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Using Behavioral Strategies to Improve Social Skills in Children & Adolescents
with Autism Spectrum Disorder
Moira Lewis, M.S. CCC-SLP
Health Education Workshop
Summer 2010
Overview
• Introduction & Overview of current research in social skills training
• Intervention methods• Behavioral Basis for group interventions• Peer tutor information•Questions & Answers
Criteria for ASD
• Impairment in socially reciprocal behavior
• Impairment in communication
• Restricted and repetitive behaviors and/or interests
Subtypes
•
Autism
•
Asperger’s Disorder
•
Childhood Disintegrative Disorder
•
Rett’s Disorder
•
Pervasive Developmental Disorder ‐‐
not otherwise specified
Social Skills Training for
children on the autism spectrum
Social Skills Groups: A Growing Trend
•
Research and evidence‐based programs have not caught up with the popularity and number of social skills groups, clinics, and materials at this point in time
• We know there is a need for both intervention and additional evidence
• Children and adolescents with ASD do desire and deserve friendships and long lasting relationships
• Do we know what works best?
Social Skills Groups: A Growing Trend
•
Pre‐planned lessons and social skills instruction books are widely available and used, and continue to be published
•
Are worksheets and pre planned lessons addressing individual skills from week to week the most effective
way to teach?
• What is a more effective way for children to learn & practice
Consider this:• Allow individual needs of the children to dictate the
lessons and activities
Growing too fast?
• No single approach will be successful with everyone, especially in a group setting
•
Parents and teachers are eager to find an effective way to improve a child’s ability to interact and lead to successful relationships
• Providers have been pushed to employ multiple methods to address social skills intervention
• A majority have not been empirically tested• Good news: research is being conducted as we speak• Bad news: Difficult area of research to implement well.
Why so difficult?
• We need programs with empirical support for efficacy
• Randomized clinical trials are difficult to do especially in school and clinical settings
•
We need social outcome measures to assess subtle changes/improvement in social skills and behavior
• Most social skill programs rely on curriculum that is anecdotally based, not systematically tested
• Future directions currently being ‘tested’
Social Delays: across the spectrum…
• Lack of interest in interaction
• Poor eye contact
• Little use of nonverbal communicative means
• Lack of social or emotional reciprocity
• Deviant or absent language
• In those with speech, inability to sustain a conversation
• Cognitive impairment
Components of Successful Social Behavior: Varied & Complex
To name a few….
• Imitation• Learning give and take• Perspective taking• Regulating reactions• Opportunities for interactions over time• ‘Personal History’• Verbal and nonverbal communication• Understanding non literal language and sarcasm• Problem solve simple conflicts with peers
Within Autism….
•
Children with ASD often miss out on the incidental learning opportunities for these social skills
• Decreased levels of motivation and interest in others
• Difficulty interpreting subtle social cues• Interactions and social rules constantly change
• Varied learning styles
How can we accommodate social behaviors and weaknesses unique to autism in a group setting?
• Incorporating ‘discussion’ of social skills among learners is not likely to always be successful
• Verbal learning=often a weakness of children with ASD
• Most children require a great deal of practice, repetition, and reinforcement to be able to :
• Learn a skill + apply it flexibly•
Being told what to do in a social situation vs. applying or performing the behavior flexibly in the correct setting
• Real interaction is CRITICAL
In Vivo Socialization
• It is not the activities alone that help children learn social skills
•
It is the EXPERIENCE of carrying out the activity, with facilitation from adults and with peers
•
Acceptance and responsiveness should be consistently promoted so that members come to feel they ‘belong’
•
May promote self esteem, a sense of accomplishment, a sense of friendship, a motivation to pursue successful peer relationships
Evidence-based Approaches to Social Skills Programming
Scripting and Fading (McClannahan
& Krantz, 2005)
• Construct scripts:• Choose phrases that gain access to favorite objects and activities (“Tickle me!”)
• Select scripts that contain different words• Use fully grammatical forms• Make scripts age‐appropriate• Start w/ 1‐2 scripts, increase as mastered
• Record scripts• Use model to introduce use of scripts• Teach script sequence• Increase number of scripts used• Fade portions of scripts
Scripting Social Skills
• Provide explicit written script of interaction, e.g.,
– Walk up to a classmate
– Make eye contact
– Say, “Hi ____________”
• Practice script w/ clinician• Practice w/ peer• Script Fading:
Cut off increasingly large parts of script,
until client can do the scene independently
Scripting with Peer Training
Peers taught 5 facilitative skills w/o target child present:
1. Look, wait, and listen2. Answer questions3. Start talking4. Say something nice5. Keep talking
Target children given written scripts for social interaction (“Can I play checkers with you?”)
Incidental Teaching(McGee et al., 1999)
•
Materials are controlled
so that target child must interact to obtain needed objects and complete favored activities
• Interactions are ‘engineered,’:• Child is assigned to complete puzzle• Peer holds all puzzle pieces and is told to hold them until asked
• Child must ask for each piece to complete task
Creating communication temptations and barriers.
