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J Autism Dev Disord (2009) 39:12681277 DOI 10.

1007/s10803-009-0741-4

ORIGINAL PAPER

Social Competence and Social Skills Training and Intervention for Children with Autism Spectrum Disorders
Albert J. Cotugno

Published online: 14 April 2009 Springer Science+Business Media, LLC 2009

Abstract This study examined the effectiveness of a 30 week social competence and social skills group intervention program with children, ages 711, diagnosed with Autism Spectrum Disorders (ASD). Eighteen children with ASD were assessed with pretreatment and posttreatment measures on the Walker-McConnell Scale (WMS) and the MGH YouthCare Social Competence Development Scale. Each received the 30-week intervention program. For comparison, a matched sample of ten non-ASD children was also assessed, but received no treatment. The ndings indicated that each ASD intervention group demonstrated signicant gains on the WMS and signicant improvement in the areas of anxiety management, joint attention, and exibility/transitions. Results suggest that this approach can be effective in improving core social decits in individuals with ASD. Keywords Autism spectrum Social competency Social skills

Introduction Autism Spectrum Disorders (ASD) are neurological disorders of unknown origin signicantly affecting an individuals social interaction, language and communication, and behavioral range of activities and interests. In 2007, the
Portions of this paper were presented at the annual convention of the American Psychological Association, Boston, August 2008. A. J. Cotugno (&) Department of Psychiatry, Massachusetts General Hospital/ YouthCare, Harvard Medical School, 47A River Street, Suite A200, Wellesley, MA 02481, USA e-mail: acotugno@partners.org

Centers for Disease Control and Prevention (2007) estimated prevalence rates for autism and related disorders in the range of 1 in 150 individuals. As the numbers of children reported with ASD have increased, concerns have been raised regarding the availability and appropriateness of treatment interventions across a range of educational, clinical, and treatment settings. Those children with ASD who are characterized by signicant impairment in social interaction present with a range of behaviors including an inability to understand and interpret nonverbal behaviors in others, a failure to develop age-appropriate peer relationships, a lack of interest or enjoyment in social interactions, and a lack of social or emotional reciprocity. They may also demonstrate restrictive, repetitive, and stereotyped patterns of behavior, most often characterized by preoccupation with narrow, rigid and inexible interests or ways of thinking or behaviors and many exhibit serious communication decits, particularly in pragmatic language. These issues create signicant problems in engaging in normal and typical peer social interactions, often resulting in avoidance of social contacts, overarousal in social situations, an inability to understand and follow expected social rules and expectations, and tacit or explicit social rejection. Multiple theories have been proposed for the causes of primary social decits in ASD children, including decits in theory of mind (Baron-Cohen et al. 1985; Baron-Cohen 1995; Wing and Gould 1979), weak central coherence (Frith 1989; Frith and Happe 1994), and executive dysfunction (Minshew and Goldstein 1998; Ozonoff 1993, 1995; Pennington and Ozonoff 1996). Each appears to have demonstrated value and applicability, however, it is likely that there is no single cause for social decits in ASD children, but rather it is related to a complex set of multiple interacting factors (Santangelo and Tsatsanis 2005).

