If you've ever vacationed in a foreign country or have friends who have recently come to the United States, then you have probably noticed the importance of understanding social rules. In some nations, certain gestures can have a completely different meaning than they do in the United States and using the wrong ones, making physical contact, or even infringing on someone's personal space can result in an embarrassing, awkward, or even dangerous situation.
For children with an autism spectrum disorder (ASD), a group of developmental disorders which include autistic disorder, Asperger syndrome, and pervasive developmental disorder-not otherwise specified (PDD-NOS), difficulties arising from the lack of understanding of social rules and cues are everyday occurrences. These can be especially troubling for affected children and adults who are "high functioning," a group that has grown dramatically in size in recent years and represents at least 40 percent of all children with an ASD. Because people within this group do not have substantial impairments in their overall cognitive functioning and have relatively good language skills, their peers, teachers, and even their parents can find it very hard to appreciate the seriousness of their disability. These children typically receive a diagnosis of either high functioning autism (HFA) or Asperger syndrome (AS), but despite the criteria indicated in the Diagnostic and Statistical Manual, Fourth Edition Text Revision (DSM-IV TR) for telling one from the other (e.g., early language delay only with HFA), respected clinicians have pointed out that the distinction can be hard to draw in practice. Therefore, many people have been focusing more on the similarities between these groups, especially since research has suggested that similar interventions are helpful for both groups of children.
Reciprocal social interaction, the process of reading, understanding, initiating, and responding to the social cues of others, is a core deficit and hallmark symptom for children with autism spectrum disorders (although it is clearly not the only concern). Research at Kennedy Krieger Institute has found that these social deficits can be identified as early as 14 months of age, well before communication deficits and stereotyped behaviors typically appear. This suggests that deficiencies in social interaction lie at the heart of these conditions and may even contribute to language delays and problem behaviors. (Intuitively, this idea seems reasonable, given that language functions to promote social interactions and considering that problem behaviors often are defined in a social context.)
Children with HFA and AS have unique social challenges because they often look and act like "typical kids" in many situations. Their language skills are, by definition, pretty good, and they achieve, or even over-achieve, in learning basic academic concepts. This can generate increased expectations among family members, teachers, and peers who assume that affected children will also be able to understand the rules of social interaction. Unfortunately, these children rarely meet these expectations, but recent research has led to a greater understanding of this core deficit and is being translated into evidence-based interventions.
For children with HFA and AS, deficits in social engagement might include poor eye contact, difficulty initiating and maintaining conversations, lack of appreciation of other people's perspectives, a poor understanding of relationships, and an overly literal interpretation of language. Some children with HFA and AS might have little interest in socializing with their peers, while others may want to socialize but lack the skills to be successful. Individuals with HFA and AS typically have "one-sided conversations," and often have an area of intense interest, which tends to drive their conversations with others. Children with HFA and AS also tend to have other subtle deficits, particularly in terms of emotional self-regulation (e.g., adapting to a difficult situation), changing routines, and organizational skills.
In order to develop the most effective methods for addressing these deficits, scientists have examined the brain to understand which areas are involved with social engagement. In recent years, some studies have employed functional magnetic resonance imaging (fMRI) to visualize the inner workings of the brain. fMRI is a noninvasive, painless procedure in which detailed pictures of the brain can be generated without the use of x-rays or other radiation, and fMRI can provide pictures showing which areas are activated during a specific activity. In autism research, fMRIs have been very useful for understanding which areas of the brain are affected during important elements of social interaction. One such study revealed that the amygdala, an essential area for guiding emotional reactions, and the fusiform face area (FFA), an area which is important for recognizing faces and facial features, were less active for children with autism than for typically-developing children when they looked at pictures of actual faces.