Peer Group Entry(Beilinson
& Olswang, 2003)
• Lead Child is assigned a role to establish group membership
• Child is prompted to initiate interactions• Child is given highly valued objects, game, or ‘prop’
• Target child is taught five‐step sequence for entering group, using Visual Schedule
Peer Group Entry
1. Walk over to your friend.
2. Watch your friend.
3. Get a toy like your friend is using.
4. Do the same thing as your friend.
5. Tell an idea.
Buddy Time(English et al., 1997)
• 20 min. period during school day• Each child assigned a buddy• Buddies rotate• Class or peers are taught ‘buddy’ rules sequentially• Both buddies receive reward if follow rules for entire
buddy period:
1. STAY2. PLAY3. TALK: say name, talk about the play,
respond to partner, repeat then say more about it, ask a Question
Direct Instruction, con’t.The “Conversation Can” (Brinton, Robinson & Fujiki, 2005):
• Brainstorm a list of topics classmatesmight want to discuss• Write each on a slip of paper• Put slips in can• Take turns pulling out a topic• Start conversation:
– Think first: What should I say– Say two things about the topic– Ask interlocutor a question about the topic– Listen while interlocutor answers
Social Stories(Gray, 2000)
• Descriptive sentences: statements of fact– Many children play on the playground during recess.
• Perspective sentences: refer to internal states– Some children like to make a lot of noise.
• Affirmative sentences: express a common value– One child goes down the slide at a time.– This is a safe thing to do.
• Control sentences: identify personal strategies– When I have to wait my turn on the slide, I can count the
people in front of me to make the time go faster.• Cooperative sentences: what others can do to help.
– The teacher can help me if I feel impatient. She can talk to me while I wait.
Example Social Story
Quirmbach, 2008 Review• Reviewed 52 studies using Social Stories• Studies aimed a variety of ages and ability levels• ALL used case study methodology• 60% reported positive outcomes
– On a range of behaviors– Most target reducing inappropriate behaviors
• Data on increasing pro‐social behaviors is less abundant
Comic Strip Conversations• Use ‘think’ and ‘word’ bubble cartoons• Provide a visual tool to show conversation and thinking
Sam, I saw a
cowcatcher on an old‐
fashioned train
yesterday. Do you
know what that is?
Sam doesn’t know
as much as I do
about trains. I will
find out if he knows
what the
cowcatcher does
before I tell him
about the one I saw
Games Based on Special Interests(Baker et al., 1998)
Develop social games based on special interests of target child
• Involve target child in development of materials and rules• Have target child teach game to peer• Set up special opportunities to play game• Take turns choosing games to play during interactive game time
• Use favorite games as a method of developing an interaction‐ naturally motivating!
Video Modeling(Nikopoulos
& Keenan, 2003)
• Use commercial material such as My School Day(http://www.modelmekids.com/)
• Video tape peers conducting interactions such as greeting, negotiating, etc.
• Use video clips from TV shows to exemplify interactions (may use negative interaction)
• Rehearse with written scripts first• Verbal rehearsal
Video Modeling
• View video, discuss reactions• View video, attend to focused cue, discuss what was noticed or what changed
• Re‐enact scene on video with clinician• Re‐enact with peer• DESCRIBE VERBALLY while watching• Improvise similar situation
Social Cognitive Skills Training
(Timleret al., 2005)
Role play social scripts in peer group• Situation paragraph read to group• 4‐5 situations/ 2 hour session•
6 weeks of 2 sessions/week
Guide role play to identify what they know about situation from their own and
other’s perspective (thinking about
thinking)
Ask Questions, identify a range of response strategies by • selecting goal, • stating alternative strategies to reach goal• Evaluating consequences after response
Social Skills Groups
• Can use commercial curricula, such as• Navigating the Social World (McAfee, 2001)• Skillstreaming the Adolescent (Goldstein & McGinnis, 2000)
• Provide consistent group structure
• Check‐in, greet• Review last meeting’s skill• Introduce new skill• Model and role play new skill• Snack, social time• Activity that allows real‐life practice of new skill• Summary
Peer Support Networks (Haring & Breen, 1992)
• Select 2‐5 peers to serve as social support for student with ASD
• Assign each support peer a 20 minute period/day to structure activities for student with ASD, e.g.:– Lunch: use Prompt and Praise to engage with others at table
–
Recess: teacher or clinician creates scripts for entering games; peer support and target student practice in private, then on playground
Meta-analysis of Social Skills Interventions: Bellini
et al., 2007
• Most effective when• Deficits of child are systematically matched to intervention strategy•
Ex.: If child lacks skills to enter peer group, teach those; if child can enter but cannot participate and maintain participation, teach those skills
• Targeting social‐cognitive skills; use meta‐linguistic and meta‐cognitive strategies
• Done in classroom settings• As opposed to settings contrived for the purpose
Principles of Pragmatic Intervention Strategies: Involve the SLP
• SLPs have a legitimate role in assessing and developing social/pragmatic skills
• Students with ASD will not acquire social skills from exposure; they require mediated experiences
• Verbal, written and graphic supports are effective• Peer involvement is an essential element
– Peers need training, but it is not extensive
Effective Techniques: Social Skills Training
(Timler
et al., 2007)
• Teacher Redirects• Prompting children to play with one another• Rephrasing or restating one child’s statement for another
• Praising children for playing together• Direct instruction in social language• Modeling and practice with explicit cues• Role play with prompting• Corrective feedback• Authentic contexts (peer involvement)• Self‐monitoring for older students
Treatment & Goal Planning
•
Group leaders should learn what behaviors are of most concern to parents and teachers and note what behaviors the child exhibits that indicate poor social understanding and interaction
• Initial observation is critical• Standard assessments can also be incorporated
Steps for evaluating social behavior in preparation for goal planning
1.