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Reviews of social competency and social skill development in children with ASD consistently indicate deciencies in key social skills (Gresham 1981; Hollinger 1987; Hops and Finch 1985; McConnell and Odom 1986; McConnell 2002) and that these decits signicantly interfere with social relationships (Welsh et al. 2001). Given the social-interpersonal decits attributed to ASD and their effects and that long-term social adjustment for children is directly related to the development of appropriate social competency (Matson and Swiezy 1994; Parker and Asher 1987; Shopler and Mesibov 1983), interventions which address the social competency needs and concerns of ASD individuals appear critical in overcoming many of the negative and debilitating effects of these disorders. Although group-based interventions have often been employed to enhance social competency and developmental skills and generally show signicant benets (Hwang and Hughes 2000; McConnell 2002; Rogers 2000), many question the efcacy of these treatments (Barry et al. 2003; Krasney et al. 2003; Williams et al. 2006), particularly their inability to generalize to real-life situations. Variations in research design, sample size, skills targeted, settings where treatments occur, instruments used to measure outcome, effect sizes, and generalization effects, have made evaluation of effectiveness and replication of ndings difcult. As a result, some authors have suggested guidelines for research with group interventions with children with ASD (Krasney et al. 2003; Mesibov 1986; Mesibov 1986). To date, many group-based interventions have used cognitive-behavioral strategies, pragmatic language development, theory of mind constructs, or specic social skills training, to enhance and sustain appropriate social skill development. Many social skills training programs have been constructed specically for children with ASD and have covered a wide array of skills, but have often lacked controlled, empirically-based assessment (e.g., Adams 2006; Baker 2003; Bloomquist 1996; McAfee 2002). Mesibov (1984) was rst to report the use of a group-based social skills training approach for individuals with ASD, in a qualitative study, using modeling, coaching, and roleplay, followed by other similar studies by LaGreca (1993) and Williams (1989). More controlled studies followed, focusing on different aspects of social competence and social skill training including social anxiety and social aggression (Steerneman et al. 1996), emotion recognition (Wimmer and Perner 1983), theory of mind (Ozonoff 1995; Perner and Wimmer 1985; Givers et al. 2006), and multiple areas of social skill development (Tse et al. 2007). In addition to basic social skill deciencies, three key issues that are consistently described as core decits related to social impairment in ASD individuals are stress/anxiety (Baron et al. 2006), attention (Frith 1989; Rosenn 2002),

and exibility/transitions, each of which have related perceptual, neuropsychological, and behavioral components (Klin et al. 2002) and each of which appear to be governed by underlying developmental aspects. These variables were chosen for study here because they are consistently referenced as important deciencies in nearly all groups of individuals with ASD studied. Relatively little research on effective interventions in these areas has occurred to date. Given the social impairments present in ASD individuals, in both key underlying processes and structures and specic social skills, a social competency and social skills training and intervention program was developed that combines group-based, therapeutic interventions, socialcognitive learning approaches, and directed skill instruction within a stage-based, cognitive-developmental framework. The purpose of this study was to describe a group treatment model for school-age children with ASD and to present data on the effectiveness of a multidimensional structure and skill based approach over a year long social competence/ social skill training program. We hypothesize that addressing specic areas of social competency and providing training in specic social skills will signicantly improve and enhance the social interactions of individuals with ASD in group situations.

Method Participants This study consisted of 18 children all from self-referred families to Massachusetts General Hospital (MGH)/ YouthCare. MGH/YouthCare is a small, community-based, independent program within the Department of Psychiatry at MGH which focuses primarily on treatment and consultation to children and adolescents with Autism Spectrum Disorders (ASD). All families were self-supporting, voluntary participants. Referrals came from general care and developmental pediatricians, specialty ASD programs both within and outside the hospital, school referrals, and website contacts. Following application, children and families were screened and interviewed for appropriateness within our group program. Children were included in this study, if at referral, they met the following criteria: (a) they were between the ages of 7 and 11; (b) they had received a prior diagnosis on the autism spectrum (i.e., Autistic Disorder, Pervasive Developmental Disorder-Not Otherwise Specied, Aspergers Disorder) meeting DSM IV criteria (American Psychiatric Association 1994), conrmed by neuropsychological evaluation by professionals with no connection to our program; (c) they had obtained a Full Scale or Verbal Scale IQ on the WISC IV within the

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average range (80119) or higher; (d) they demonstrated no signicant language or communication decits; and (e) they participated in at least a partial inclusion program in a regular education curriculum. Our group placement process also includes the completion of several steps described in detail elsewhere (Cotugno 2008). Eighteen children were selected and divided into two age clusters, one cluster of ten children ages 7.08.2, and a second cluster of children, ages 10.011.0. Each cluster demonstrated no signicant within group differences on any variable, including intelligence or academic achievement, demonstrating signicant homogeneity. For treatment purposes, each cluster was divided into two groups (for a total of four separate treatment groups) with all groups administered by the same licensed group clinician who had extensive training and experience working with children with ASD. For each cluster of two groups, a consistent stage-based, group focused competency/skill curriculum was employed with variations dependent on age and developmental factors. Children selected for group participation attended 1 h weekly sessions for 30 weeks. Two groups of ve children each, one group ages 78 and one group ages 1011, were randomly selected from two local public schools to match the ages and grades of the intervention groups. These ten children constituted the two control groups. Children were included only if they met the following criteria: (a) they had never been referred to nor ever received any special education services; (b) they were receiving no current psychological or school-based services (i.e., individual, group therapy or counseling); and (c) they had no prior contact with MGH/ YouthCare. Measures As part of the screening and assessment process, the following instruments were used in this study at both pretreatment and posttreatment phases. 1. The Walker-McConnell Scale of Social Competence and Social Adjustment (WMS). The WMS is a 43 item teacher completed scale clustered into three subscales, including teacher-preferred social behavior, peer-preferred social behavior, school adjustment behavior, and a total scale score. Normative data for 1,812 subjects by age and grade is provided and validity and reliability of the WMS meets established standards (Walker and McConnell 1995). However, no information is provided regarding specic norms or its utility with children with ASD. The WMS measures two correlated constructs related to social functioning: social competence and school adjustment. Social competence is dened as the development of effective interpersonal relationships with peers and adults. The WMS includes 16 items addressing teacher-preferred

