The Efficacy of Social Skills Treatment for Children with ... · nature of Asperger Syndrome and...

EDUCATION AND TREATMENT OF CHILDREN Vol. 29, No. 4, 2006

The Efficacy of Social Skills Treatment forChildren with Asperger Syndrome

Lisa M. ElderArgosy University, Phoenix

Linda C. CaterinoArizona State University, Tempe

Janet ChaoMelmed Center, Scottsdale Arizona

Dina ShacknaiMelmed Center, Scottsdale, Arizona

Gina De SimoneArgosy University, Phoenix

Abstract

Children with Asperger Syndrome present with significant social skillsdeficits, which may contrihute to clinical prohlems such as anxiety, depression,and/or other behavioral disorders. This article provides a description of thenature of Asperger Syndrome and provides possible treatment interventions,specifically focusing on the efficacy of social skills programs in clinic andschool populations.

Asperger Syndrome (AS) is a chronic condition that affectsan individual's social, emotional, and adaptive functioning.

Treatment is complex and multifaceted, and may be long term. Whilethe treatment of Asperger Syndrome can include individual and familypsychotherapy, psychopharmacology, special education, occupationaltherapy, and speech and language therapy, the focus of this article ison group Social Skills Training.

Difficulties in social skill acquisition and generalization are oftenthe most significant challenge for children with AS. Socialization defi-cits can result in significant hardships including an inability to meet

Correspondence to Linda Caterino, Ph.D, Training Director, School PsychologyProgram, Division of Psychology in Education, Arizona State University, Tempe, AZ85287; e-mail: [email protected].

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the demands of everyday life and difficulty fulfilling vocational andsocial relationship aspirations (Klin & Volkmar, 2003). Failure to inter-vene could result in symptoms of depression, anxiety, or behavior dis-orders (Barnhill, 2001). Social skills treatment is a well documented im-portant intervention for children with AS (Attwood, 1998; 2000; 2003;Bock, 2001; Klin, Sparrow, Marans, Carter, & Volkmar, 2000; Kransy,Williams, Provencal, & Ozonoff, 2003; Myles & Simpson, 2001; Myles,2003), although little empirical evidence exists to support this premise(Greenway, 2000; Gresham, Sugai, & Horner, 2001).

For the few studies that do exist there has been some sugges-tion that social skills treatment is effective. However, problems exist increating and evaluating treatment interventions that are reliably effec-tive and valid. Inclusionary and exclusionary criteria for the disorderare difficult to establish. For example, there is little clinical consensuson the diagnostic criteria for AS, with the exception of nomenclaturefrom the Diagnostic and Statistical Manual of Mental Disorders, text re-vision (DSM-IV-TR) (American Psychiatric Association, 2000), and onthe nature of how, and if, these disorders differ from Autistic Disorder(AD). There are also problems inherent in studying this type of spe-cial population, particularly due to the small numbers of individualsaffected, which creates statistical problems for any empirical study.Instruments to evaluate outcome, as it pertains to a child's social skillability, are also difficult to utilize due to the low sensitivity of theseinstruments to detect change and the lack of specificity to the area ofsocial skill that the treatment may be targeting. Determining whichsocial skill area to be addressed can also be challenging, as each child'sfunctioning will vary. This paper will review Asperger Disorder, itscharacteristics and assessment, as well as research on social skillstreatment for children with AS. It will also provide recommendationsfor future research and study.

Asperger Syndrome

History

In 1944, Hans Asperger identified a small group of children,adolescents, and adults who exhibited social peculiarities and sociallyisolative behavior, while appearing cognitively and linguistically typ-,ical (as cited in Myles & Simpson, 2002). In particular, he describedfour boys, ages six to 11 who had impairments in nonverbal commu-nication, comprehension of affect, and behavioral and conduct prob-lems. Wing (1981) later coined the term 'Asperger Syndrome," addingother dimensions to Asperger's original observations and proposingthat formal diagnostic criteria be developed to support the increasingnumber of clinical accounts.

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Prevalence

An increasing number of individuals have been diagnosed withAS (Ehlers & Gillberg, 1993). The mean age for a diagnosis of AS isapproximately eight years old (Eisenmajer, Prior, Leekham, Wing,Gould, Welham, & Ong, 1996). Although the DSM-IV-TR (APA, 2000)does not provide reliable prevalence rates, AS has been estimated tooccur in as many as 48 per 10,000 children. In 1989, Gillberg and Gill-berg estimated prevalence rates to be about 10 to 26 per 10,000, basedon a review of existing literature. In a later study, Ehlers and Gillberg(1993) noted that the prevalence might be higher, approximately 71in 10,000 children (97 in 10,000 for boys and 44 in 10,000 for girls).Fombonne and Tidmarsh (2003), however, noted that the prevalencerate could be as low as 2 per 10,000, although they warned that fewsurveys of AS have been performed to date, and prevalence estimatescan vary enormously, perhaps reflecting differences in methodologybetween studies and differing diagnostic criteria.

Characteristics ofthe Syndrome

Asperger Syndrome is currently understood as "a developmen-tal disorder characterized by significant difficulties in social interac-tion and emotional relatedness and by unusual patterns of narrowinterests and unique stereotyped behavior" (Church, Alisanski, &Amanullah, 2000, p. 12). The diagnosis of Asperger's Disorder wasfirst added to the American Psychiatric Association's Diagnostic andStatistical Manual of Mental Disorders, fourth edition (APA, 1994) as aPervasive Developmental Disorder. The primary diagnostic criteriawere listed as "severe and sustained impairment in social interac-tion and the development of restricted, repetitive patters of behaviorinterests and activities" (p. 75). Further criteria included significantimpairment in nonverbal behaviors such as eye contact, facial expres-sions, body postures and social gestures; failure to develop appro-priate peer relationships, lack of spontaneous seeking to share enjoy-ment and lack of social \ emotional reciprocity (i.e., sharing interests,achievements, etc.). In addition, the following behaviors were noted:repetitive and stereotypical behaviors, restricted interests and activi-ties, abnormal preoccupation with certain topics of interest, rigidityin rituals or routines, motor mannerisms (i.e., complex whole-bodymovements, or hand or finger flapping or twisting), and persistentpreoccupation with parts of wholes). While there is not a clinicallysignificant delay in language, there is a deficit in pragmatic language(the function or social use of language, used in conversation, turn-tak-ing, etc.), as well as nonverbal communication (i.e., social interaction,gestures, facial expression, eye contact, and/or body posture) (APA,

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1994, p. 77). These symptoms are consistent with diagnostic criteriapresented in the most current version of the DSM-IV-TR (APA, 2000).

Language

There is a lack of consensus in the literature concerning languagedelays in Asperger Syndrome. Some authors report no history of lan-guage delay (Ghaziuddin & Mountain-Kimchi, 2004; Starr, Szatmari,Brysion & Zwaigenbaum, 2003), while Attwood (1998) suggests thatabout 50 percent of children with Asperger Syndrome are delayedin the development of speech, but do talk by age five. Starr and col-leagues (2003) report that children with AS demonstrate difficulties inthe areas of pragmatics (use of language in a social context), prosody(the melody of speech) and nonverbal communication. They maylack an understanding of idioms and display literal interpretations.They tend to use pedantic speech, idiosyncratic words, vocalizationof thoughts, and have difficulties in auditory discrimination and ver-bal fluency. Their rate of speech may be unusual or may lack fluency,and there is often poor modulation of volume, although inflection andtone may not be as marked as in autism. Speech is often tangential andcircumstantial, conveying a looseness of association and incoherence.Communication style is also characterized by marked verbosity. Cog-nitively, these individuals amass a large amount of factual informa-tion about a topic of interest. This interest can interfere with learningin general because it may absorb too much of the child's attention andmotivation and impede the child's ability to engage in reciprocal so-cial exchanges (Klin & Volkmar, 2003; Tantam, 1988).

Motor Coordination

Children with Asperger Syndrome also display motor clumsi-ness (Smith, 2000). Gillberg and Billstedt (2000) noted that motor dis-orders, specifically. Developmental Coordination Disorder (DCC),are relatively common in AS. These deficits include clumsiness andabnormal gait patterns (for example, they may not swing their armswhen walking or running). They may also have difficulty in learningto ride a bike, in playing ball games, throwing, catching, and kicking(Attwood, 1998). Tantam also found deficiencies in the AS group onbalance, copying a meaningless hand gesture, and flexing the termi-nal joining of a finger in imitating (Tantam, 1988). He also indicatedthat children with AS may also have poor fine motor skills, especiallyin tying shoelaces and handwriting (Tantam, 1988). However, Ghazi-uddin, Tsai, and Ghaziuddin (1992) reported that the presence of poorcoordination, may not be a differentiating factor between AS andHFA.