Observe the child
2.
Identify positive pro social behaviors, strengths,
weaknesses, and problem behaviors3.
Conduct a functional analysis of the behavior
4.
Hypothesize about what motivates the behavior
5.
Observe each child’s approach to the group as a whole‐
do they assume a certain role? Are they ambivalent about
joining? Provocative? Are they completely silent? Do they
take on a clowning role? Are they less mature or more
mature than other group members?6.
Target goals for change‐
( Aim to )Eliminate problem
behaviors and teach/practice/develop new, pro‐social
behaviors
Treatment and Goal Planning: your contribution
• Note positive and negative behaviors displayed•
Note strengths, weaknesses, interests, and communicate about favorite games and activities
• Document, for negative behaviors: the setting, events, antecedents, consequences, possible motivating factors
Preparation
•
These observations and notes can be formally organized into a functional assessment of behavior
•
Which is then used to develop and guide a treatment plan
• Refer to Applied Behavior Analysis
for a detailed discussion of functional behavior assessment.
Sample Treatment PlanProsocial target behaviors(example)
Reinforcement/teaching strategies
Competing behaviors*
Strategies for prevention/ replacement behaviors
1. Joining activities with Peers
1a. Special star chart with stars for joining in each activity, a lot of praising,1b. Working in dyads, conversation games
1a. Insisting on drawing1b. Insisting on
showing others how good he is at art
1a. Ignoring
1b. Asking peers if they are interested
2. Becoming Flexible and plans & rules
2a. Stars for being okay with changes
2b. Games on flexibility
2a. Rigid about the agenda
1a. Ignoring/redirecting1b. Asking peer tutors for
feedback “Do you want to have a friend who tells you negative things about you all the time?”
3. Monitor body position/ space
3a. Stars for ‘Body Still3b. Encouraging him to monitor peers who are still
3a.Flapping habit3b. Gets very close to peers to speak
3a. Hand signal from group as a reminder3b. Encourage peer tutor to notice the behavior
Visual schedule
for group
therapy
sessions
Friends Group
1. Greeting
2. Rules!
3. Planet Game
4. Snack
5. Quiz Show
6. Closing
Peer Tutors as Social Models• Boys & Girls• No clinical concerns or outstanding behavior issues
• Natural ‘helpers’• Recruited from other classrooms•
Given a general overview and specific instructions for tutoring, prompting, or modeling each week
Peer tutor worksheet, example
Children with Autism Spectrum Disorders can:
•
Have trouble understanding language, especially if sentences are
complicatedKeep language simple
•
Have trouble understanding things they can’t see, like ‘yesterday’
or ‘next
week’Use pictures to teach things that are hard to think about abstractly
•
Have difficulty knowing whether their voice is too loud or too softTell the child directly that they are speaking too loudly or too
softly•
Have trouble with touching other children when they should keep their
hands to themselves Tell the child the rule “keep your hands on your own body”
Things to remember: Advocate for your child
•
Consider your child’s learning style•
Provide input regarding social ‘successes and messes’
outside of
school•
Recruit and incorporate typical peers and buddies‐
use other kids
as a resource•
Ask about generalization of skills and communication across
teachers and settings (i.e. classroom, playground, paraprofessionals,etc.)
•
Social Skills instruction can be kept simple•
Average standardized testing can be deceiving
•
Support can always be ‘backed off’•
Avoid “cookbook”
techniques
•
Always ask!
Critical Components
Typically Developing
Peers
Activities designedto learn and practice
appropriate Interaction
ParentParticipation
Group therapy experience:focus on process
Functional assessmentof behavior
Important to consider
• Children can be agents of change for each other
•
Children with autism can actively experience interactions through games and activities that are socially motivating
• ….While receiving continual reinforcement for appropriate behavior
•
If the children enjoy interacting with each other = a positive experience = reinforcing in its own right
Thank you!
•
A special acknowledgement to Kathy Koenig and the clinicians andinvestigators at the Yale Child Study Center, and their work thus far with the Social Skills Development Program
Questions?