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J Autism Dev Disord (2009) 39:1268–1277

DOI 10.1007/s10803-009-0741-4

ORIGINAL PAPER

Social Competence and Social Skills Training and Intervention


for Children with Autism Spectrum Disorders
Albert J. Cotugno

Published online: 14 April 2009


 Springer Science+Business Media, LLC 2009

Abstract This study examined the effectiveness of a Centers for Disease Control and Prevention (2007) esti-
30 week social competence and social skills group inter- mated prevalence rates for autism and related disorders in
vention program with children, ages 7–11, diagnosed with the range of 1 in 150 individuals. As the numbers of
Autism Spectrum Disorders (ASD). Eighteen children with children reported with ASD have increased, concerns have
ASD were assessed with pretreatment and posttreatment been raised regarding the availability and appropriateness
measures on the Walker-McConnell Scale (WMS) and the of treatment interventions across a range of educational,
MGH YouthCare Social Competence Development Scale. clinical, and treatment settings.
Each received the 30-week intervention program. For Those children with ASD who are characterized by
comparison, a matched sample of ten non-ASD children significant impairment in social interaction present with a
was also assessed, but received no treatment. The findings range of behaviors including an inability to understand and
indicated that each ASD intervention group demonstrated interpret nonverbal behaviors in others, a failure to develop
significant gains on the WMS and significant improvement age-appropriate peer relationships, a lack of interest or
in the areas of anxiety management, joint attention, and enjoyment in social interactions, and a lack of social or
flexibility/transitions. Results suggest that this approach emotional reciprocity. They may also demonstrate restric-
can be effective in improving core social deficits in indi- tive, repetitive, and stereotyped patterns of behavior, most
viduals with ASD. often characterized by preoccupation with narrow, rigid
and inflexible interests or ways of thinking or behaviors
Keywords Autism spectrum  Social competency  and many exhibit serious communication deficits, particu-
Social skills larly in pragmatic language. These issues create significant
problems in engaging in normal and typical peer social
interactions, often resulting in avoidance of social contacts,
Introduction overarousal in social situations, an inability to understand
and follow expected social rules and expectations, and tacit
Autism Spectrum Disorders (ASD) are neurological dis- or explicit social rejection.
orders of unknown origin significantly affecting an indi- Multiple theories have been proposed for the causes of
vidual’s social interaction, language and communication, primary social deficits in ASD children, including deficits
and behavioral range of activities and interests. In 2007, the in theory of mind (Baron-Cohen et al. 1985; Baron-Cohen
1995; Wing and Gould 1979), weak central coherence
Portions of this paper were presented at the annual convention of the
(Frith 1989; Frith and Happe 1994), and executive dys-
American Psychological Association, Boston, August 2008. function (Minshew and Goldstein 1998; Ozonoff 1993,
1995; Pennington and Ozonoff 1996). Each appears to have
A. J. Cotugno (&) demonstrated value and applicability, however, it is likely
Department of Psychiatry, Massachusetts General Hospital/
that there is no single cause for social deficits in ASD
YouthCare, Harvard Medical School, 47A River Street,
Suite A200, Wellesley, MA 02481, USA children, but rather it is related to a complex set of multiple
e-mail: acotugno@partners.org interacting factors (Santangelo and Tsatsanis 2005).