Sensory Sensitivity

Individuals with Asperger Syndrome may also respond differ-ently to sensory stimuli than do typical children (Gillberg & Billstedt,2000). They may have a high pain threshold, hut a low threshold forother sensory stimuli. For example, they may not be able to toleratehigh pitched or complex sounds or sudden or unexpected noises andmay he overly sensitive to certain fabrics, articles of clothing, foodtextures or tastes and odors (Dunn, Saiter, & Rirmer, 2002).

Cognitive Abilities

Little is known about the cognitive abilities of students with AS(Myles & Simpson, 2002), although the DSM-IV-TR (APA, 2000) positsnormal intellectual and language development as necessary for a di-agnosis of AS. Individuals with Asperger Syndrome typically exhibitnormal cognitive ability with performance on intelligence tests char-acterized by high verbal scores and lower nonverbal scores (Ehlers,Nyden, Gillberg, Dahlgren-Sandberg, Dahlgren, Hjelmquist, & Oden,1997; Klin, Volkmar, Sparrow, Cichetti, & Rourke, 1995; Ghaziuddin& Mountain-Kimchi, 2004; Ozonoff, South, & Miller, 2000). However,Barnhill, Hagiwara, Myles, and Simpson's (2000) results were contra-dictory. They studied the cognitive profiles (most used the WechslerIntelligence Scale for Children—Third Edition, 1991) of 37 children(ages 3 to 15 years) diagnosed with AS and found no significant differ-ence between their Verbal and Performance IQ scores.

Barnhill et al. (2000) noted that there did not appear to be a dis-tinctive cognitive profile for individuals with AS, but rather behavior-al and academic characteristics served as better diagnostic indicators.Subjects obtained high scores on the Block Design (good nonverbalreasoning and visual-motor-spatial integration). Information (generalknowledge and long-term recall). Similarities (verbal conceptualiza-tion), and Vocabulary (good range of knowledge or information andmemory) subtests. Low scores were found on the Coding, Arithmetic(poor visual-motor coordination and distractibility, respectively), andComprehension (poor social judgment) subtests. The low scores onCoding were attributed to distractibility, poor pencil control, disinter-est, lethargy, excessive concern to detail, or visual memory difficul-ties. Barnhill et al. (2000) also found that average intellectual criteria,deemed necessary for a diagnosis of AS, according to the DSM-IV-TR, may not necessarily be true in all cases of individuals exhibitingsimilar symptoms. The academic profile of children with AS is highlyvariable.

Academically, children with AS or high functioning autismmay have difficulties in reading, especially reading comprehension

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(Goldstein, Minshew & Seigel, 1994; O'Connor & Klein, 2004). How-ever, some children may develop hyperlexia (Snowling & Frith, 1986),which is a highly developed word recognition, without accompany-ing reading comprehension abilities. This may be particularly evidentin adolescents where the inferential demands may be greater than foryounger students (Goldstein et al., 1994).

Social Behavioral

Individuals with AS have been identified as having difficultywith "theory of mind" tasks. That is, they lack an understanding andappreciation of the feelings, thoughts, needs, and intentions of others,how their behavior impacts others, and the meaning of reciprocity inrelationships (Baron-Cohen, Leslie, & Frith, 1985). From about the ageof four, typically developing children understand that other peoplehave thoughts, knowledge, beliefs, and desires that influence and ex-plain their behavior. Conversely, children with AS have difficulty con-ceptualizing and appreciating the thoughts and feelings of anotherperson. This deficit has a major impact on the child's social reason-ing skills and behavior. For example, they may struggle to determinewhether someone's thoughts or actions are intentional or accidental(Attwood, 2000).

Individuals with AS may find themselves socially isolated, al-though they are not usually withdrawn in the presence of other peo-ple. They may approach others in an inappropriate or eccentric fash-ion, initiating long-winded and pedantic conversations about theirfavorite topics (i.e., trains, math, dinosaurs, etc.) with little regard forthe other person's interest. They are unable to move past these awk-ward approaches and may appear insensitive to others' feelings, in-tentions, and nonverbal communication. They may be able to describecorrectly, in a cognitive and formal fashion, other people's (or theirown) emotions; however, they are unable to act on this knowledge inan intuifive and spontaneous manner (Klin & Volmar, 2003).

Most individuals with AS have an awareness of being "different"from others. Self-esteem problems are common, particularly amongadolescents with AS (Myles & Simpson, 2002). As children move intoadolescence and then young adulthood, they may experience increas-ingly more stress as conflict with social norms becomes more com-plex. They may become more vulnerable to anxiety and/or depres-sion (Bamhill, 2001). Bamhill found that social failure was positivelycorrelated with depression. The greater the depression, the more thatstudents with AS attributed their social problems to their ability andeffort. Family tension may also contribute to emotional problems foran individual in the autism spectrum (Tantam, 2000).


Individuals with AS may express their distress in various ways(Kim, Szatmari, Bryson, Streiner, & Wilson, 2000). They may have astrong awareness of their need for contact with others or a desire forcloseness. Nevertheless, they may cope with environmental stress bywithdrawing or isolating themselves from other people, even familymembers. Other individuals with AS might not be affected by theirisolative tendencies and prefer to maintain distance. Likewise, thesame emotional difficulties, which could result in depression in oneAS individual, may lead to frustration and antisocial behavior in an-other. One factor that may mediate this expression of distress is thedegree of empathy a person with AS experiences with others. Anxi-ety disorders are a particularly common expression of distress, whichmay be more apparent by observation of their external behaviors (i.e.,rituals) than by self-report. However, a diagnosis of anxiety can becritical since long-standing anxiety can lead to depression and pos-sibly suicidal ideation (Tantam, 2000). Behavioral problems may be-come more evident as feelings of stress mount and the child with ASexperiences an increasing lack of control. He or she may see the worldas threatening and unpredictable (Myles & Simpson, 2002) and reactin aggressive ways. Some researchers have stressed that social deficitsand increasing behavioral problems could contribute to psychologicalproblems for children with AS (Green, Gilchrist, Burton, & Cox, 2000;Tonge, Brereton, Gray, & Einfeld, 1999).

Assessment

There is currently no consensus regarding the types of assess-ment instruments that should be used to diagnose Asperger Syndrome.Freeman, Cronin and Candela (2002) suggested that a comprehensiveassessment for AS should include an interview with the primary care-taker for the purposes of obtaining a comprehensive developmentalhistory (including pregnancy, neonatal, and postnatal history, medicalhistory, history of medications, family history of developmental dis-orders and psychiatric illnesses, and family and psychosocial factors).An interview with the child should also be conducted to determinethe level of the child's communication, academic, social skills, andadaptive functioning.

Observation is another important component in making an ac-curate diagnosis, which might be conducted in natural (home and/orschool) and/or artificial settings (structured child and/or parent in-terview). Cognitive testing might be important for intervention pur-poses. Adaptive behavior is an additional area of interest, as childrenwith AS tend to possess a limited range of daily living skills (Szatmariet al., 1995). Communication assessment should examine nonverbal

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forms of communication, non-literal language, pragmatics, persever-ation, metalinguistics, reciprocity, and rules of conversation (Klin &Volkmar, 2003). It may also be important to assess for issues of atten-tion and hyperactivify (Klin ef al., 2000).

When diagnosing AS, utilizing a screening questionnaire thatassesses for typical characteristics may be important. Many have ar-gued against the utility of such instruments, as they closely follow theDSM-IV-TR (2000) criteria, rather than resembling Asperger's origi-nal case observations (Gillberg & Gillberg, 1989; Szatmari et al., 1989).Currently, there are several rating forms that a clinician can use to as-sess for characteristics of AS, as they relate to DSM-IV-TR (APA, 2000)criteria and diagnosis. The Autism Spectrum Screening Questionnaire(ASSQ, Ehlers, Gillberg, & Wing 1999) assesses for social interaction,communication problems, restricted and repetitive behavior, and mo-tor clumsiness. Ehlers et al. (1999) reported that the ASSQ is a reliableand valid parent and teacher screening tool used for assessing charac-teristics of high-functioning autism spectrum disorders.

