Social Skills Intervention for Adolescents with Autism Spectrum Disorders
Systematic Review of Intervention for Adolescents with Autism Spectrum Disorders
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Systematic Review of Intervention for Adolescents with Autism
Spectrum DisordersT A McDonald
Integrated Autism Education, Treatment, and Leadership
University of Wisconsin – Madison
Advisors
Wendy Machalicek
Colleen Moore
Image from: http://www.mcghealth.org/for-professionals/McgContentPage.aspx?nd=2011
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Background
➢ Early intervention➢ Increase in type➢ Increase in empirical designs
➢ Teen intervention➢ Adaptations from child interventions➢ Few tested with adolescents
➢ Many of these not empirical designs
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Implications for Adolescence
➢ Negative consequences“As students with autism spectrum disorder reach
adolescence, the potential impact of inappropriate social behavior increases” (Graetz, Mastropieri, & Scruggs; 2009).
➢ Developmental Changes“...adolescence may be a particularly difficult time for higher
functioning youth with ASD due to increasing anxiety and awareness of social difficulties” (White et al.; 2009).
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Implications for Adolescence
➢ Increased expectations with age“...since writing skills may affect later job performance, it is
essential to identify effective writing interventions for this population” (Delano, 2007)
“Among employment age adults with disabilities, some of the lowest employment rates are individuals on the autism spectrum” (Burke et al., 2010).
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Stakeholders
➢ Stakeholders➢ Parents, teachers, clinicians, therapists, the
adolescent with ASD
➢ Evidence Based Practice➢ Does it work?➢ Evidence with children
➢ Carry over to teen?
➢ Locating what works➢ Individual articles, reviews?
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Articles and Reviews
➢ Organized around intervention➢ Social Stories, Video Modeling, Functional
Communication, Cognitive-Behavioral➢ What about target concerns?
➢ Many on ASD but mostly with children➢ Will the tx generalize to adolescence?➢ Mixed data of children and adolescents
➢ Unable to determine outcomes for adolescents
➢ Many interventions for adolescents➢ But not with ASD
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Current Study
➢ Review adolescent interventions➢ Empirical designs
➢ ASD
➢ Identify target concerns➢ Organize interventions around target
concerns
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MethodsMethods
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RedOffice.com Presentation templates Slide No. 9
ASD IncludedAutism, PDD-NOS,
Asperger's Syndrome
Adolescent Age Range12 - 22
Criteria for Inclusiona) Peer Review Journalb) At least one participant with ASD diagnosis AND adolescent age rangec.) Empirical designd.) Outcome data presentede.) Adolescent(s) outcome data distinguishable
Data Base Search
Search Terms1)1) Autism, intervention, teenAutism, intervention, teen2) Pervasive developmental Pervasive developmental disorder, intervention, disorder, intervention, adolescen* adolescen*3) Autism, intervention, Autism, intervention, adolescen* adolescen*4) Pervasive developmental Pervasive developmental disorder, teen disorder, teen5)5) Autism, intervention, adultAutism, intervention, adult6)6) Pervasive developmental Pervasive developmental disorder, intervention, adult disorder, intervention, adult
Data BasesMedLine
PsychINFOERIC
Exclusion●Dissertations●Non English●Animal●Phamacological & Electroconvulsive●Case Studies and
Reports●Rett's & Fragile X
Total Articles Located
1) 429 articles1) 429 articles2) 7 articles2) 7 articles3) 122 articles3) 122 articles4) 2 articles4) 2 articles5) 305 articles5) 305 articles6) 60 articles6) 60 articles
Reviews 38
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Certainty of Evidence
➢ Empirical designs➢ Group design with control
➢ Multiple baseline
➢ Reversal
➢ Alternating treatment
➢ Visual inspection➢ Significant improvement for
at least one adolescent participant with ASD
➢ Interobserver Agreement➢ 20% of experimental
sessions
➢ 80% or more agreement
➢ Operationally defined➢ DV's & IV's
➢ Clear description of procedures
Conclusive/Inconclusive (Millar et. al. 2006)
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ResultsResults
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Characteristics of Participants- Age
• Age of participants with ASD (In single subject)
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Characteristics of Participants- Diagnosis
• (In single subject designs)
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Gender Ratio
• (all designs)
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Settings
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Design Types
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Conclusive