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Reviews of social competency and social skill devel- and flexibility/transitions, each of which have related per-
opment in children with ASD consistently indicate defi- ceptual, neuropsychological, and behavioral components
ciencies in key social skills (Gresham 1981; Hollinger (Klin et al. 2002) and each of which appear to be governed
1987; Hops and Finch 1985; McConnell and Odom 1986; by underlying developmental aspects. These variables were
McConnell 2002) and that these deficits significantly chosen for study here because they are consistently refer-
interfere with social relationships (Welsh et al. 2001). enced as important deficiencies in nearly all groups of
Given the social-interpersonal deficits attributed to ASD individuals with ASD studied. Relatively little research on
and their effects and that long-term social adjustment for effective interventions in these areas has occurred to date.
children is directly related to the development of appro- Given the social impairments present in ASD individu-
priate social competency (Matson and Swiezy 1994; Parker als, in both key underlying processes and structures and
and Asher 1987; Shopler and Mesibov 1983), interventions specific social skills, a social competency and social skills
which address the social competency needs and concerns training and intervention program was developed that
of ASD individuals appear critical in overcoming many of combines group-based, therapeutic interventions, social-
the negative and debilitating effects of these disorders. cognitive learning approaches, and directed skill instruction
Although group-based interventions have often been within a stage-based, cognitive-developmental framework.
employed to enhance social competency and develop- The purpose of this study was to describe a group treatment
mental skills and generally show significant benefits model for school-age children with ASD and to present data
(Hwang and Hughes 2000; McConnell 2002; Rogers 2000), on the effectiveness of a multidimensional structure and
many question the efficacy of these treatments (Barry et al. skill based approach over a year long social competence/
2003; Krasney et al. 2003; Williams et al. 2006), particu- social skill training program. We hypothesize that
larly their inability to generalize to real-life situations. addressing specific areas of social competency and pro-
Variations in research design, sample size, skills targeted, viding training in specific social skills will significantly
settings where treatments occur, instruments used to mea- improve and enhance the social interactions of individuals
sure outcome, effect sizes, and generalization effects, have with ASD in group situations.
made evaluation of effectiveness and replication of find-
ings difficult. As a result, some authors have suggested
guidelines for research with group interventions with Method
children with ASD (Krasney et al. 2003; Mesibov 1986;
Mesibov 1986). Participants
To date, many group-based interventions have used
cognitive-behavioral strategies, pragmatic language devel- This study consisted of 18 children all from self-referred
opment, theory of mind constructs, or specific social skills families to Massachusetts General Hospital (MGH)/
training, to enhance and sustain appropriate social skill YouthCare. MGH/YouthCare is a small, community-based,
development. Many social skills training programs have independent program within the Department of Psychiatry
been constructed specifically for children with ASD and at MGH which focuses primarily on treatment and con-
have covered a wide array of skills, but have often lacked sultation to children and adolescents with Autism Spectrum
controlled, empirically-based assessment (e.g., Adams Disorders (ASD). All families were self-supporting, vol-
2006; Baker 2003; Bloomquist 1996; McAfee 2002). untary participants. Referrals came from general care and
Mesibov (1984) was first to report the use of a group-based developmental pediatricians, specialty ASD programs both
social skills training approach for individuals with ASD, in within and outside the hospital, school referrals, and
a qualitative study, using modeling, coaching, and role- website contacts.
play, followed by other similar studies by LaGreca (1993) Following application, children and families were
and Williams (1989). More controlled studies followed, screened and interviewed for appropriateness within our
focusing on different aspects of social competence and group program. Children were included in this study, if at
social skill training including social anxiety and social referral, they met the following criteria: (a) they were
aggression (Steerneman et al. 1996), emotion recognition between the ages of 7 and 11; (b) they had received a prior
(Wimmer and Perner 1983), theory of mind (Ozonoff 1995; diagnosis on the autism spectrum (i.e., Autistic Disorder,
Perner and Wimmer 1985; Givers et al. 2006), and multiple Pervasive Developmental Disorder-Not Otherwise Speci-
areas of social skill development (Tse et al. 2007). fied, Asperger’s Disorder) meeting DSM IV criteria
In addition to basic social skill deficiencies, three key (American Psychiatric Association 1994), confirmed by
issues that are consistently described as core deficits related neuropsychological evaluation by professionals with no
to social impairment in ASD individuals are stress/anxiety connection to our program; (c) they had obtained a Full
(Baron et al. 2006), attention (Frith 1989; Rosenn 2002), Scale or Verbal Scale IQ on the WISC IV within the