The Asperger Syndrome Diagnostic Interview (ASDI) (Gillberg,Gillberg, Rastam, & Wentz, 2001) is another screening instrumentbased on Gillberg and Gillberg's (1989) criteria that closely resemblesAsperger's original observations. The ASDI is not intended for use inmaking a diagnosis of AS in accordance with the DSM-IV-TR (APA,2000). The ASDI measures six areas: Social, Interests, Routines, Verbaland Speech, Non-verbal Communication, and Motor and appears tohave acceptable reliability and validity (Gillberg et al., 2001).

The Asperger Diagnostic Interview (LeCouteur, Rutter, Lord, Rios,Robertson, Holdgrafer, & McLennan, 1989) measures six areas: Social,Interests, Routines, Verbal and Speech, Non-verbal Communication,and Motor and appears to have acceptable reliability and validity. TheAutism Diagnostic Interview Revised (Lord, Rutter & Le Couteur, 1994)is a semi-structured, investigator-based 90-minute interview for care-givers of children and adults with a possible pervasive developmentaldisorder. The interview is appropriate for children with mental agesfrom about 18 months into adulthood and linked to ICD-10 and DSM-IV criteria.

The Asperger Syndrome Diagnostic Scale (ASDS) (Myles, Jones-Bock, & Simpson, 2001) has been used as a diagnostic tool to assess forcharacteristics of AS based on the DSM-IV-TR (APA, 2000) criteria forchildren ages 5 to 18 years. The ASDS which targets five specific areasof behavior (cognitive, maladaptive, language, social, and sensorimo-tor) is a 50 item yes or no questionnaire which takes approximately10 to 15 minutes to complete. The ASDS yields an AS Quotient whichindicates the likelihood that an individual qualifies for a diagnosis ofAS.


The Autism Diagnostic Observation Schedule (ADOS) (Lord, Rut-ter, DiLavore, & Risi, 1999) is a semi-structured naturalistic assess-ment of communication, social interaction and play designed for indi-viduals suspected of having autism or other pervasive developmentaldisorders. The ADOS takes about 30 minutes to administer and byusing the ADOS, psychologists can observe the child participating invarious activities, for example, observing how a young child requeststhat the examiner continue blowing up a balloon and rate their per-formance.

Measures of social perception are becoming of increasing inter-est to researchers investigating reliable and valid intervention strate-gies for children diagnosed with AS (Ozonoff & Miller, 1995), Despitethe need for standardized, reliable and valid measures to assess forverbal and non-verbal social skills, only a few of these instrumentsexist (Gresham, 1981; Koning & Magill-Evans, 2001). The Social SkillsRating System (SSRS) (Gresham & Elliot, 1990) takes approximately 10minutes to complete and can be filled out by the student, parent, and/or teacher. It is designed to evaluate skills such as empathy, self-con-trol, cooperation, and assertiveness. The student forms yield three so-cial skills subscale scores, including Cooperation, Assertive, and Em-pathy. The parent and teacher forms yield four social skills subscalescores (Cooperation, Assertive, Responsibility, and Self-Control), inaddition to two problem behavior subscale scores (Internalizing andExternalizing).

Diagnostic Considerations: Distinction between Autism andAsperger Syndrome

There is intense debate surrounding the classification of thecharacteristics associated with AS, as being similar, if not the samecondition as high functioning autism (HFA) with varying character-istics (Bowman, 1988); or as part of the autism spectrum disorders(Freeman, Cronin, & Candela, 2002; Meyer & Minshew, 2002); or asa separate and distinct diagnosis (Klin, Sparrow, Marans, Carter, &Volkmar, 2000; Ozonoff, Rogers, & Pennington, 1991),

Bowman (1988) conducted a case study with a family of fourboys, all diagnosed with characteristics of autistic-like disorders andconcluded that the variation between the two conditions (AS and AD)could best be explained on the basis of severity within the same dis-order, Kim, Szatmari, Bryson, Streiner, and Wilson (2000) noted thatalthough there are differences at any point in time between AS andHFA, children with autism who develop good language skills, even-tually come to resemble older AS children. Thus, children with autis-tic symptoms should be diagnosed with the same disorder.

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Others argue that AS should be conceptualized as part of a spec-trum of autistic disorders or as existing on an autistic continuum. Ina review of several studies which evaluated the diagnostic dilemmaof AS and AD, Eisenmajer et al. (1996) found few clinical differencesexisted between HFA and AD as defined by clinical practitioners, withthe exception that AS children sought friendships more than the ADchildren. Eisenmajer et al. concluded that AS exists on a continuumwith AD and is not a separate disorder.

Szatmari, Archer, Fisman, Streiner, and Wilson (1995) found thatchildren (4—6 years of age) with AS and AD differed on social deficitmeasures and in the types of repetitive and stereotypic behaviors ex-hibited. While the groups differed on measures of adaptive behaviorin socialization, but no differences were found on measures of non-verbal cognition.

Ozonoff, South, and Miller (2000, using the DSM-IV (APA, 1994)criteria found few group differences in current presentation and cog-nitive functioning between AS and AD, but several differences inearly history. Children with AS showed better imaginative play andcreative abilities than children with HFA, and children with AS alsodemonstrated more circumscribed interests. Differences in historicalvariables were found which emphasized early language develop-ment, behavior problems in pre-school years, DSM-IV lifetime symp-tomatology, and greater use of special education services in the HFAgroup than the AS group.

McLaughlin-Cheng (1998) conducted a meta-analysis of chil-dren, adolescents, and adults between the ages of 5 and 23 years ofage with diagnoses of Asperger's Syndrome (AS), Autism (AD), andHigh Functioning Autism (HFA) in order to determine if differencesexisted in levels of cognitive functioning and/or adaptive behavior.Results indicated that children and adolescents with AS performedbetter overall than those with AD or HFA on cognitive and adaptivebehavioral measures. Meyer and Minshew (2002) debated earlier con-clusions that individuals with AS performed better cognitively, statingthat AS and HFA are nearly indistinguishable on cognitive measures,but that children with AS seem to perform better on tasks which re-quire use of theory of mind and abstract reasoning.

Starr, Szatmari, Bryson, and Zwaigenbaum (2003) compared thetwo-year outcome of 58 children, ages 6 to 8 years old, who were di-agnosed with AS and AD using the Autism Diagnostic Interview (ADI)(LeCouteur, Rutter, Lord, Rios, Robertson, Holdgrafer, & McLennan,1989). The AD group experienced a greater decrease in communicationsymptom severity over time relative to the AS group, and there was atrend for the AS group to show a greater increase in social symptoms.


Children with AS showed a greater increase in symptoms of impair-ment in social reciprocity than did children with AD. The magnitudeof the differences observed between the two groups seen at inceptionwas maintained two years later, Starr et al.(2003) concluded that dif-ferent outcomes follow different trajectories over time, supportingtheir premise that symptoms and level of functioning represent inde-pendent phenotypes in PDD.

Howlin (2003) compared 34 adults with autism and 42 with AS,matched for age and nonverbal IQ, with the ADI-R (Lord, Rutter, &LeCouteur, 1994) and found early childhood differences. For childrenwith AS, first concerns included general behavioral problems, ritual-istic and stereotyped behavior/interests, and motor delays/difficulties,whereas the autism group displayed early social difficulties and motordelays as prominent concerns. Early differences appeared to diminishover time; even motor clumsiness did not appear to be significantlydifferent between the groups. She concluded that there appears to beno consistent evidence that there are any major differences in rates ofsocial, emotional, and psychiatric problems, current symptomatology,motor clumsiness or neurological profiles between the two groups.She did acknowledge that when children are matched on Full ScaleIQ, the AS groups have better developed verbal skills and significantdifferences in academic attainment; although, cognitively, both groupswere similar in functioning.

Still, theorists remain who propose a distinct diagnosis of AS, asseparate from HFA and AD. Differentiation appears to be importantas targets for intervention become narrower, and diagnosis can haveimplications for availability of services. Klin and Volmar (2000) sup-port the viewpoint that AS and HFA should be distinct and separatediagnoses based on specific clinical characteristics, which include so-cial, cognitive, and adaptive functioning. Tonge, Brereton, Gray, andEinfeld, (1999) found that children and adolescents with AS present-ed with higher rates of psychopathology than those with HFA, weremore disruptive, antisocial, and anxious, and had more problems withsocial relationships. But while clear distinctions between AS and ADare still debatable, it is important to delineate some differences for thepurpose of effective intervention planning.