social behavior and 17 items addressing peer-preferred social behavior. School adjustment is dened as satisfactorily meeting the behavioral and academic standards of teachers within instructional settings. The WMS includes ten items addressing school adjustment within the classroom. A total score including all 43 items represents a school-based social-behavioral adjustment index. 2. The MGH YouthCare Social Competency/Social Skill Development Scale (SCDS). The SCDS is a 55 item scale completed by parents of each participant in a YouthCare program, providing a broad measure of social competency and social skill development for children with ASD. Parents rate the child on important cognitive aspects (e.g., stress/anxiety, attention, exibility/transitions), social interpersonal skills (e.g., converses with peers), and selfawareness (e.g., controls self). All items are ranked on a 5point Likert scale. For the purposes of this study, a total of six items from the SCDS were selected for analysis and study at pretreatment and posttreatment, two items each, addressing stress/anxiety management, joint attention, and exibility/transitions. Procedures This study employed a pretest-posttest design. Prior to group placement, each family provided detailed medical, developmental, and educational histories, including all past and current evaluation information and participated in a parent/caretaker and child interview. Parents of each group participant completed the SCDS and the classroom teacher of each group participant completed the WMS in order to assess social competencies and social skills in the different settings of home and school. This information was used to assess each child for appropriateness for group placement and to construct individual goals for each child prior to placement within a group. This information was then pooled for all participants in the same group to create group goals focusing on each particular stage of group development. Each of the 18 children with ASD selected participated in once-weekly, year-long, group sessions (a total of 30 sessions). At posttreatment following a 30-week intervention program, parents again completed the SCDS and teachers, for both the treatment group participants and the non-ASD control sample, completed the WMS.

Social Competency and Social Skills Training and Intervention Program This intervention program employed a peer-based, group model within a cognitive-developmental framework using group therapy, cognitive-behavioral, and skill instruction

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techniques to address the social competency needs and concerns of these children with ASD. A comprehensive initial assessment provided information for the elaboration of specic areas of interest, individual goals for each child, and group goals once a group was assembled. This program also addressed the specic stages of development that groups of children with ASD are observed to move through as they evolve. Within each stage of development, opportunities are provided for the group to address and comprehend aspects of social interaction and to develop adaptive strategies to manage social issues most effectively. The group leader and participants jointly set stage goals and evaluate progress toward meeting those goals. As specic stage goals are met, group members discuss and elaborate subsequent stage goals. At each stage within this framework, key group process variables are targeted and addressed within the group (i.e., building culture, relating and connecting, attending to task and peers, joint decision making) and related skills for instruction based on these variables are elaborated. Specic skill instruction is based both on individual needs within the group and the needs of the group as a whole (e.g., eye gaze, asking questions, etc.) and is structured to focus on and develop more effective and age appropriate strategies for interactions with peers in natural settings. The program used in this study was also designed to specically address key areas of deciency (core decits) in individuals with ASD: stress and anxiety management, joint attention, and exibility/transitions. Each social competency group met weekly for 1 h from September through June for a total of 30 sessions. Each group was led by a group clinician with training and expertise in working with children with ASD and in group therapy interventions. Sessions were constructed so as to maintain a high degree of consistency from session to session and included three components: (a) an introductory period (greetings, sharing time, announcements); (b) a group decision-making task designating the activity for that particular session (selected by the group participants from a cluster of activities determined in advance by the group leader and focusing on issues specic to the particular stage). For example at Stage 2 Group Cohesion, the group leader provides several specic activities or games which focus on strengthening the bond between group members through the development of group awareness, disclosure, and feedback mechanisms, from which the group members must choose. All members were required to participate in the activity; and (c) a snack time and group discussion of the activity. This was used for processing group interactions, conicts, and dynamics, relating the work of that particular session to previous sessions, connecting key process variables and specic skills. A preview of the next session also occurred.