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average range (80–119) or higher; (d) they demonstrated social behavior and 17 items addressing peer-preferred
no significant language or communication deficits; and (e) social behavior. School adjustment is defined as satisfac-
they participated in at least a partial inclusion program in a torily meeting the behavioral and academic standards of
regular education curriculum. Our group placement process teachers within instructional settings. The WMS includes
also includes the completion of several steps described in ten items addressing school adjustment within the class-
detail elsewhere (Cotugno 2008). room. A total score including all 43 items represents a
Eighteen children were selected and divided into two school-based social-behavioral adjustment index.
age clusters, one cluster of ten children ages 7.0–8.2, and a 2. The MGH YouthCare Social Competency/Social Skill
second cluster of children, ages 10.0–11.0. Each cluster Development Scale (SCDS). The SCDS is a 55 item scale
demonstrated no significant within group differences on completed by parents of each participant in a YouthCare
any variable, including intelligence or academic achieve- program, providing a broad measure of social competency
ment, demonstrating significant homogeneity. For treat- and social skill development for children with ASD. Par-
ment purposes, each cluster was divided into two groups ents rate the child on important cognitive aspects (e.g.,
(for a total of four separate treatment groups) with all stress/anxiety, attention, flexibility/transitions), social
groups administered by the same licensed group clinician interpersonal skills (e.g., converses with peers), and self-
who had extensive training and experience working with awareness (e.g., controls self). All items are ranked on a 5-
children with ASD. For each cluster of two groups, a point Likert scale. For the purposes of this study, a total of
consistent stage-based, group focused competency/skill six items from the SCDS were selected for analysis and
curriculum was employed with variations dependent on age study at pretreatment and posttreatment, two items each,
and developmental factors. Children selected for group addressing stress/anxiety management, joint attention, and
participation attended 1 h weekly sessions for 30 weeks. flexibility/transitions.
Two groups of five children each, one group ages 7–8
and one group ages 10–11, were randomly selected from Procedures
two local public schools to match the ages and grades of
the intervention groups. These ten children constituted the This study employed a pretest-posttest design. Prior to
two control groups. Children were included only if they group placement, each family provided detailed medical,
met the following criteria: (a) they had never been referred developmental, and educational histories, including all past
to nor ever received any special education services; (b) and current evaluation information and participated in a
they were receiving no current psychological or parent/caretaker and child interview. Parents of each group
school-based services (i.e., individual, group therapy or participant completed the SCDS and the classroom teacher
counseling); and (c) they had no prior contact with MGH/ of each group participant completed the WMS in order to
YouthCare. assess social competencies and social skills in the different
settings of home and school. This information was used to
Measures assess each child for appropriateness for group placement
and to construct individual goals for each child prior to
As part of the screening and assessment process, the fol- placement within a group. This information was then
lowing instruments were used in this study at both pre- pooled for all participants in the same group to create group
treatment and posttreatment phases. goals focusing on each particular stage of group develop-
1. The Walker-McConnell Scale of Social Competence ment. Each of the 18 children with ASD selected partici-
and Social Adjustment (WMS). The WMS is a 43 item pated in once-weekly, year-long, group sessions (a total of
teacher completed scale clustered into three subscales, 30 sessions).
including teacher-preferred social behavior, peer-preferred At posttreatment following a 30-week intervention
social behavior, school adjustment behavior, and a total program, parents again completed the SCDS and teachers,
scale score. Normative data for 1,812 subjects by age and for both the treatment group participants and the non-ASD
grade is provided and validity and reliability of the WMS control sample, completed the WMS.
meets established standards (Walker and McConnell 1995).
However, no information is provided regarding specific
norms or its utility with children with ASD. Social Competency and Social Skills Training
The WMS measures two correlated constructs related to and Intervention Program
social functioning: social competence and school adjust-
ment. Social competence is defined as the development of This intervention program employed a peer-based, group
effective interpersonal relationships with peers and adults. model within a cognitive-developmental framework using
The WMS includes 16 items addressing teacher-preferred group therapy, cognitive-behavioral, and skill instruction

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techniques to address the social competency needs and During each session within this program, primary
concerns of these children with ASD. A comprehensive emphasis is placed on interventions which focus on the
initial assessment provided information for the elaboration following: developmental leveling (group and skill-based
of specific areas of interest, individual goals for each child, experiences targeted to the overall developmental level of
and group goals once a group was assembled. the group); self-management (each individual takes
This program also addressed the specific stages of responsibility for self-managing and self-controlling one’s
development that groups of children with ASD are own behavior in order to meet group expectations); peer
observed to move through as they evolve. Within each mediation (peer to peer interactions designed to address
stage of development, opportunities are provided for the and resolve group issues and conflicts as they arise);
group to address and comprehend aspects of social inter- priming (complex tasks are broken into simple steps with
action and to develop adaptive strategies to manage social preparation and training provided for managing new
issues most effectively. The group leader and participants aspects of a task based upon previously learned skills and
jointly set stage goals and evaluate progress toward meet- strategies); and direct instruction (specific skills are selec-
ing those goals. As specific stage goals are met, group ted, taught, and reinforced within the group setting).
members discuss and elaborate subsequent stage goals. At Activities used during group sessions were selected
each stage within this framework, key group process based on the following criteria:
variables are targeted and addressed within the group (i.e.,
1. Current stage of group development;
building culture, relating and connecting, attending to task
2. Specific group goals related to the stage of group
and peers, joint decision making) and related skills for
development;
instruction based on these variables are elaborated. Specific
3. Specific social skills related to group goals.
skill instruction is based both on individual needs within
the group and the needs of the group as a whole (e.g., eye
gaze, asking questions, etc.) and is structured to focus on A Stage Model of Group Development
and develop more effective and age appropriate strategies for Individuals with ASD
for interactions with peers in natural settings. The program
used in this study was also designed to specifically address In groups of children with ASD, a consistent sequence and
key areas of deficiency (core deficits) in individuals with order of stages of development have been previously
ASD: stress and anxiety management, joint attention, and observed and documented (Cotugno 2008, 2009). Specific
flexibility/transitions. to each stage, there emerge processes and sets of behaviors
Each social competency group met weekly for 1 h from that appear necessary in order to pass successfully through
September through June for a total of 30 sessions. Each the particular stage and on to subsequent stages. They are:
group was led by a group clinician with training and
Stage 1 Group formation and orientation.
expertise in working with children with ASD and in group
Stage 2 Group cohesion.
therapy interventions. Sessions were constructed so as to
Stage 3 Group stability, relationships, and connections.
maintain a high degree of consistency from session to
Stage 4 Group adaptations and perspective taking.
session and included three components: (a) an introductory
Stage 5 Terminations, loss, and goodbyes.
period (greetings, sharing time, announcements); (b) a
group decision-making task designating the activity for that
particular session (selected by the group participants from a Stage 1
cluster of activities determined in advance by the group
leader and focusing on issues specific to the particular The first stage consists of Group Formation and Orienta-
stage). For example at Stage 2 Group Cohesion, the group tion, a process where the group comes together and gets to
leader provides several specific activities or games which know one another as individuals and as a group. Here, the
focus on strengthening the bond between group members group begins to understand how to react, respond, and
through the development of group awareness, disclosure, interact with one another while engaging in conversation,
and feedback mechanisms, from which the group members sharing of interests, and establishing connections. Group
must choose. All members were required to participate in goals provide a focus on the common and shared experi-
the activity; and (c) a snack time and group discussion of ences and are intended to provide structure and information
the activity. This was used for processing group interac- and opportunities to share feelings, thoughts, and experi-
tions, conflicts, and dynamics, relating the work of that ences in a new situation. Specific skills relate to the group
particular session to previous sessions, connecting key goals of fostering and developing cohesion, connections,
process variables and specific skills. A preview of the next and relationships within the group. These include: learning
session also occurred. about one another (sharing information, asking questions,