Treatment

Social Skills Training

Social skills represent a complex area within human behavior(Myles & Simpson, 2001; Myles, 2003), Social interactions can be con-fusing and sometimes painful for children whose rigid adherenceto social conventions is positively reinforced in some settings, but

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punished in others (Myles & Simpson, 2002). Children and adoles-cents who are deficient in social skills and who are poorly acceptedby peers have a high incidence of school maladjustment, delinquency,child psychopathology, and adult mental health difficulties (Gresham,1981). Attwood (2003) speculated about the potential negative conse-quences that might result for a child who fails to develop peer rela-tionships. Further, the lack of close friends could be a contributingfactor in childhood depression (Barnhill, 2001). Thus, the relevanceof social skills training becomes important for the individual's adjust-ment (Ciechalski & Schmidt, 1995; Ruberman, 2002).

In a survey of mothers of children with AS, 78 percent rated so-cial skills training for their children as extremely important (Little,2003). Gresham, Sugai, and Homer (2001) noted a lack of empiricalevidence for the use of social skills training as an effective interven-tion strategy, particularly for students with high-incidence disabili-ties, such as learning disabilities, mental retardation, emotional dis-turbance, or ADHD. Hwang and Hughes (2000) found that social in-teractive strategies had the potential for increasing social and commu-nicative skills in children with autism. Children with AS are typicallyunable to participate fully in age-appropriate relations due to theirlack of understanding of social skills (Bock, 2001), thus interventionshould focus on strengthening the "ability to negotiate the verbal so-cial world" (Landa, 2000, p. 146). Rogers (2000) noted that social skillstraining involving peer participation might be effective.

Gresham (1988) stated that individuals who are highly sociallycompetent are able to meet the demands of everyday functioning.They possess appropriate peer reinforcement behaviors, communica-tion skills, problem-solving skills, and social self-efficacy and can de-velop such adaptive behaviors as independent functioning, self-direc-tion, personal responsibility, and functional academic skills. Childrenand adolescents with social skill deficits and poor acceptance frompeers, have a high incidence of school maladjustment, delinquency,child psychopathology, and adult mental health difficulties.

Gresham (1988) delineated four reasons for social skills prob-lems: skill deficits, performance deficits, self-control skill deficits, andself-control performance deficits. Children with social skill deficitsdo not have the necessary skill in their repertoire, or they may omitthe critical steps needed to perform the behavioral sequence or donot perform the behavior with appropriate frequency or intensity(performance deficit). Self-control deficits apply to individuals whohave not learned a particular social skill because of some type of in-terfering response (cognitive-verbal, physiological/emotional, and/orovert/motoric). Children with self-control performance deficits have


the specific social skills within their repertoire, but do not performthese skills at acceptable levels due to problems in antecedent and/orconsequent/control (i.e., a child with impulsivity) (Gresham, 1988).AS children could easily fall into any one of the categories of self-con-trol deficiencies as interfering behaviors may be high (i.e., selectiveattention, anxiety, etc.). Skill (not knowing the skill) and performance(knowing the skill but not successfully performing it) deficits can alsobe observed.

Gresham (1988) conceptualized social skill training as a four-stepprocess. Teaching social skills involves promoting skill acquisition,enhancing skill performance, removing interfering behaviors, and fa-cilitating generalization. Within the realm of promoting the skill, theindividual learns appropriate social behavior via modeling, coaching,and instructions/ explanations. He stated that enhancing skill perfor-mance involves behavioral rehearsal, reinforcement based techniques,peer initiation strategies, and cooperative learning strategies. Remov-ing the interfering behavior may involve a response-cost system,group contingencies, differential reinforcement, or self-instructionalprocedures. Facilitating generalization can involve utilizing naturalcommunity-based reinforcements, diverse training opportunities, orincorporating functioning mediators (i.e., social stimuli).

Attwood (2000) suggested that social skills training might tar-get the identification of specific emotions, the contexts in which theymight be appropriate, and modulation skills to help manage the inten-sity of the emotions. AS individuals tend to use imitation and model-ing to camouflage their difficulties with social integration. They mightneed help in clarifying why certain behaviors are expected in varyingcontexts. Once these "codes of conduct" are explained, however, thechild often rigidly enforces them. Over time, the child with AS canleam the codes of social conduct by intellectual analysis, rather thanby natural intuition (Attwood, 1998).

Howlin and Yates (1993) recommended specific techniques suchas role-playing, team activities, structured games and analysis of vid-eotaped social behavior. Social skill group goals might include increas-ing self-awareness; developing strategies to compensate for social def-icits, improving conversational skills, and encouraging independentliving skills (Howlin & Yates, 1993). Barnhill (2001) suggested that theoptimal means for learning social skills involves modeling, role-play,and feedback. Gutstein and Sheely (2002) emphasized social and emo-tional development concepts such as collaboration, perspective tak-ing, and conversation strategies. Falk-Ross, Iverson and Gilbert (2004)suggested teaching pragmatic language using card games. In this waythe children can learn to initiate conversation, respond, take turns.

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and remain on topic. Body language, facial cues, gestures and voicetone can also be practiced using this technique.

Children with AS struggle to decipher nonverbal behavior ac-curately in a social context (Attwood, 1998; Davies, Bishop, Manstead,& Tantam, 1994). Duke, Nowicki, and Martin (1996) suggested that so-cial success is greatly influenced by the ability to interpret nonverbalbehavior. Nonverbal behavior involves a proscribed set of unwrittenrules that must be flexible enough to use in any given situation. Sincethey are not written down or formalized, they must be inferred inorder to achieve social acceptance. Some nonverbal behaviors may bepart of a child's behavioral repertoire that has developed from birth(Duke et al., 1996), while other skills must be acquired and general-ized. These skills can include knowledge of paralanguage, facial ex-pressions, postures and gestures, interpersonal distance and touch(boundaries), rhythm and time, and "objectics" (personal style andhygiene that is similar to the generally accepted peer group). Duke etal. (1996) proposed a school-based curriculum to teach nonverbal be-haviors in areas of paralanguage (aspects of sound that communicateemotion), facial expression, space and touch, gestures and posture,rhythm and time, and personal hygiene.

Myles and Simpson (2001) also acknowledged the importanceof self-esteem building as the child with AS may be highly aware thatthey may look, act, feel, and in some ways, are different from otherpeople. They suggested self-esteem strategies to include placing thechild in the role of helper, focusing on what the child is doing right(using reframing), finding out what the child does well and helpinghim or her do more of it, and complimenting the child and teachinghim or her to compliment themselves.

Kransy, Williams, Provencal, and Ozonoff (2003) designed aPROGRESS curriculum (Program for Remediating and ExpandingSocial Skills), which emphasized the following goals: basic interac-tional skills, conversational skills, play and friendship skills, emo-tion processing skills, and social problem solving. These were furtherbroken down into Nonverbal behaviors (eye contact, social distance,voice volume, and facial expression); Conversation (how to initiate,maintain and end a conversation; turn taking in conversations, mak-ing comments, asking questions, etc.); Friendship and Relationshipskills (qualities of being a good friend, greeting others, respondingto greetings, joining groups, sharing, compromising and followinggroup rules); Understanding thoughts and feelings of self and others(perspective taking, empathy, etc.); and finally. Problem Solving (whatto do when you are teased or excluded, etc.). They also described tech-niques such as making the abstract concrete by explicitly operational-izing the new skill and teaching children to differentiate this behav-


ior or skill from other behaviors using visually-based instruction, ahigh level of structure and predictability, providing special attentionin transitions, using scaffolded language support, providing multipleand varied learning opportunities, providing other focused activities,fostering self-awareness and self-esteem, selecting relevant goals, se-quencing skills in a progressive manner and providing opportunitiesfor generalizafion and ongoing practice (p. 111).

