher, was using a Social Story TM about how to work with your peers on a group project with Sam, one of her students who has Asperger Syndrome. Mrs. Cohn reported at a team meeting that it wasn't working because Sam still wasn't cooperating with his classmates. The team members looked at the Social Story TM and found it was written according to the formula. They asked Mrs. Cohn when she was using the story, and discovered she would hand it to Sam after he became upset when trying to work with a group. The team explained that the story was meant to be used prior to the social situation and recommended Mrs. Cohn read the story with Sam the day before group work was to begin, and also to send home a copy so Sam's parents could review the story with him too. Mrs. Cohn tried using the story this way and found Sam was able to improve his social behaviors as listed in the Social Story TM.

Skills identified by the social skills assessment should be targeted in the development of IEP and treatment objectives.

Social objectives should:

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  Define short-term, immediate behaviors
  
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  Be connected directly to the intervention strategies
  
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  Describe specific levels of performance
  

Examples of possible social objectives:

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  Scotty will join in play activities with peers in a structured playgroup a minimum of 5 times per session.
  
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  Scotty will respond to the social initiations of peers on the playground with a minimum response ratio of 70%.
  
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  Scotty will raise his hand before answering questions during classroom discussions (90% of questions answered).
  

Social skills training refers to instruction or support designed to improve or facilitate the acquisition and/or performance of social skills. Social skills training programs address three primary objectives: promote skill acquisition, enhance the performance of existing skills, and facilitate the generalization of skills across settings and persons. Most children acquire social skills through learning that involves observation, modeling, coaching, social problem solving, behavior rehearsal, feedback, and reinforcement-based strategies (Gresham & Elliot, 1990).

Social skills training can be delivered across a variety of settings (e.g., home, community, classroom, resource room, playground, and therapeutic clinic) and with multiple persons (e.g., family members, teachers, counselors, speech and language pathologists, social workers, occupational and physical therapists, psychologists, physicians, case managers). In addition, social skills can be taught in an individual, group, or class-wide format. Successful social skills training programs promote cooperation between parents (and other family members and caregivers) and professionals.

One final consideration for teaching social skills is to address both social accommodations and social assimilation (Bellini, 2006). Social accommodation involves modifying the physical or social environment to promote positive social interactions. Examples of social accommodations include training peer mentors and conducting autism awareness training. Social assimilation refers to instruction that facilitates skill development or fundamental changes in the child that allows the child to be more successful in social interactions. Examples of social assimilation include social skill intervention strategies that are child specific, such as video modeling, social stories, self-monitoring, and so on.

There are number of important questions to consider when selecting social skill strategies, including the following:

1. Does the strategy target the skill deficits identified in the social assessment?

2. Does the strategy enhance performance?

3. Does the strategy promote skill acquisition?

4. Does the strategy facilitate generalization? If not, what is the plan for facilitating generalization?

5. Is there research to support its use? If not, what is your plan to evaluate its effectiveness with the child?

6. Is it developmentally appropriate for the child?