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attending to others, exploring for common interests, etc.), negative issues that arise, time management, modes of
learning about how the group can work together, communication, decision-making, and responses to the
acknowledging common issues (anxiety in relationships, needs of the group. As the issues change or as the group
needs for flexibility, etc.), and creating a group plan. needs shift, the group must develop the capacity at this
stage to quickly adjust and adapt, using the group inter-
Stage 2 actions to decide the types of adaptations required. At this
stage, the group learns to manage and direct itself while
The second stage of Group Cohesion relates to the capacity managing and resolving conflict, to repair breaks in rela-
to form a bond as a group and to use that bond as a force to tionships, to adapt to change, to consider multiple points of
hold the group together as it begins to deal with increasingly view and alternative ways of thinking, and to flexibly
more stressful issues. Information learned from Stage 1 manage unknown or unpredictable situations.
sessions, particularly in the areas of stress-anxiety, atten- At Stage 4, increasing emphasis is placed on goals
tion, and flexibility/transitions, will inform the construction relating to flexibility, the ability to shift, and on ‘‘theory of
of Stage 2 goals. Group goals foster interaction, while mind,’’ the capacity to think about and experience what
individual goals work on specific aspects of a group mem- another person might be thinking or feeling, as well as
ber’s thinking or behavior that might interfere with effective openness and resiliancy when faced with difficult, per-
group participation and involvement. Group goals provide plexing, and hard to solve problems. Goals are constructed
the opportunity for interaction, while individual goals focus to ensure practice in self-management and self-direction by
on the specific needs of the individual to make interactions requiring honest and respectful interactions, appropriate
successful. Specific skills relate to the overall group goals of confrontation, discussion of alternative solutions to prob-
acknowledging, managing, and coping with the stress and lems, and unanimous agreement in decision-making. Spe-
anxiety that arises as individuals take risks to share personal cific skills addressed include: negotiating compromise,
information, joining others in an attempt to gain support and recognizing and using criticism, seeing things through
feedback, expressing needs that may be embarrassing, and another person’s eyes, apologizing, and getting ‘‘unstuck’’.
recognizing intimacy and affiliation needs.
Stage 5
Stage 3
The Stage 5 Termination, Loss, and Endings, relates to
The third stage of Group Stability, Relationships, and endings, losses, significant transitions, and goodbyes.
Connections emphasizes the power of interactive group Attempts are made to understand the thoughts, feelings,
process to tap into the established and now ongoing stability and emotions that these events stir up and the effects that
that comes from the familiarity achieved between group they have on interactions with peers and others. This stage
members on rules, boundaries, and managing positive/neg- focuses on recognizing what these experiences are like,
ative interactions. Group members identify with other group how to tell when they occur, and what effect they have on
members and with the group leader and strong alliances each member. The goals focus on addressing and managing
develop. The group becomes more active in structuring the thoughts, feelings, and emotions, related to change, tran-
sessions based on a consensus and approval of group needs sitions, losses, and endings. Specific skills addressed at
and is positioned to initiate discussions, allocate time, Stage 5 include: expressing termination emotions, under-
resolve conflicts, respect and take care of one another, and to standing endings, and saving the memories.
move forward on the articulated goals. Group goals focus on
a gradual shift in the arrangement of power and control from
group leader to the group and on communication enhance- Three Specific Areas Addressed in this Study
ment within the group, group management of conflict and
hostility when it arises, and total acceptance of each group Three significant issues, prominent in nearly all interper-
member within the group as a whole. Specific skills focused sonal interactions with individuals with ASD, were a spe-
upon include learning about: nonverbal communication, cific focus of this study and are addressed and considered
working cooperatively, giving and getting feedback/criti- within group goals at each stage. They include: (a) the
cism, emotional regulation, and anxiety management. experience and management of stress and anxiety; (b) joint
attention; and (c) flexibility/transitions.
Stage 4 In order to address and manage the stress and anxiety
that individuals with ASD experience, particularly around
This stage of Group Adaptation and Perspective Taking interactions in group situations, group sessions provide
relates to the capacity to adapt flexibly to the positive and progressive and systematic training in basic stress and