Bock (2001) described a group strategy to assist individuals withAS in their social and behavioral learning by coaching them to attend torelevant social cues, processing these cues, pondering their relevanceand meaning, and selecting an appropriate response during novel so-cial interactions (thereby increasing generalization). Bock called thisthe SODA strategy (Stop, Observe, Deliberate, and Act), which servesas an ongoing cueing system and helps students to develop an orga-nizational schema for the setting within which social interaction willoccur. Questions such as: "What is the rooin arrangement? What isthe activity schedule or routine? Where should I go to observe?" areused as prompts. The "Observe" component helps students note so-cial cues used by people in this setting. Questions include, "What arepeople doing or saying? What is the length of a typical conversation?What do people do after they've visited?" At the "Deliberate" com-ponent, students are cued to consider what they might say or do andhow others would perceive them. Questions include, "What would Ilike to do or say? How will I know when others would like to visit, lin-ger, or would prefer to end the conversation?" The "Act" componentthen helps students interact with others by prompting them (in vivo)to approach a person with whom they would like to visit, say "Hello,how are you?" listen to the person and ask related questions, and lookfor cues that this person would like to visit longer or would like to endthe conversation.

Myles and Simpson (2001) and Myles (2003) reviewed severalsocial skill strategies that might be effective for children and adoles-cents with AS. They noted that for individuals who do not developadequate social skills, the impact might range from not being ableto develop and keep friendships, to being ridiculed by peers to notbeing able to keep a job due to a lack of understanding of the envi-ronmental culture. Myles and Simpson (2001) noted that one impor-tant area in social skills treatment is the "hidden curriculum," or the"dos" and "don'ts" of everyday behavior. In school, children with ASneed to be aware of teachers' expectations, teacher-pleasing (and dis-pleasing) behavior, which students to interact with and those to stayaway from, and behaviors that attract positive and negative attention.Temple Grandin, an adult with AS, developed her own set of rules to

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guide her social interactions and behavior in society (as cited in Mylesand Simpson, 2001). Her rule system consists of "Really Bad Things,Courtesy Rules, Illegal But Not Bad, and Sins of the System" (p. 281).Myles and Simpson (2001) proposed a systematic approach to devel-oping an individual's "hidden curriculum" which involves six steps:1) provision of a rationale for the relevancy of developing this typeof approach; 2) presentation of what the student needs to know; 3)development of a model of appropriate social behavior; 4) verificationof learning behavior (i.e., via teacher monitoring); 5) evaluation by theteacher and the student in order to gauge which behaviors have beenlearned and which have not (or need work on); and 6) generalizationvia opportunities to practice this strategy in the community.

The use of social stories can be an effective method of provid-ing guidance and direction to promote social awareness, self-calm-ing, and self-management when responding to social situations (Gray,2000). The individual stories contain four sentence types: 1) descrip-tive—information about the setting, subjects, and actions; 2) direc-tive—statements about the appropriate behavioral response; 3) per-spective—sentences describing the feelings and reactions of others inthe targeted situations; and 4) control—analogies of similar actions.Attwood (2000) noted that the social story is written with the inten-tion of providing information about what people are doing, thinkingor feeling, the sequence of events, identifying significant social cuesand their meaning, and providing a script of what to do or say. Socialstories provide a "visitor's guide" of this culture by explaining socialconventions and their rationale.

Gray (1994) also proposed the concept of cartooning, which in-volves the use of visual symbols. The purpose of cartooning is to en-hance the processing abilities and understanding of the environmentin individuals with autism. Comic strip conversations have been usedas an effective way to illustrate and interpret social situations. Attwood(1998) noted that comic strip conversations "allow children to analyzeand understand the range of messages and meanings that are part ofnatural conversation and play" (p. 72). Attwood (2000) further notedthat comic strip conversations provide a means of visually illustrat-ing communication that occurs in conversation. Attwood commentedthat this type of tool could be useful for clinicians when analyzing achild's motives if a specific incident has caused considerable distressas well as in illustrating what types of alternative responses the childcould make.

Efficacy of social skills treatment

There is little research detailing the efficacy of social skills train-ing (SST) specifically for individuals diagnosed with AS or HFA


(Greenway, 2000). Mesibov (1984) was the first to evaluate the efficacyof a social skills group for adolescents and adults with AS. The groupgoals included targeting interpersonal skills, enhancing self-esteem,and promoting positive peer experience. Techniques included model-ing, coaching and role-play While qualitative measures (participants,families' and staff members' impressions) were promising, no objec-tive pre-post assessment was conducted. Williams (1995) investigateda four-year long program that emphasized perspective taking, conver-sation, voice tone, flexibility and listening. Qualitative data suggestedsome progress was made in friendship, but perspective taking abilitydid not show a commensurate rate of progress. Statistically significantimprovement was demonstrated in talking with peers, initiating con-versations with staff, using appropriate facial expressions and fiuencyof speech.

Marriage, Gordon, and Brand (1995) investigated the effects of ashort-term social skills group for children with AS. Techniques includ-ed role-playing, video-taping, prompting with card, viewing movies,and playing games. Parent ratings showed little post improvement,but qualitative ratings were noted in self-confidence and social skillacquisition.

Ozonoff and Miller (1995) looked at the progress of five ado-lescent boys who participated in a four and a half month trainingprogram. Improvement was noted in perspective taking versus theno treatment control group, but post treatment ratings did not showgeneralization.

Howlin and Yates (1999) evaluated the effectiveness of socialskills groups for adults diagnosed with AS. The researchers foundthat during the group experience, participants showed a good under-standing of social rules and a degree of awareness of other people'sfeelings and emotions, though they noted problems with contextualchanges and generalization. Other changes included changes in jobstatus and living situations.

Hwang and Hughes (2000) found that social skills training re-sulted in some immediate gains in social and affective behaviors,nonverbal and verbal communication, eye contact, joint attention,and imitative play. Gutstein and Whitney (2002) pointed out, how-ever, that these gains were not maintained over time, nor were theygeneralizable to other settings. Gutstein and Whitney emphasizedthat if long-term gains were to be made, then social skills training forchildren with AS must be based on the intrinsic enjoyment of experi-ence-sharing encounters. Goals of intervention must include not onlyscripted social survival skills, but should also incorporate social ref-erencing and coordination of actions, perceptions, feelings, and ideaswith social partners.

652 ELDER etal.

Bamhill, Tapscott-Cook, Tebbenkamp, and Myles (2002) con-ducted a study to investigate the effectiveness of social skills inter-vention targeting nonverbal communication for adolescents with ASutilizing the Diagnostic Analysis of Nonverbal Accuracy (DANVA2)(Nowicki & Duke, 1997) as a pre- and post assessment measure ofnonverbal social perception. Barnhill et al. (2002) found that eventhough their intervention strategy (nonverbal skills training) lackedstatistical significance; they felt that two positive outcomes emerged.One was that some social relationships were developed and main-tained across the 8-week treatment segment and beyond. Fifty per-cent of the participants (N=8) continued to contact each other severalmonths after the treatment ended. The second noteworthy outcomewas that participants were able read the nonverbal communication ofothers following the intervention (i.e., facial expression or decipher-ing paralanguage) in a natural community setting.

Bauminger (2002) evaluated the efficacy of a 7-month, cognitivebehavioral intervention program designed to enhance the social com-petence of high-functioning children with autism, ages 8-17. Parentsand teachers were actively involved in the process. Children demon-strated improvement in the areas of social cognition/problem solving,emotional understanding, and social interaction; more specifically,speech initiation/contact with a peer and eye contact. Bauminger(2002) acknowledged that generalizability was difficult to determineand that there was the absence of a control group to rule out naturalis-tic changes that could occur due to maturity or by nature of receivingmore individualized attention.

Kransy, Willliams, Provencal, and Ozonoff (2003) reviewed fivestudies that measured the effectiveness of social skills training withchildren with autism. They reported significant improvement in so-cial skills, positive peer experiences, and enhanced self-esteem post-treatment.

Barry, Klinger, Lee, Palardy, Gilmore, and Bodin (2003) also not-ed that little research has been conducted to determine the efficacy ofsocial skills treatment for children with high-functioning autism. Bar-ry et al. (2003) developed an 8-week group intervention designed toprovide social skills instruction to specific to social rules and scripts.The researchers noted that the intervention was effective in improvingsocial behavior, specifically, greetings, play, initiating social contact,and conversation skills. However, they noted that skills improved asthey were being taught but did not endure in other settings, and skillsnot addressed as part of the intervention remained the same.