During each session within this program, primary emphasis is placed on interventions which focus on the following: developmental leveling (group and skill-based experiences targeted to the overall developmental level of the group); self-management (each individual takes responsibility for self-managing and self-controlling ones own behavior in order to meet group expectations); peer mediation (peer to peer interactions designed to address and resolve group issues and conicts as they arise); priming (complex tasks are broken into simple steps with preparation and training provided for managing new aspects of a task based upon previously learned skills and strategies); and direct instruction (specic skills are selected, taught, and reinforced within the group setting). Activities used during group sessions were selected based on the following criteria: 1. 2. 3. Current stage of group development; Specic group goals related to the stage of group development; Specic social skills related to group goals.

A Stage Model of Group Development for Individuals with ASD In groups of children with ASD, a consistent sequence and order of stages of development have been previously observed and documented (Cotugno 2008, 2009). Specic to each stage, there emerge processes and sets of behaviors that appear necessary in order to pass successfully through the particular stage and on to subsequent stages. They are: Stage Stage Stage Stage Stage Stage 1 The rst stage consists of Group Formation and Orientation, a process where the group comes together and gets to know one another as individuals and as a group. Here, the group begins to understand how to react, respond, and interact with one another while engaging in conversation, sharing of interests, and establishing connections. Group goals provide a focus on the common and shared experiences and are intended to provide structure and information and opportunities to share feelings, thoughts, and experiences in a new situation. Specic skills relate to the group goals of fostering and developing cohesion, connections, and relationships within the group. These include: learning about one another (sharing information, asking questions, 1 2 3 4 5 Group formation and orientation. Group cohesion. Group stability, relationships, and connections. Group adaptations and perspective taking. Terminations, loss, and goodbyes.

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attending to others, exploring for common interests, etc.), learning about how the group can work together, acknowledging common issues (anxiety in relationships, needs for exibility, etc.), and creating a group plan. Stage 2 The second stage of Group Cohesion relates to the capacity to form a bond as a group and to use that bond as a force to hold the group together as it begins to deal with increasingly more stressful issues. Information learned from Stage 1 sessions, particularly in the areas of stress-anxiety, attention, and exibility/transitions, will inform the construction of Stage 2 goals. Group goals foster interaction, while individual goals work on specic aspects of a group members thinking or behavior that might interfere with effective group participation and involvement. Group goals provide the opportunity for interaction, while individual goals focus on the specic needs of the individual to make interactions successful. Specic skills relate to the overall group goals of acknowledging, managing, and coping with the stress and anxiety that arises as individuals take risks to share personal information, joining others in an attempt to gain support and feedback, expressing needs that may be embarrassing, and recognizing intimacy and afliation needs. Stage 3 The third stage of Group Stability, Relationships, and Connections emphasizes the power of interactive group process to tap into the established and now ongoing stability that comes from the familiarity achieved between group members on rules, boundaries, and managing positive/negative interactions. Group members identify with other group members and with the group leader and strong alliances develop. The group becomes more active in structuring the sessions based on a consensus and approval of group needs and is positioned to initiate discussions, allocate time, resolve conicts, respect and take care of one another, and to move forward on the articulated goals. Group goals focus on a gradual shift in the arrangement of power and control from group leader to the group and on communication enhancement within the group, group management of conict and hostility when it arises, and total acceptance of each group member within the group as a whole. Specic skills focused upon include learning about: nonverbal communication, working cooperatively, giving and getting feedback/criticism, emotional regulation, and anxiety management. Stage 4 This stage of Group Adaptation and Perspective Taking relates to the capacity to adapt exibly to the positive and