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anxiety management techniques, such as deep breathing, Results


rhythmic counting, and visual imaging. This training is
repeated and practiced consistently in subsequent sessions, This study examined whether teacher and parent ratings of
particularly when stress arises and serves to trigger group social competency, social behavior, and school adjustment
discussions about what causes anxiety, what it feels like, improved over a 9-month period for children with ASD, ages
and what techniques or methods can assist in managing it. 7–11, who were provided with weekly group intervention
A second major focus of these groups is on joint attention, which combined group therapy, cognitive-behavioral, and
the capacity to direct and employ attentional capacities as skill instruction techniques within a stage-based, cognitive-
they relate to shared interpersonal requirements and expec- developmental framework. In addition, three issues known
tations. Group participants are taught how to understand and to affect social-interpersonal behavior, stress and anxiety
to appropriately react to attentional expectations with the management, joint attention, and flexibility/transitions, were
focus on interactions between individuals. Because joint a specific focus of the competency and skill-based inter-
attention is known to be an important and necessary compe- ventions across each of the five stages of group development.
tency for reciprocal interchange and communication in group Table 1 provides the pretreatment and posttreatment
situations, group goals are constructed around the develop- means for scores on each of four scales on the WMS for
ment and enhancement of joint attention with activities the two clusters of children with ASD (7–8 year olds and
selected at each stage by the group leader which will develop 10–11 year olds) who received social competency
and reinforce joint attention between group participants. intervention.
A third issue affecting individuals with ASD and which For both the 7–8 and 10–11 year old intervention groups
is addressed at each stage within groups relates to the issue of children with ASD, teacher ratings on the WMS were
of flexibility and transitions. Because the requirements to significantly improved across the four scales, teacher-pre-
be flexible, to adjust and accommodate to change, and to ferred social behavior, peer-preferred social behavior,
transition (i.e., shift attention) between tasks and activities school adjustment behavior, and total score. The younger
are known to create significant degrees of stress and ten- group (ages 7–8) showed greatest improvement on teacher-
sion in the majority of individuals with ASD, triggering preferred (t = 2.29, p \ .05) and peer-preferred behavior
increased anxiety, and often overload (i.e., meltdown), (t = 2.30, p \ .05), while the older group (ages 10–11)
group goals are constructed related to these issues to showed greatest improvement in school adjustment behavior
anticipate and prepare for the stress related to the needs for (t = 2.89, p \ .01). For both groups of children with ASD,
flexibility/transition throughout the group stages. total score showed similar overall gains from pretreatment to
Throughout the course of the group, activities chosen posttreatment (t = 2.53, p \ .05; t = 3.11, p \ .01).
are previewed and discussed in order to understand how Upon review of the cluster of group goals established at
they relate to the individual and group goals and the spe- the outset of group sessions by each of the intervention
cific social skills to be addressed during that session for groups, these results are consistent with the younger chil-
that activity. Discussions are provided in language appro- dren’s goals focusing on meeting rule expectations, com-
priate for the age of group members. Following a brief pleting tasks as requested, understanding and cooperating
priming period and exercise, specific social competencies with peers more effectively, and learning more about peers
and social skills are modeled and demonstrated by the and what they like to do. For the groups of older children
group leader with explicit verbal and nonverbal reinforce- with ASD, the cluster of group goals established at the
ments. and ongoing feedback. outset focused more on the completion and quality of tasks

Table 1 Pretreatment and


Pretreatment Posttreatment t
posttreatment means and t-tests
for two groups of ASD children ASD groups, ages 7–8 (N = 10)
Teacher-preferred social behavior 46.2 52.7 2.29*
Peer-preferred social behavior 43.8 50.9 2.30*
School adjustment behavior 31.4 34.6 2.52*
Total score 121.4 138.3 2.53*
ASD groups, ages 10–11 (N = 8)
Teacher-preferred social behavior 44.5 48.8 2.04*
Peer-preferred social Behavior 44.0 47.0 2.58*
School adjustment behavior 32.0 41.1 2.89**
* p \ .05
Total score 120.5 136.4 3.11**
** p \ .01

