effective social skills interventions for adults with asd

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


• 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


• 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


• 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


• Promote skill generalization

• Include peers

• Use multiple trainers

• Practice in naturalistic settings


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



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

The Multi-Media Social Skills Project MODULE 3: Barriers to Social Relationships



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

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

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]

http://www.paautism.org/

mailto:[email protected]

effective social skills interventions for adults with asd

Documents