negative issues that arise, time management, modes of communication, decision-making, and responses to the needs of the group. As the issues change or as the group needs shift, the group must develop the capacity at this stage to quickly adjust and adapt, using the group interactions to decide the types of adaptations required. At this stage, the group learns to manage and direct itself while managing and resolving conict, to repair breaks in relationships, to adapt to change, to consider multiple points of view and alternative ways of thinking, and to exibly manage unknown or unpredictable situations. At Stage 4, increasing emphasis is placed on goals relating to exibility, the ability to shift, and on theory of mind, the capacity to think about and experience what another person might be thinking or feeling, as well as openness and resiliancy when faced with difcult, perplexing, and hard to solve problems. Goals are constructed to ensure practice in self-management and self-direction by requiring honest and respectful interactions, appropriate confrontation, discussion of alternative solutions to problems, and unanimous agreement in decision-making. Specic skills addressed include: negotiating compromise, recognizing and using criticism, seeing things through another persons eyes, apologizing, and getting unstuck. Stage 5 The Stage 5 Termination, Loss, and Endings, relates to endings, losses, signicant transitions, and goodbyes. Attempts are made to understand the thoughts, feelings, and emotions that these events stir up and the effects that they have on interactions with peers and others. This stage focuses on recognizing what these experiences are like, how to tell when they occur, and what effect they have on each member. The goals focus on addressing and managing thoughts, feelings, and emotions, related to change, transitions, losses, and endings. Specic skills addressed at Stage 5 include: expressing termination emotions, understanding endings, and saving the memories.

Three Specic Areas Addressed in this Study Three signicant issues, prominent in nearly all interpersonal interactions with individuals with ASD, were a specic focus of this study and are addressed and considered within group goals at each stage. They include: (a) the experience and management of stress and anxiety; (b) joint attention; and (c) exibility/transitions. In order to address and manage the stress and anxiety that individuals with ASD experience, particularly around interactions in group situations, group sessions provide progressive and systematic training in basic stress and

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anxiety management techniques, such as deep breathing, rhythmic counting, and visual imaging. This training is repeated and practiced consistently in subsequent sessions, particularly when stress arises and serves to trigger group discussions about what causes anxiety, what it feels like, and what techniques or methods can assist in managing it. A second major focus of these groups is on joint attention, the capacity to direct and employ attentional capacities as they relate to shared interpersonal requirements and expectations. Group participants are taught how to understand and to appropriately react to attentional expectations with the focus on interactions between individuals. Because joint attention is known to be an important and necessary competency for reciprocal interchange and communication in group situations, group goals are constructed around the development and enhancement of joint attention with activities selected at each stage by the group leader which will develop and reinforce joint attention between group participants. A third issue affecting individuals with ASD and which is addressed at each stage within groups relates to the issue of exibility and transitions. Because the requirements to be exible, to adjust and accommodate to change, and to transition (i.e., shift attention) between tasks and activities are known to create signicant degrees of stress and tension in the majority of individuals with ASD, triggering increased anxiety, and often overload (i.e., meltdown), group goals are constructed related to these issues to anticipate and prepare for the stress related to the needs for exibility/transition throughout the group stages. Throughout the course of the group, activities chosen are previewed and discussed in order to understand how they relate to the individual and group goals and the specic social skills to be addressed during that session for that activity. Discussions are provided in language appropriate for the age of group members. Following a brief priming period and exercise, specic social competencies and social skills are modeled and demonstrated by the group leader with explicit verbal and nonverbal reinforcements. and ongoing feedback.
Table 1 Pretreatment and posttreatment means and t-tests for two groups of ASD children

Results This study examined whether teacher and parent ratings of social competency, social behavior, and school adjustment improved over a 9-month period for children with ASD, ages 711, who were provided with weekly group intervention which combined group therapy, cognitive-behavioral, and skill instruction techniques within a stage-based, cognitivedevelopmental framework. In addition, three issues known to affect social-interpersonal behavior, stress and anxiety management, joint attention, and exibility/transitions, were a specic focus of the competency and skill-based interventions across each of the ve stages of group development. Table 1 provides the pretreatment and posttreatment means for scores on each of four scales on the WMS for the two clusters of children with ASD (78 year olds and 1011 year olds) who received social competency intervention. For both the 78 and 1011 year old intervention groups of children with ASD, teacher ratings on the WMS were signicantly improved across the four scales, teacher-preferred social behavior, peer-preferred social behavior, school adjustment behavior, and total score. The younger group (ages 78) showed greatest improvement on teacherpreferred (t = 2.29, p \ .05) and peer-preferred behavior (t = 2.30, p \ .05), while the older group (ages 1011) showed greatest improvement in school adjustment behavior (t = 2.89, p \ .01). For both groups of children with ASD, total score showed similar overall gains from pretreatment to posttreatment (t = 2.53, p \ .05; t = 3.11, p \ .01). Upon review of the cluster of group goals established at the outset of group sessions by each of the intervention groups, these results are consistent with the younger childrens goals focusing on meeting rule expectations, completing tasks as requested, understanding and cooperating with peers more effectively, and learning more about peers and what they like to do. For the groups of older children with ASD, the cluster of group goals established at the outset focused more on the completion and quality of tasks