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Empirically Investigated Treatments
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Major Target Areas of Concern
• (In all designs) (Articles often contained multiple targets)
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Specific Area Examples
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Specific Area Examples
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Elimination of Drooling by an Adolescent Student with Autism
Attending Public High School
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Appearance and Social Opportunities(Kay, Harchik, & Luiselli, 2006)
Poor Appearance Infrequent positive relationships Ostracization Reduced number of friendships Decreased social acceptability
Drooling Unsanitary Unattractive Foul Odor Interfere with communication
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MethodProcedure: duration & steps
(Kay, Harchik, & Luiselli, 2006)
Duration Baseline sessions began prior to intervention
Classroom: 1 week Community vocation: 3 days Cooking class: 1 day
Session length 5 – 7 mins Concluded 20 correct teaching trials Steps
Check participant every 5 mins Dry mouth: praise + edible (DRO) Saliva present: “wipe your mouth” + “swallow” Dependent measure: pools of saliva After 2 consecutive days of fewer than 2 pools/hour, 5 min intervals increased 15 min
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Results(Kay, Harchik, & Luiselli, 2006)
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MethodDiscussion & Limitations
(Kay, Harchik, & Luiselli, 2006)
Conclusive Drooling behavior eliminated
Limitations Contribution of components Intervention setting specific Data not recorded: lips & chin saliva; mouth wipes Hygiene issues in cooking class: 15 min checks
maintained No follow-up No measure of social change One-on-one aide; what about self- management?
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MethodParticipant
(Kay, Harchik, & Luiselli, 2006)
Participant Male age 17 Autism & mental retardation Public High School (inclusive setting) Single words & phrases Self care with adult assistance
Drooling Behavior Apparent since childhood Interfering with school
Education: work surfaces Social: ostracized
No medical intervention Phobia
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MethodMeasurement & Agreement
(Kay, Harchik, & Luiselli, 2006)
Measurement Number of saliva pools
Work environment surfaces Diameter of 1 inch or more
Included 95% of all saliva pools Recorded, then wiped clean Three locations daily:
Classroom (3hrs) Community vocational site (2hrs) Cooking class (1hr)
Number of pools converted to average/hour
Interobserver agreement Classroom: 96% (93- 100%) Community vocational site 91% (89- 94%) Cooking class 93% (91- 95%)
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MethodDesign & Procedure(Kay, Harchik, & Luiselli, 2006)
Design Multiple baseline across three locations
Classroom, community vocational site, cooking class
Procedure Baseline
Aide wiped surface clean after detecting pool Chin accumulation Behavior disregarded
Intervention Preteaching
“Swallow” “Wipe your mouth”
Verbal instructions, partial physical guidance, contingent praise to prompt, positive reinforcement of correct response
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Parent-Assisted Social Skills Training to Improve Friendships in Teens with
Autism Spectrum DisordersLaugeson, E. A., Frankel, F., Mogil, C., & Dillon, A. R. (2008)
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Background●Typical Teens vs. Teens with ASDs
●Typical Teens:–Best Friends●By 4th grade*●Aids resilience to life events**●Aids self esteem***●Aids social competence & social problem solving****●Neg correlated with anxiety and depression***
●Teens with ASDs–Missing out on these experiences–Need extra support and instruction
–(*Fankel, 1996; *McGuire & Weisz, 1982; **Miller & Ingham, 1976; ***Buhrmester, 1990, ****Nelson & Aboud, 1985)
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Background
●Previous Research●Mostly children●Lower functioning range●Not formally tested (social competence)
●Exceptions:●Ozonoff and Miller (1995)●Tse et al (2007)
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PEERS
●Program for the Education and Evaluation of Relational Skills●Adapted from Children's Friendship Training–Evidence base: ADHD, Fetal Alcohol Spectrum, children with ASD●(Frankel & Myatt, 2003), (O'Connor et. al., 2006), (Frankel & Myatt, 2007)Small Group Format
●Small Group Format
●Parent instruction●Separate concurrent sessions
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Current Study
●PEERS intervention content:●Evidence base practices–Didactic instruction, role playing, modeling, behavioral rehearsal, coaching with performance feedback, weekly socialization assignments with consistent homework review
●Social etiquette–Social situations with accompanying rules & steps–Teens provided instruction in steps