We know from all the research that has been done on the role of the FFA, including fMRI experiments and case studies of individuals with damage in that area due to traumatic brain injury or stroke, that faces have a special status among the virtually infinite complex patterns we have to perceive every day. Given how subtle the real differences are between one face and another compared to how distinct faces are from everything else, this seems sensible. Thus, impaired FFA function can have severe consequences when it comes to recognizing faces and facial expressions, and children with HFA or AS may never be able to perform these tasks as effortlessly as unaffected children and adults. However, training can lead to improvements in skills, even if other less specialized areas of the brain have to compensate for what should normally be the FFA's responsibility. For example, one intervention showing promise involves a computer program that presents various faces showing different emotions alone or along with voices. Individuals with autism are able to significantly improve their abilities through practice with this program, although use of their new skills in everyday settings is not as notable (probably because diminished ability to recognize facial features represents only one of many deficits involved in social engagement, including perspective-taking and social problem-solving).
In contrast to interventions explicitly focused on understanding the meanings of facial expressions, other programs target a variety of abilities at once. The underlying theory behind this strategy is that specific deficits do not exist in isolation, but rather interact with each other during the process of social interaction to cause impairments. Of course, this suggests that intervention may be more difficult since multiple skills have to be targeted for change, but there is good evidence that this is what needs to be done. Studies on narrowly focused interventions have repeatedly shown that increasing specific skills in isolation (e.g., facial expression recognition) does not usually improve overall social functioning.
An intervention that is proving to be especially effective involves participation in social skill groups, and these programs are becoming more prevalent during the school-age years when regular education shifts emphasis from social development to academics. For the majority of school-age children with HFA and AS, entry into a regular education classroom presents new social challenges that become increasingly complex over time, and whether it is unstructured time on the playground, being part of a group or team, or navigating from one classroom to another, most of the day requires some form of interaction with other people. Typically-developing children will be able to adjust easily to these new situations, but children with HFA and AS will need considerable supports. Social skill groups can be an important source of that support.
Teaching social skills to a group of school-age children with HFA and AS involves gathering a group of children together to do the types of things that typical kids enjoy (e.g., hanging-out together, just talking, playing games). For children with HFA and AS, these can be frustrating activities, which often lead to rejection, lowered self-esteem, and increased anxiety. Therefore, programs need to be structured to teach the skills necessary for more successful social interactions.
Social skill groups typically take place in a clinic or school and can be facilitated by a psychologist, speech-language pathologist, counselor, or specialized teacher. It is important for the facilitator to have training and experience tailored to the particular characteristics of his or her group, and participants should be screened to ensure that they fit in with the language and maturity levels of other group members. In our six- to eight-year-old group at Kennedy Krieger Institute, for example, we expect a child to speak in full sentences, remain attentive for at least 10 minutes at a time, be able to initiate and maintain a conversation with some assistance, and exert some control over aggressive and disruptive behaviors.
Goals for the group often focus on elements of social engagement, problem-solving, and emotion recognition, with content and expectations adjusted to the initial skills of individual participants. Social engagement goals include increasing social awareness and communication skills, with specifics focused on things like starting and maintaining a conversation, understanding social cues (e.g., a person looking at their watch when they are bored), and perspective-taking. Problem-solving goals are particularly important for helping children with HFA and AS deal with disappointment, develop alternative solutions when obstacles are encountered, or arrive at acceptable compromises.
Each group session includes the opportunity to practice previously taught skills and the teaching and modeling of new skills. Once the facilitator has gathered the members together, group members greet each other. Employing behavioral training techniques, group members are encouraged to ask typical questions one would ask of friends (e.g., How are you? What did you do this weekend?). The group facilitators prompt them through the process of asking questions and responding appropriately, as well as using appropriate nonverbal skills (turning their body toward them, engaging in good eye contact). The expectations for this activity increase over the course of the time as the participants become more adept at social engagement. Following this activity, a specific skill for that session is taught and modeled by the group facilitators through the use of game-based learning activities that provide concrete examples of how to use the skill, when to use the skill, and how the use of that skill affects others. The facilitators lead the group in taking turns, asking questions, and giving or showing examples. The skill is then practiced by having children "perform" the skill with each other or with a facilitator using a variety of different situations. Finally, the skill is generalized to different activities by incorporating it into various "new" activities (e.g., practicing adjusting to disappointment while playing the game, saying "I'm sorry," or using it appropriately during a snack time).