Carter, Meckes, Pritchard, Swensen, Wittman, and Velde (2004)designed and implemented an after-school program for children (ages


8 to 15) with Asperger's Syndrome. The six session program includedsuch topics as getting to know each other, conversation starters, defin-ing friendship, celebrating with friends, trust and saying good bye forthe elementary aged group and more advanced topics for the adoles-cent group including what is friendship, forming friendship relations,volunteering, maintaining a friendship and saying good-bye. Verbalfeedback was obtained from younger students and written from older.Parents responded to an e-mail survey. Group satisfaction was the pri-mary information solicited and the feedback they received from bothparents and youth was positive.

Elder, Caterino, and Virden (2004) evaluated the efficacy of so-cial skills treatment for children with AS. Eight children (7 boys and 1girl) participated in an accelerated 8- day summer session social skillsgroup. The social skills treatment curriculum consisted of the follow-ing core concepts: recognizing and expressing emotions in self andothers, physical versus mental feelings, stress and relaxation, initiat-ing conversations, using nonverbal conversations skills, maintainingconversation, and bullying and teasing. Parents and children ratedskill level pre and post treatment. Variables measured included socialskills, problem behaviors, and parental stress utilizing the Social SkillsRating System (SSRS) (Gresham & Elliott, 1990), the Parenting StressIndex (PSI) (Abidin, 1995), and the Clue Breakers Survey (unpublished),an instrument designed specifically for this study. The PSI indicatedthat parenting stress significantly decreased post-treatment. Posi-tive trends included less problem behavior and overall family stress,increased recognition and expression of emotion in self and others,improved knowledge of physical versus mental feelings, improvedstress and relaxation skills, improved ability to initiate and maintainconversations and nonverbal communication, and better conflict reso-lution.

Challenges

Gresham et al. (2001) emphasized that a persistent problem withmuch of the SST literature is the inability of the researchers to dem-onstrate consistent and durable gains in social skills across settings aswell as maintenance over tinjie. Gresham et al. (2001) noted that SSTcould produce significant and seemingly insignificant effects on socialcompetence functioning. Another possible reason for the weak effectsof SST involves the assessment instruments used to evaluate pre- andpost functioning. Gresham et al. (2001) found that in some studies theassessment instruments used were not closely related to the variablesbeing measured. Furthermore, a number of studies appeared to useassessment instruments that lacked validity and reliability or even

654 ELDER et al.

used "home-made" measures (Greenway, 2000; Gresham et al., 2001).Finally, one of the strongest areas of weakness appeared to be relatedto failure to demonstrate sufficient generalization and maintenance ofthe learned social skills (Gresham et al., 2001; Howlin & Yates, 1999;Hwang & Hughes, 2000). Greenway (2000) noted that the lack of suc-cess of SST might also be influenced by a lack of precision in targetingsmall aspects of social skills and a lack of opportunity to practice newskills.

Caldarella and Merrella's (1997) meta-analysis of social skillsdomains noted that the following components are most often empha-sized in successful social skills programs: peer relations, self-manage-ment, compliance, assertiveness, and academics. Gresham, Sugai andHomer's (2001) meta-analysis of social skills groups for students withor at risk for high-incidence disabilities found that effective SST strat-egies generally incorporated modeling, coaching and reinforcementand tended to utilize cognitive-behavioral procedures, as well as spe-cific intervention strategies.

Future Directions

The socialization deficits of AS can also result in significantstress and conflict in families of individuals with AS due to the in-dividual's difficulties in meeting the demands of everyday life andtheir problems with educational, vocational, and social relationships(Klin & Volkmar, 2003; Lainhart, 1999; Little, 2002). While presentlysupport groups for parents of AS exist, as well as internet chat rooms,researchers (Sofronoff & Farbotko, 2002) have also suggested that par-ents participate in parent management training (PMT), aimed at pro-moting parenting skills and strengthening family functioning. Rela-tional Developmental Intervention (Gutstein & Sheely, 2002) providesfor intensive parental involvement through seminars and continuedinternet support. However, there are not many programs currently inexistence for parents and families of children with AS. Programs thatallow parents to participate in social skills groups, either with theirchild, or in separate but simultaneous groups, should be explored.These programs may vary in the participation of parents; for example,parents could participate in a partnership with their child or be silentobservers seated in the outer perimeter of the group. Programs forsiblings might also be developed. As always, further research needs tobe conducted to evaluate the effectiveness of such parent and familyprograms.

In addition, significant challenges exist in the classroom settingfor teachers who shoulder the responsibility of educating childrenwith AS whose challenges might include narrow interests, selective


attention, and abnormal social interactions (Myles & Simpson, 2002).Since schools are the most natural environments for children, socialskills training programs should also be established in educational set-tings (Garter et al., 2004). School programs also provide for exposureto competent peer models and allow for more intense and longer pro-grams (Gresham, 2001). In this way, fluency as well as acquisition andperformance can be developed. Greater practice should also allow forgeneralizability to multiple settings and long-term maintenance. Inaddition, schools and families need to work together to teach and re-inforce the same social skills, using similar techniques whenever pos-sible. Ultimately, more research is needed in examining the efficacyof social skills groups for children with HFA or AS, particularly forschool-age children.

References

Abidin, R. R. (1995). Parenting Stress Index (3rd Ed.). Lutz, FL: Psycho-logical Assessment Resources.

Achenbach, T. M. (1991). Child behavior checklist/4-18. Burlington:University of Vermont, Department of Psychiatry.

Achenbach, T. M. (2001). Child behavior checklist/6-18. Burlington:University of Vermont, Department of Psychiatry.

American Psychiatric Association. (1994). Diagnostic and statisticalmanual of mental disorders (4th Ed.). Washington, DC: Author.

American Psychiatric Association. (2000). Diagnostic and statisticalmanual of mental disorders (4th ed., text rev.). Washington, DC:Author.

Attwood, T. (1998). Asperger's Syndrome: A guide for parents and profes-sionals. Philadelphia: Jessica Kingsley.

Attwood, T. (2000). Strategies for improving the social integration ofchildren with Asperger Syndrome. Autism, 4(1), 85-100.

Attwood, T. (2003). Frameworks for behavioral interventions. Childand Adolescent Psychiatric Clinics of North America, 12(1), 65-86.

Barnhill, G. P. (2001). Social attributions and depression in adolescentswith Asperger Syndrome. Focus On Autism and Other Develop-mental Disabilities, 26(1), 46-53.

Bamhill, G. P, Hagiwara, T, Myles, B., Simpson, R. L. (2000). AspergerSyndrome: A study of the cognitive profiles of 37 children andadolescents. Pocus On Autism and Other Developmental Disabili-ties, 15(3), 146-153.

656 ELDER etal.

Barnhill, G. P., Tapscott-Cook, K, Tebbenkamp, K., & Myles, B. (2002).The effectiveness of social skills intervention targeting non-verbal communication for adolescents with Asperger Syn-drome and related pervasive developmental delays. Focus OnAutism and Other Developmental Disabilities, 17(2), 112-118.

Baron-Cohen, S., Leslie, A. M., & Frith, U. (1985). Does the autisticchild have a "theory of mind?" Cognition, 21, 37-46.

Barry, T. D., Klinger, L. G., Lee, J. M., Palardy, N. Gilmore, T., & Bodin,S. D. (2003). Examining the effectiveness of an outpatient clin-ic-based social skills group for high-functioning children withautism, journal of Autism and Developmental Disorders, 33(6),685-701.

Bauminger, N. (2002). The facilitation of social-emotional understand-ing and social interaction in high-functioning children withautism: Intervention outcomes. Journal of Autism and Develop-mental Disorders, 32(4), 283-298.

Bock, M. A. (2001). SODA strategy: Enhancing social interaction skillsof youngsters with Asperger Syndrome. Intervention in Schooland Clinic, 36(5), 272-278.

Bowman, E. P. (1988). Asperger's syndrome and autism: The case forconnection. British Journal of Psychiatry, 152, 377-382.

Caldarella, P., & Merrell, K. (1997). Common dimensions of socialskills of children and adolescents: A taxonomy of positive be-haviors. School Psychology Review, 26, 264-278.

Carter, C, Meckes, L., Pritchard, L., Swensen, S. Wittman, P. P, & Vel-de, B. (2004). The friendship club: An after-school programfor children with Asperger syndrome. Family and CommunityHealth, 27(2), 143-150.

Church, C, Alisanski, S., & Amanullah, S. (2000). The social, behav-ioral, and academic experiences of children with AspergerSyndrome. Focus On Autism and Other Developmental Disabili-ties, 15(1), 12-20.