Pretreatment ASD groups, ages 78 (N = 10) Teacher-preferred social behavior Peer-preferred social behavior School adjustment behavior Total score ASD groups, ages 1011 (N = 8) Teacher-preferred social behavior Peer-preferred social Behavior School adjustment behavior Total score 44.5 44.0 32.0 120.5 46.2 43.8 31.4 121.4

Posttreatment

52.7 50.9 34.6 138.3 48.8 47.0 41.1 136.4

2.29* 2.30* 2.52* 2.53* 2.04* 2.58* 2.89** 3.11**

* p \ .05 ** p \ .01

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and activities, listening and responding more carefully, and using time and efforts in more organized and efcient ways. It appears that at different ages, the individual and group goals selected by each of the groups reect developmentally appropriate choices directed toward what are perceived as their most pressing needs. The younger children appeared to be struggling most with learning how to act appropriately and to learn appropriate peer behavior, while the older groups were concerned with social acceptance as it relates to school-based behavior and academic performance. Regarding parent ratings of competency in the areas of stress and anxiety management, joint attention, and exibility/transitions, results were generally in positive directions for each variable, but with some variability. Table 2 lists the percentage of group participants at pretreatment and posttreatment who received scores of two or one (no or limited demonstration of the positive, adaptive behavior) on the SCDS items. Both the younger and older groups of children with ASD demonstrated signicant improvement in parent ratings of stress and anxiety management, joint attention, and exibility/transitions from pretreatment to posttreatment. However, the younger group demonstrated a greater shift to more positive and effective ways of managing and coping on each of these variables than the older group. Upon review of the group goals for each of the groups during the course of yearlong sessions, the goals selected and focused upon by the younger children more frequently addressed stress/tension/ anxiety issues (what we came to call comfort concerns), while the older group more frequently addressed interactive concerns, learning to get along, and resolving conicts. Both younger and older groups focused their group goals on joint attention issues (active listening and responding, taking turns, giving compliments) with equal frequency. Nevertheless, while each group demonstrated signicant improvement over time in stress/anxiety management, joint
Table 2 Number and percentage of SCDS scores of two or one by age group for two questions for each key variable assessed Pretreatment N ASD groups, ages 78 Anxiety and stress mgmt Joint attention Flexibility/transitions ASD groups, ages 1011 Anxiety and stress mgmt Joint attention Flexibility/transitions 16 11 11 100 69 69 7 4 5 44 25 31 17 12 17 85 60 85 9 7 11 45 35 55 % Posttreatment N %

attention, and exibility/transitions as reported by parent observation, further study of how individual and group goal setting and task and activity selection affect change and outcome on these variables is warranted. The data for the comparison control group of neurotypical children was included to insure consistency with WMS normative data which does not provide separate normative data for children with ASD and to provide a control group with similar demographics to the children with ASD who were assessed and treated. For the comparison control group of neurotypical children who received no intervention, pretreatment and posttreatment scores on the WMS are provided in Appendix 1. Control children, performed at expected levels on both pretreatment and posttreatment measures, demonstrating no signicant change, and maintaining high levels of performance as compared to the children with ASD at both pretreatment and posttreatment. The results of this study provide strong support for the hypothesis that a group-based intervention which focuses specically on decient social competencies and skills can benet children with ASD by reducing anxiety in social situations, increasing the number of and attention to positive peer social interactions, and increasing exibility and willingness to change, as observed by parents. This study also provides evidence that improved stress and anxiety management, joint attention, and exibility/transitions in group situations can contribute directly to improvements in teacher-preferred and peer-preferred social behavior and school adjustment.