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and activities, listening and responding more carefully, and attention, and flexibility/transitions as reported by parent
using time and efforts in more organized and efficient ways. observation, further study of how individual and group goal
It appears that at different ages, the individual and group setting and task and activity selection affect change and
goals selected by each of the groups reflect developmentally outcome on these variables is warranted.
appropriate choices directed toward what are perceived as The data for the comparison control group of neurotypical
their most pressing needs. The younger children appeared to children was included to insure consistency with WMS
be struggling most with learning how to act appropriately normative data which does not provide separate normative
and to learn appropriate peer behavior, while the older data for children with ASD and to provide a control group
groups were concerned with social acceptance as it relates with similar demographics to the children with ASD who
to school-based behavior and academic performance. were assessed and treated. For the comparison control group
Regarding parent ratings of competency in the areas of of neurotypical children who received no intervention, pre-
stress and anxiety management, joint attention, and flexi- treatment and posttreatment scores on the WMS are provided
bility/transitions, results were generally in positive direc- in Appendix 1. Control children, performed at expected
tions for each variable, but with some variability. Table 2 levels on both pretreatment and posttreatment measures,
lists the percentage of group participants at pretreatment demonstrating no significant change, and maintaining high
and posttreatment who received scores of two or one (no or levels of performance as compared to the children with ASD
limited demonstration of the positive, adaptive behavior) at both pretreatment and posttreatment.
on the SCDS items. The results of this study provide strong support for the
Both the younger and older groups of children with ASD hypothesis that a group-based intervention which focuses
demonstrated significant improvement in parent ratings of specifically on deficient social competencies and skills can
stress and anxiety management, joint attention, and flexi- benefit children with ASD by reducing anxiety in social situ-
bility/transitions from pretreatment to posttreatment. How- ations, increasing the number of and attention to positive peer
ever, the younger group demonstrated a greater shift to more social interactions, and increasing flexibility and willingness
positive and effective ways of managing and coping on each to change, as observed by parents. This study also provides
of these variables than the older group. Upon review of the evidence that improved stress and anxiety management, joint
group goals for each of the groups during the course of year- attention, and flexibility/transitions in group situations can
long sessions, the goals selected and focused upon by the contribute directly to improvements in teacher-preferred and
younger children more frequently addressed stress/tension/ peer-preferred social behavior and school adjustment.
anxiety issues (what we came to call ‘‘comfort concerns’’),
while the older group more frequently addressed interactive
concerns, learning to get along, and resolving conflicts. Both Discussion
younger and older groups focused their group goals on ‘‘joint
attention’’ issues (active listening and responding, taking Despite the prevalence of social skill interventions for chil-
turns, giving compliments) with equal frequency. Never- dren with ASD which indicate generally positive effects,
theless, while each group demonstrated significant surprisingly little formal or controlled research on the spe-
improvement over time in stress/anxiety management, joint cific benefits of different approaches, comparisons between
approaches, and comparisons with typical and non-ASD
Table 2 Number and percentage of SCDS scores of two or one by populations, has taken place until recently. Generally, stud-
age group for two questions for each key variable assessed ies of social skills based groups for ASD children report
Pretreatment Posttreatment modest improvement and high overall parent and participant
N % N %
satisfaction, but relatively poor generalizability.
The purpose of this study was to examine the effec-
ASD groups, ages 7–8 tiveness of a group-based, 30 week, social competence and
Anxiety and stress mgmt 17 85 9 45 social skill training and intervention program with ASD
Joint attention 12 60 7 35 children, ages 7–11. This study combined group-based
Flexibility/transitions 17 85 11 55 therapeutic interventions, social-cognitive learning
ASD groups, ages 10–11 approaches, and directed social skills instruction within a
Anxiety and stress mgmt 16 100 7 44 stage-based, cognitive-developmental model. This study
Joint attention 11 69 4 25 found that a specially designed, social competency and
Flexibility/transitions 11 69 5 31 social skills training and intervention program providing
Percentages reflect the number of group participants receiving a score
systematic intervention and instruction can substantially
of two or one, scores reflecting no or very limited demonstration of improve performance on specific social competencies and
positive, adaptive behavior in social skill development.