Ciechalski, J. C, & Schmidt, M. W. (1995). The effects of social skillstraining on students with exceptionalities. Elementary SchoolGuidance and Counseling, 29, 217-222.

Conoley, J. C, & Impara, J. C. (1995). The twelfth mental measurementsyearbook. Lincoln, NB: The Buros Institute of Mental Measure-ments, University of Nebraska Press.

Davies, S., Bishop, D., Manstead, A. S. R., & Tantam, D. (1994). Faceperception in children with Autism and Asperger's Syndrome.Journal of Child Psychology and Psychiatry, 35(6), 1033-1057.


Dunn, W., Saiter, J., & Rinner, L. (2002). Asperger syndrome and sen-sory processing: A conceptual model and guidance for inter-vention planning. Focus on Autism and Other DevelopmentalDisorders, 27(3), 172-185.

Ehlers, S., & Gillberg, C. (1993). The epidemiology of Asperger Syn-drome. A total population study. Journal of Child Psychologyand Psychiatry, 34(8), 1327-1350.

Ehlers, S., Gillberg, C, & Wing, L. (1999). A screening questionnairefor Asperger Syndrome and other high functioning AutismSpectrum Disorders in school age children. Journal of Autismand Developmental Disorders, 29(2), 129-141.

Ehlers, S., Nyden, A., Gillberg, G., Dahlgren-Sandberg, A., Dahlgren,S. O., Hjelmquist, E., & Oden, A. (1997). Asperger Syndrome,Autism, and attention disorders: A comparative study of cog-nitive profiles of 120 children. Journal of Child Psychology andPsychiatry, 38{2), 207-217.

Eisenmajer, R., Prior, M., Leekam, S., Wing, L., Gould, J., Welham, M.,& Ong, B. (1996). Gomparison of clinical symptoms in Autismand Asperger's Disorder. Journal of the American Academy ofChild and Adolescent Psychiatry, 35(11), 1523-1531.

Elder, L. M., Gaterino, L. G., & Virden T. J. (2004). Efficacy of socialskills treatment for children with Asperger Syndrome. Un-published doctoral dissertation (Glinical Research Project),Argosy University/Phoenix, Phoenix, Arizona.

Faulk-Ross, F., Iverson, M., & Gilbert, M. (2004). Teaching and learn-ing approaches for children with Asperger's syndrome. Teach-ing Exceptional Children, 36(4), 48-55.

Fombonne, E., & Tidmarsh, L. (2003). Epidemiologic data on Asperg-er Disorder. Child and Adolescent Psychiatric Clinics of NorthAmerica, 12(1), 15-21.

Freeman, B. J., Gronin, P., & Gandela, P. (2002). Asperger syndrome orautistic disorder? The diagnostic dilemma. Focus on Autismand Other Developmental Disabilities, 175(3), 145-151.

Ghaziuddin, M., & Mountain-Kimichi, K. (2004). Defining the intel-lectual profile of Asperger syndrome: Gomparison with highfunctioning autism. Journal of Autism and Developmental Disor-ders, 34(3), 279-284.

Ghaziuddin, M., Tsai, L. Y, & Ghaziuddin, N. (1992). Brief report:A comparison of diagnostic criteria for Asperger syndrome.Journal of Autism and Developmental Disorders, 22(4), 643-649.

658 ELDER etal.

Gillberg, C, & Billstedt, E. (2000). Autism and Asperger Syndrome:Coexistence with other clinical disorders. Acta PsychiatricaScandinavica, 102(5), 321-331.

Gillberg, I. C, & Gillberg, C. (1989). Asperger Syndrome - Some epi-demiological considerations: A research note. Journal of ChildPsychology and Psychiatry, 30(4), 631-638.

Gillberg, C, Gillberg, C, Rastam, M., & Wentz, E. (2001). The Asperg-er Syndrome (and high functioning Autism) Diagnostic Inter-view (ASDI): A preliminary study of a new structured clinicalinterview. Autism, 5(1), 57-66.

Goldstein, G., Minshew, N.J., & Seigel, D. J. (1994) Age differences inacademic achievement in high-functioning autistic individu-als. Journal of Clinical and Experimental Neuropsychology, 16,671-680.

Gray, C. (1994). Comic strip conversations. Arlington, TX: Future Hori-zons.

Gray, G. (2000). New social stories: Illustrated edition. Arlington, TX: Fu-ture Horizons.

Green, J., Gilchrist, A., Burton, D., & Gox, A. (2000). Social and psy-chiatric functioning in adolescents with Asperger Syndromecompared with Gonduct Disorder. Journal of Autism and Devel-opmental Disorders, 30(4), 279-293.

Greenway, G. (2000). Autism and Asperger Syndrome: Strategies topromote prosocial behaviours. Educational Psychology in Prac-tice, 16(3), 469-486.

Gresham, F. M. (1981). Assessment of children's social skills. Journal ofSchool Psychology, 19(2), 120-133.

Gresham, F. M. (1988). Social skills: Gonceptual and applied aspects ofassessment, training, and social validation. In J. C. Witt, S. N.Elliott, & F. M. Gresham (Eds.), Handbook of behavior therapy ineducation (pp. 523-546). New York: Plenum.

Gresham, F. M., & Elliott, S. N. (1990). Social skills rating system. GirclePines, MN: American Guidance Services.

Gresham, F. M., & Reschly, D. J. (1987). Dimensions of social compe-tence: Method factors in the assessment of adaptive behavior,social skills, and peer acceptance. Journal of School Psychology,25, 367-381.

Gresham, F. M., Sugai, G., & Horner, R. H. (2001). Interpreting out-comes of social skills training for students with high-inci-dence disabilities. Exceptional Children, 67, 331-344.


Gutstein, S. E., & Sheeiy, R. K. (2002). Relationship development inter-vention with children adolescents and adults: Social and emotionaldevelopment activities for Asperger's Syndrome, Autism, and PDDand NLD. Philadelphia, PA: Jessica Kingsley.

Gustein, S. E., & Whitney, T. (2002). Asperger Syndrome and the de-velopment of social competence. Focus on Autism and OtherDevelopmental Disabilities, 17(3), 161-171.

Holaday, M., Moak, J, & Shipley, M. A. (2001). Rorschach protocolsfrom children and adolescents with Asperger's disorder. Jour-nal of Personality Assessment, 76(3), 482-495.

Hwang, B., & Hughes, C. (2000). The effects of social interactive train-ing on early social communicative skills of children with Au-tism. Journal of Autism and Developmental Disorders, 30(4), 331-343.

Howlin, P., & Yates, P. (1999). The potential effectiveness of social skillsgroups for adults with Autism. Autism, 3(3), 299-307.

Impara, J. C, & Plake, B. S. (1998). The thirteenth mental measure-ments yearbook. Lincoln, Nebraska: The Buros Institute ofMental Measurements, University of Nebraska Press.

Kim, J. A., Szatmari, P., Bryson, S. E., Streiner D. L., & Wilson, F. J.(2000). The prevalence of anxiety and mood problems amongchildren with Autism and Asperger Syndrome. Autism, 4(2),117-132.

Klin, A., Volkmar, F. R., Sparrow, S. S., Cichetti, D. V., & Rourke, B.P. (1995) Validity and neuropsychological characterization ofAsperger syndrome. Journal of Child Psychology and Psychiatry,36,1127-1140.

Klin, A., Sparrow, S. S., Marans, W. D., Carter, A., & Volkmar, F. R.(2000). Assessment issues in children and adolescents withAsperger Syndrome. In A. Klin, F. R. Volkmar, & S. S. Spar-row (Eds.), Asperger Syndrome (pp. 309-339). New York:Guilford Press.

Klin, A., & Volkmar, F. R. (2003). Asperger Syndrome: Diagnosis andexternal validity. Child and Adolescent Clinics of North America,12(1), 1-13.

Klin, A., Volkmar, F. R., & Sparrow, S. S. (Eds.) (2000) Asperger Syn-drome. New York: Guilford Press.

Koning, C, & Magill-Evans, J. (2001). Social language skills in adoles-cent boys with Asperger Syndrome. Autism, 5(1), 23-36.