Discussion Despite the prevalence of social skill interventions for children with ASD which indicate generally positive effects, surprisingly little formal or controlled research on the specic benets of different approaches, comparisons between approaches, and comparisons with typical and non-ASD populations, has taken place until recently. Generally, studies of social skills based groups for ASD children report modest improvement and high overall parent and participant satisfaction, but relatively poor generalizability. The purpose of this study was to examine the effectiveness of a group-based, 30 week, social competence and social skill training and intervention program with ASD children, ages 711. This study combined group-based therapeutic interventions, social-cognitive learning approaches, and directed social skills instruction within a stage-based, cognitive-developmental model. This study found that a specially designed, social competency and social skills training and intervention program providing systematic intervention and instruction can substantially improve performance on specic social competencies and in social skill development.

Percentages reect the number of group participants receiving a score of two or one, scores reecting no or very limited demonstration of positive, adaptive behavior

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1275 Table 3 Pretreatment and posttreatment means and t-tests for two groups of non-ASD control children receiving no intervention Pretreatment Posttreatment t Non-ASD group, ages 78 (N = 5) Teacher-preferred social behavior Peer-preferred social behavior School adjustment behavior Total score 59.6 60.8 40.6 159.0 60.4 63.2 40.0 163.6 65.2 72.4 43.8 181.4 .38 .70 .35 .71 1.9 .47 .11 1.10

Results of this study indicated signicant improvement in overall social competency scores for all groups of children with ASD based on WMS scores. Signicant improvement also occurred as reported by parent observation on key variables in core decit areas on the SCDS of stress and anxiety management, joint attention, and exibility and transitions. Overall, these results provide a strong indication that social competency groups that focus on process-oriented variables combined with skill-based instruction can benet individuals with ASD in specic areas of social interaction. However, while the gains through intervention by the children with ASD were signicant at posttreatment, these children continued to lag the control peers in signicant ways. At pretreatment, children with ASD were performing at levels signicantly lower than their normal peers on all measures of social competency and social interaction, but with intervention, were able to make signicant gains over time. While not able to attain normal scores after the 30-week intervention, children with ASD who have signicant social decits and impairments may be capable of making ongoing cumulative gains when interventions are extended over longer periods of time and are targeted to areas of need. The results suggest the need for continued emphasis in areas of core decits, increased intensity of interventions to improve the rate of progress, consistent and ongoing reinforcement to solidify and internalize learned acquired competencies and skills, and a specic focus on the transfer and generalizability of these competencies and skills to unrehearsed social situations. Although group interventions may have their limitations, the nature of decits and impairments related to ASD requires that social competency-based interventions, particularly involving peer-based situations, continue to be tested, explored, and rened for their efcacy and generalizability. Limitations affecting this study included: a small sample size, generally limited by the need to keep group size small and manageable; limited prior research on the social competencies and social cognitive processes which inuence and determine social skill development; the ongoing need for more precise assessment and measurement tools for the ASD population (e.g., the WMS reported adequate validity with typical school-based populations, but no data on individuals with ASD); the lack of a true no treatment control group of children diagnosed with ASD; and the lack of randomization across all groups. Also, further evaluation of structure-based, process-oriented approaches within a cognitive-developmental model appears indicated.

Non-ASD group, ages 1011 (N = 5) Teacher-preferred social 69.4 behavior Peer-preferred social behavior School adjustment behavior Total score 74.0 43.6 187.0

All mean comparisons were nonsignicant

Appendix 2 Parent Rating Questions on the SCDS Collected at Pretreatment and Posttreatment Anxiety Control and Management Enters and acclimates to group without anxiety. Manages anxiety effectively. Joint Attention Participates in group structure and activities. Attends to others. Flexibility/transitions Accepts peers initiation of activities. Gets self unstuck without help. Parents respond by rating on a scale of 15 as follows: (1) never; (2) once in a while; (3) often; (4) frequently; (5) all the time.

References
Adams, L. (2006). Group treatment for Asperger Syndrome: A social skill curriculum. San Diego: Plural. American Psychiatric Association. (1994). Diagnostic and statistical manual for mental disorders (4th ed.). Washington, DC: American Psychiatric Association. Baker, T. E. (2003). Social skill training: For children and adolescents with Asperger Syndrome and social communication problems. Kansas: Autism Asperger. Baron, M. G., Groden, J., Groden, G., & Lipsitt, L. P. (Eds.). (2006). Stress and coping. New York: Oxford University Press. Baron-Cohen, S. (1995). Mindblindness: An essay on autism and the theory of mind. Cambridge, MA: MIT Press.

Appendix 1 See Table 3.

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