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Results of this study indicated significant improvement Table 3 Pretreatment and posttreatment means and t-tests for two
in overall social competency scores for all groups of chil- groups of non-ASD control children receiving no intervention
dren with ASD based on WMS scores. Significant Pretreatment Posttreatment t
improvement also occurred as reported by parent obser-
vation on key variables in core deficit areas on the SCDS of Non-ASD group, ages 7–8 (N = 5)
stress and anxiety management, joint attention, and flexi- Teacher-preferred social 59.6 60.4 .38
behavior
bility and transitions. Overall, these results provide a strong
Peer-preferred social behavior 60.8 63.2 .70
indication that social competency groups that focus on
process-oriented variables combined with skill-based School adjustment behavior 40.6 40.0 .35
instruction can benefit individuals with ASD in specific Total score 159.0 163.6 .71
areas of social interaction. Non-ASD group, ages 10–11 (N = 5)
However, while the gains through intervention by the Teacher-preferred social 69.4 65.2 1.9
behavior
children with ASD were significant at posttreatment, these
Peer-preferred social behavior 74.0 72.4 .47
children continued to lag the ‘‘control’’ peers in significant
School adjustment behavior 43.6 43.8 .11
ways. At pretreatment, children with ASD were performing
Total score 187.0 181.4 1.10
at levels significantly lower than their ‘‘normal’’ peers on
all measures of social competency and social interaction, All mean comparisons were nonsignificant
but with intervention, were able to make significant gains
over time. While not able to attain ‘‘normal’’ scores after
the 30-week intervention, children with ASD who have Appendix 2
significant social deficits and impairments may be capable
of making ongoing cumulative gains when interventions Parent Rating Questions on the SCDS Collected at
are extended over longer periods of time and are targeted to Pretreatment and Posttreatment
areas of need. The results suggest the need for continued
emphasis in areas of core deficits, increased intensity of Anxiety Control and Management
interventions to improve the rate of progress, consistent Enters and acclimates to group without anxiety.
and ongoing reinforcement to solidify and internalize Manages anxiety effectively.
learned acquired competencies and skills, and a specific
focus on the transfer and generalizability of these compe- Joint Attention
tencies and skills to unrehearsed social situations. Participates in group structure and activities.
Although group interventions may have their limitations, Attends to others.
the nature of deficits and impairments related to ASD
requires that social competency-based interventions, par- Flexibility/transitions
ticularly involving peer-based situations, continue to be Accepts peer’s initiation of activities.
tested, explored, and refined for their efficacy and general- Gets self ‘‘unstuck’’ without help.
izability. Limitations affecting this study included: a small
sample size, generally limited by the need to keep group size Parents respond by rating on a scale of 1–5 as follows: (1)
small and manageable; limited prior research on the social never; (2) once in a while; (3) often; (4) frequently; (5) all
competencies and social cognitive processes which influ- the time.
ence and determine social skill development; the ongoing
need for more precise assessment and measurement tools for
the ASD population (e.g., the WMS reported adequate
References
validity with typical school-based populations, but no data
on individuals with ASD); the lack of a true no treatment Adams, L. (2006). Group treatment for Asperger Syndrome: A social
control group of children diagnosed with ASD; and the lack skill curriculum. San Diego: Plural.
of randomization across all groups. Also, further evaluation American Psychiatric Association. (1994). Diagnostic and statistical
manual for mental disorders (4th ed.). Washington, DC:
of structure-based, process-oriented approaches within a
American Psychiatric Association.
cognitive-developmental model appears indicated. Baker, T. E. (2003). Social skill training: For children and
adolescents with Asperger Syndrome and social communication
problems. Kansas: Autism Asperger.
Baron, M. G., Groden, J., Groden, G., & Lipsitt, L. P. (Eds.). (2006).
Appendix 1
Stress and coping. New York: Oxford University Press.
Baron-Cohen, S. (1995). Mindblindness: An essay on autism and the
See Table 3. theory of mind. Cambridge, MA: MIT Press.