In our group, we incorporate research-based teaching strategies to increase chances for success. For example, we utilize a reward system in which points are earned over the course of the session for engaging in positive social behaviors (e.g., asking someone an appropriate question, initiating a conversation, making good eye contact). At the end of each session, which lasts between 60 and 90 minutes, children who receive "enough" points can trade them in for a prize of their choice. In addition, we make frequent use of visual schedules and other visual representations of different concepts (e.g., showing the difference between "thinking" versus "saying" by using a picture of a person with a "thought bubble" and a "speaking bubble"). Finally, and most importantly, our activities include things that are fun and motivating for the child (e.g., content consistent with their intense interests, like cars or Star Wars).
A major obstacle in teaching social skills to children with HFA and AS is their difficulty in generalizing skills to new settings, and careful consideration needs to be given to this concern for programs to be effective. One method used to enhance the broader use of these skills is training caregivers to identify and create opportunities for their child to practice social skills in play sessions with peers or adults. The program at Kennedy Krieger sets aside time for one facilitator to meet separately with the parents each week. During this period, goals are explained, specific exercises are conducted, and homework activities are assigned (which typically involve practicing previously learned skills in new contexts to increase generalization). These sessions also provide a valuable time for parents to discuss their child's behavior, compare notes, and explore ways of teaching particular skills. When at home, activities involve things like working with the child prior to a play/learning session, guiding him or her during the session (by providing suggestions or modeling appropriate interactions), and discussing the session afterward.
Kennedy Krieger's experiences with social skill groups, along with those of many other groups, have shown that children with HFA and AS can make significant gains in emotional awareness and problem-solving skills. In addition, parents of group participants have reported fewer problem behaviors and increases in their own level of confidence in their ability to support their child. However, some children benefit much more than others from participation in these types of groups (e.g., children with higher verbal IQs), and all social skill groups are not as good as others (e.g., programs providing 30 hours or more of intervention are more effective than programs with a lower time commitment). However, researchers are continuing to explore strategies to improve program effectiveness for everyone.
Research evaluating intervention effectiveness typically examines behaviors and abilities prior to and then after completion of the intervention, with data collected for several (or many) measures of achievement. By comparing the same abilities measured before and after interventions, researchers can document changes quantitatively and determine if improvements occurred over and above what would be expected just by increasing maturity. Further, by comparing changes in children receiving various interventions, researchers can determine which programs are most effective, and by relating program features to the characteristics of the children, they can even determine which intervention will work best for which individuals.
In these types of studies, though, extensive experience has shown that investigators, no matter how objective they may strive to be, can see benefits of "pet" treatments that aren't really there. Wishful thinking is a powerful force, and scientists are no more immune than anyone else. However, they have long recognized this concern, and standard practices have been developed to insulate findings from this potential influence. Unfortunately, many "popular" treatments for ASD promoted over the years have never undergone rigorous testing for effectiveness, and everyone should be wary when extravagant claims of successes are not backed up by well-controlled studies conducted by independent researchers.
Summing up, many children with HFA and AS experience tremendous difficulty socializing, and this can have dramatic consequences for both their lives and the lives of their families. With the recent advancements in knowledge generated by research, we have already learned that some children with HFA and AS can show remarkable improvements in their social and problem-solving skills, and many more can benefit from effective interventions to a smaller but still significant extent. Hopefully, research will continue to provide insights into the conditions that cause autism and generate the data needed to design even more effective, evidence-based interventions, helping all affected children realize the goals and aspirations that they and their families dream of achieving.
By Brian Freedman, PhD and Wayne Silverman, PhD
Brian Freedman, PhD is a Clinical Psychologist and the Acting Clinical Director for the Kennedy Krieger Institute Center for Autism and Related Disorders.
Wayne Silverman, PhD, has investigated the science of developmental disabilities for more than 30 years and currently serves as Director of Intellectual Disabilities Research at the Kennedy Krieger Institute in Baltimore, Maryland.
An international leader in the fields of research, treatment, and education for disorders and injuries of the brain and spinal cord, Kennedy Krieger provides a wide range of services to over 13,000 children each year with developmental concerns mild to severe. For more information, visit www.kennedykrieger.org.…