660 ELDER et al.

Kransy, L., Williams, B. J., Provencal, S., & Ozonoff, S. (2003). Socialskills interventions for the Autism Spectrum: Essential ingre-dients and a model curriculum. Child and Adolescent Psychiat-ric Clinics of North American, 22(1), 107-122.

Landa, R (2000). Social language use in Asperger Syndrome and highfunctioning autism. In A. Klin, R. R. Volkmar, & S. S. Sparrow,Asperger Syndrome (pp. 125-155). New York: Guilford.

Lainhart, J. E. (1999). Psychiatric problems in individuals with Au-tism, their parents and siblings. International Review of Psychia-try, 11, 278-298.

LeCouteur, A., Rutter, M., Lord, C, Rios, P., Robertson, S., Holdgrafer,M., & McLennan, J. (1989). Autism Diagnostic Interview: Astandardized investigator-based instrument. Journal of Autismand Developmental Disorders, 19, 363-387.

Little, L. (2002). Differences in stress and coping for mother and fa-thers of children with Asperger's Syndrome and NonverbalLearning Disorders. Pediatric Nursing, 28, 565-570.

Little, L. (2003). Maternal perceptions of the importance of needs andresources for children with Asperger Syndrome and nonver-bal learning disorders. Focus on Autism and Other Developmen-tal Disabilities, 28(4), 257-266.

Lord, C, Rutter, M., & LeCouteur, A. (1994) Autism Diagnostic In-terview—Revised version of a diagnostic interview for care-givers of individuals with possible pervasive developmentaldisorders. Journal of Autism and Developmental Disorders, 24,659-685.

Lord, C, Rutter, M., DiLavore, EC. & Risi, S. (1900). Autism DiagnosticSchedule—WFS Edition. Los Angeles: Western PsychologicalServices.

Marriage, K. J., Gordon, V., Brand, L. (1995). A social skills group forboys with Asperger's syndrome. Australian and New ZealandJournal of Psychiatry, 29(1), 58-62.

Mesibov, G. B. (1984). Social skills training with verbal autistic ado-lescents and adults: A program model. Journal of Autism andDevelopmental Disorders, 24(4), 395-404.

Meyer, J. A., & Minshew, N. J. (2002). An update on neurocognitiveprofiles in Asperger Syndrome and High-Functioning Au-tism. Focus On Autism and Other Developmental Disabilities,27(3), 145-151.

McLaughlin-Cheng, E. (1998). Asperger Syndrome and Autism: A lit-erature review and meta-analysis. Focus On Autism and OtherDevelopmental Disabilities, 23(4), 234-245.


Miller, J. N., & Ozonoff, S. (1997). Did Asperger's cases have AspergerDisorder? A research note. Journal of Child Psychology and Psy-chiatry, 38(2), 247-251.

Myles, B., Barnhill, G. P., Hagiwara, T., Griswold, D. E., Simpson, R.L. (2000). A synthesis of studies on the intellectual, academic,social/emotional and sensory characteristics of children andyouth with Asperger Syndrome. Education and Training inMental Retardation and Developmental Disabilities, 36(3), 304-311.

Myles, B., & Simpson, R. L. (2001). Understanding the hidden cur-riculum: An essential social skill for children and youth withAsperger Syndrome. Intervention in School and Clinic, 36(5),279-286.

Myles, B., & Simpson, R. L. (2002). Asperger Syndrome: An overviewof characteristics. Focus on Autism and Other DevelopmentalDisabilities, 17(3), 132-137.

Myles, B., Jones-Bock, S., & Simpson, R. L. (2001). Asperger SyndromeDiagnostic Scale. Austin, TX: PRO-ED.

Myles, B. (2003). Behavioral forms of stress management for individu-als with Asperger Syndrome. Child and Adolescents PsychiatricClinics of North America, 22(1), 123-141.

Nowicki, S., & Duke, M. (1994). Individual differences in the non-verbal communication of affect: The Diagnostic Analysis ofNonverbal Accuracy scale. Journal of Nonverbal Behavior, 18(1),9-35.

National Genter on Ghild Abuse and Neglect. (1993). A report on themaltreatment of children with disabilities. Washington, DG:National Glearinghouse on Ghildren Abuse and Neglect In-formation.

O'Gonnor, I. M., & Klein, RD. (2004) Exploration of strategies for fa-cilitating the reading comprehension of high-functioning stu-dents with autism spectrum disorders. Journal of Autism andDevelopmental Disorders, 34,115-127.

Ozonoff, S., & Miller, J. N. (1995). Teaching theory of mind: A newapproach to social skills training for individuals with autism.Journal of Autism and Developmental Disorders, 25(4), 415-433.

Ozonoff, S., Rogers, S. J., & Pennington, B. R (1991). Asperger's Syn-drome: Evidence of an empirical distinction from High-Func-tioning Autism. Journal of Child Psychology and Psychiatry,32{7), 1107-1122.

662 ELDER etal.

Ozonoff, S., South, M., & Miller, J. N. (2000). DSM-IV defined AspergerSyndrome: Cognitive, behavioral, and early history differen-tiation from high functioning autism. Autism, 4(1), 29-46.

Rogers, S. (2000). Interventions that facilitate socialization in childrenwith Autism. Journal of Autism and Developmental Disorders,30(5), 399-407.

Ruberman, L. (2002). Psychotherapy of children with Pervasive Devel-opmental Disorders. American Journal of Psychotherapy, 56(2),262-274.

Sattler, J. M. (2002). Assessment of children: Behavioral and clinical applica-tions (4th Ed.). San Diego, CA: Sattler.

Silver, M., & Oakes, P. (2001). Evaluation of a new computer interven-tion to teach people with Autism or Asperger Syndjome torecognize and predict emotions in others. Autism, 5(3), 299-316.

Smith, I. M. (2000) Motor functioning in Asperger Syndrome in A.Klin, R R. Volkmar & S. S. Sparrow, (Eds.) Asperger Syndrome(p. 97-124). New York: Guilford Press..

Sofronoff, K., & Farbotko, M. (2002). The effectiveness of parent man-agement training to increase self-efficacy in parents of chil-dren with Asperger Syndrome. Autism, 6(3), 271-286.

Snowling, M & Frith, U. (1986) Comprehension in "hyperlexic" read-ers. Journal of Experimental Child Psychology, 42, 392-415.

Starr, E., Szatmari, P., Bryson, S., & Zwaigenbaum (2003). Stabilityand change among high-functioning children with pervasivedevelopmental disorders: A 2-year outcome study. Journal ofAutism and Developmental Disorders, 33(1), 15-22.

Szatmari, P., Archer, L. Fisman, S., Streiner, D. L., and Wilson, F. (1995).Asperger's Syndrome and Autism: Differences in behavior,cognition, and adaptive functioning. Journal of the AmericanAcademy of Child Adolescent Psychiatry, 34(12), 1662-1671.

Szatmari, P., Bremner, R., and Nagy, J. (1989). Asperger Syndrome: Areview of clinical features. Canadian Journal of Psychiatry, 34,554-560.

Tantam, D. (1988). Annotation: Asperger's Syndrome. Journal of ChildPsychology and Psychiatry, 29(3), 245-255.

Tantam, D. (2000). Psychological disorder in adolescents and adultswith Asperger Syndrome. Autism, 4(1), 47-62.

Tonge, B. J., Brereton, A. V., Cray, K. M., & Einfeld, S. L. (1999). Be-havioural and emotional disturbance in High-FunctioningAutism and Asperger Syndrome. Autism, 3(2), 117-130.


Towbin, K. E. (2003). Strategies for pharmacologic treatment of HighFunctioning Autism and Asperger Syndrome. Child and Ado-lescent Psychiatric Clinics of North American, 22(1), 23-45.

Tsatsanis, K. D. (2003). Outcome research in Asperger Syndrome.Child and Adolescent Psychiatric Clinics of North America, 22(1),47-63.

Wechsler, D. (1991). Wechsler Intelligence Scale for Children-Third Edi-tion. New York: Psychological Gorporation.

Williams, K. (1995). Understanding the student with Asperger Syn-drome: Guidelines for teachers. Focus on Autistic Behavior,20(2), 9-16.

Wing, L. (1981). Asperger's Syndrome: A clinical account. PsychologicalMedicine, 11,115-129.

Wing, L., & Gould, J. (1979). Severe impairments of social interactionand associated abnormalities in children: Epidemiology andclassification. Journal of Autism and Developmental Disorders,9(1), 11-29.

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