Chapter 19 Nutrition and Older Adults: Conditions and Interventions.
Effective Social Skills Interventions for Adults with ASD ...
Transcript of 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
Social Skills Deficits
• 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
Social Skills Deficits
• 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
Essential ingredients in the SSG recipe
• 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
Essential ingredients in the SSG recipe
• Promote skill generalization
• Include peers
• Use multiple trainers
• Practice in naturalistic settings
Essential ingredients in the SSG recipe
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
Skills Building (90 minutes with video modeling)
Generalization (90 minutes with same-age peers)
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
Video Modeling Examples
The Multi-Media Social Skills Project MODULE 3: Barriers to Social Relationships
Skills Building (90 minutes with video modeling)
Generalization (90 minutes with same-age peers)
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
Video Modeling Examples
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
Video Modeling Examples
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]