●Parents provided information to supervise
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Participants
●Teens (n = 33)●13-17 years of age, mean 14.6●Male (28), Female (5)●Diagnosis of ASD–HFA, Asperger's, PDD-NOS●Caucasian (14), Hispanic/Latino (6), African American (3), Asian (4), Middle Eastern (3), Mixed ethnicity (3)●Regular Ed (17), Special Ed (8), Pull out (2), Home-school (3), other Ed (3).●Participants were randomly assigned to either the Treatment or the Delayed Treatment Group
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Outcome Measures
●Test of Adolescent Social Skills Knowledge TASSK●Teen●22 items, Sentence stems with 2 choices●Knowledge of teen social skills
●(TASSK; Laugeson and Frankel, 2006)
●Friendship Qualities Scale●Teen●23 yes/no questions regarding their best friend(ship)
●(FQS; Bukowski et al, 1994)
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TASSK Example Items
●The goal of a conversation is to●Make the other person like you●Find common interests
●One of the rules for having a two way conversation is●To be an interviewer●Do not be an interviewer
●If you try to join a conversation and the people ignore you:●Move on●Speak louder so they can hear you
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Friendship Qualities Scale
●Yes / No Questions●Think of Best Friend
●My friend and I spend all of our free time together
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Outcome Measures
●Social Skills Rating Scale●Parent & Teacher●38 item questionnaire, never, sometimes, very often●Social skills scale, problem behavior scale
●(SSRS: Gresham and Elliott, 1990)
●The Quality of Play Questionnaire●Parent & Teen●12 item questionnaire, frequency of get-togethers & conflict●Hosted & invited get-togethers
●(QPQ; Frankel and Mintz, 2008)
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SSRS Info and Sample Items
●Social Skills●Cooperation–Follows your direction●Assertion–Invites others to join in activities●Responsibility–Requests permission before leaving the house●Self Control–Responds appropriately when pushed or hit
●Problem Behaviors●Externalizing–Fights with others●Internalizing–Is easily embarrassed●Hyperactivity–Acts impulsively
●** Likert–Never–Sometimes–Always
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The Quality of Play Questionnaire
●Frequency of play dates
●Number of Dates●invited vs. hosted
●Level of conflict●Criticized or teased each other
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Treatment
Completely manualized & delivered over 12 weeks
●Teen Sessions–Reciprocity in conversation–Diminishing importance of rejecting peer group–Reversing negative reputations–Instruction to promote get-togethers–Competence with teasing, bullying, conflicts–Didactic lessons–Modeling, Role-playing, Performance feedback–Homework assigned
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Treatment
●Parent Sessions●Review of homework assignments●Troubleshoot homework problems●Instruction to help teen overcome homework problems
●Teen and Parents reunited●Teens deliver review for parents●Homework finalized
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Quick Recap
●Random Assignment●Treatment & Delayed Treatment Group●Demographic information gathered●Pre-test outcome measures gathered–Teens, Parents, Teachers●Treatment●Post-test outcome measures gathered–Teens, Parents, Teachers
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Results
Non-Significant Differences at Baseline Between Treatment Group and Delayed Treatment Groups
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Results
●Statistically Significant scores for Pre and Post-test outcome variables for Treatment and Delayed Treatment
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Discussion
●Findings●Knowledge of social etiquette●Hosted get-togethers●Quality of friendships●Parent report of overall social skills
●Limitations●Bias in Parent Report?–Increase Teacher report●Need Maintenance Data●Would have liked ADOS or ADI-R●SSRS not designed for ASD
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Are the interventions comprehensive enough?
➢ Recap of Adolescent Implications➢ Increasing valence of negative behaviors
➢ Large amount on problem behaviors & self-injury
➢ Developmental changes with adolescence➢ Very little description of change. What about
sexuality? Dating?
➢ Increasing expectations➢ Very little for
➢ Academics (beyond on task, initiation, completion)➢ Occupation
➢ More (but still not much!)➢ Independence and self-care
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Other Concerns & Future Directions
➢ Standard measure of autism across studies
➢ Ideally: Assessment at time of study
➢ Report of ethnicity➢ Very little reported
➢ Next step: Hand search of journals
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Thank You!
T A Marie McDonald
Advisors
Wendy Machalicek- RPSE
Colleen Moore- Psychology