123
1276 J Autism Dev Disord (2009) 39:1268–1277

Baron-Cohen, S., Leslie, A. M., & Frith, U. (1985). Does the autistic research. Journal of Autism and Developmental Disorders, 32,
child have a theory of mind? Cognition, 21, 37–46. doi: 351–372. doi:10.1023/A:1020537805154.
10.1016/0010-0277(85)90022-8. McConnell, S. R., & Odom, S. L. (1986). Sociometrics: Peer-
Barry, T. D., Klinger, L. G., Lee, J. M., Palardy, N., Gilmore, T., & referenced measures and the assessment of social competence. In
Bodin, S. D. (2003). Examining the effectiveness of an outpatient P. S. Strain, M. S. Guralnick, & H. M. Walker (Eds.), Children’s
clinic-based social skills group for high functioning children with social behavior: Development, assessment, and modification (pp.
autism. Journal of Autism and Developmental Disorders, 33(6), 215–284). New York: Academic Press.
685–701. doi:10.1023/B:JADD.0000006004.86556.e0. Mesibov, G. B. (1984). Social skills training with verbal autistic
Bloomquist, M. L. (1996). Skills training for children with behavior adolescents and adults: A program model. Journal of Autism
disorders: A parent and therapist guidebook. New York: and Developmental Disorders, 14, 395–404. doi:10.1007/
Guilford Press. BF02409830.
Centers for Disease Control and Prevention. (2007). Prevalence of Mesibov, G. B. (1986). Social skills training for elementary school
autism spectrum disorders in multiple areas of the United States, autistic children with normal peers. In E. Schopler, E. Mesibov,
surveillance years 2000 and 2002. Surveillance Summaries, & L. J. Kunce (Eds.), Social behavior in autism (pp. 305–319).
February 9, 2007. MMWR; 56 (No. SS#1). New York: Plenum Press.
Cotugno, A. J. (2008). Social competency groups for children with Minshew, N. J., & Goldstein, G. (1998). Autism as a disorder of
Asperger’s Disorder: A discussion and a test of effectiveness. complex information processing. Mental Retardation and Devel-
Poster session at the annual meeting of the American Psycho- opmental Disabilities Research Reviews, 4, 129–136. doi:
logical Association, Boston. 10.1002/(SICI)1098-2779(1998)4:2\129::AID-MRDD10[3.0.
Cotugno, A. J. (2009). Group interventions for children with Autism CO;2-X.
Spectrum Disorders (ASD). London: Jessica Kingsley Publishers. Ozonoff, S. (1995). Executive functions in autism. In E. Schopler &
Frith, U. (1989). Autism: Explaining the enigma. Oxford: Basil G. B. Mesibov (Eds.), Learning and cognition in autism (pp.
Blackwell. 199–219). New York: Plenum Press.
Frith, U., & Happe, F. (1994). Autism: Beyond ‘‘theory-of-mind’’. Parker, J. G., & Asher, S. R. (1987). Peer relations and later personal
Cognition, 50, 115–132. doi:10.1016/0010-0277(94)90024-8. adjustment: Are low-accepted children at risk? Psychological
Givers, C., Clifford, P., Mager, M., & Boer, F. (2006). Brief report: A Bulletin, 102, 357–387. doi:10.1037/0033-2909.102.3.357.
theory-of-mind social cognition training program for school- Pennington, B. F., & Ozonoff, S. (1996). Executive functions and
aged children with pervasive developmental disorders: An open developmental psychopathology. Journal of Child Psychology
study of its effectiveness. Journal of Autism and Developmental and Psychiatry and Allied Disciplines, 37(1), 51–87. doi:
Disorders, 36(4), 567–571. doi:10.1007/s10803-006-0095-0. 10.1111/j.1469-7610.1996.tb01380.x.
Gresham, F. M. (1981). Social skills training with handicapped Perner, J., & Wimmer, H. (1985). ‘‘John thinks that Mary thinks
children: A review. Review of Educational Research, 51, 139– that…’’ Attribution of second-order beliefs by 5–10 years old
176. children. Journal of Experimental Child Psychology, 39, 437–
Hollinger, J. (1987). Social skills for behaviorally disordered children 471. doi:10.1016/0022-0965(85)90051-7.
as preparation for mainstreaming: Theory, practice and new Rogers, S. (2000). Interventions that facilitate socialization in
directions. Remedial and Special Education, 8(4), 17–27. children with autism. Journal of Autism and Developmental
Hops, H., & Finch, M. (1985). Social competence and skill: A Disorders, 30, 399–409. doi:10.1023/A:1005543321840.
reassessment. In B. H. Schneider, K. H. Rubin, & J. E. Rosenn, D. (2002). Is it Asperger’s or ADHD? AANE News, 10, 3–5.
Ledingham (Eds.), Children’s peer relations: Issues in assess- Santangelo, S. L., & Tsatsanis, K. (2005). What is known about autism:
ment and intervention (pp. 23–40). New York: Springer. Genes, brain, and behavior. American Journal of Pharmacoge-
Hwang, B., & Hughes, C. (2000). The effects of social interactive nomics, 5, 71–92. doi:10.2165/00129785-200505020-00001.
training on early social communicative skills of children with Shopler, E., & Mesibov, G. B. (Eds.). (1983). Autism in adolescents
autism. Journal of Autism and Developmental Disorders, 30, and adults. New York: Plenum Press.
331–343. doi:10.1023/A:1005579317085. Steerneman, P., Jackson, S., Pelzer, H., & Muris, P. (1996). Children
Klin, A., Jones, W., Schultz, R., Volkmar, F., & Cohen, D. (2002). with social handicaps: An intervention program using a theory-
Defining and quantifying the social phenotype in autism. The of-mind approach. Clinical Child Psychology and Psychiatry, 1,
American Journal of Psychiatry, 159(6), 895–908. doi: 252–263. doi:10.1177/1359104596012006.
10.1176/appi.ajp.159.6.895. Tse, J., Strulovitch, J., Tagalakis, V., Meng, L., & Fombonne, E.
Krasney, L., Williams, B. J., Provencal, S., & Ozonoff, S. (2003). (2007). Social skills training for adolescents with Asperger
Social skills interventions for the autism spectrum: Essential Syndrome and high-functioning autism. Journal of Autism and
ingredients and a model curriculum. Child and Adolescent Developmental Disorders, Online paper #S108033-006-0343-3.
Psychiatric Clinics of North America, 12(1), 107–122. doi: Walker, H. M., & McConnell, S. R. (1995). The Walker-McConnell
10.1016/S1056-4993(02)00051-2. scale of social competence and school adjustment: Elementary
LaGreca, A. M. (1993). Social skills training with children: Where do version. SanDiego, CA: Singular Publishing.
we go from here? Journal of Clinical Child Psychiatry, 22, 288– Welsh, M., Park, R. D., Widaman, K., & O’Neil, R. (2001). Linkages
298. doi:10.1207/s15374424jccp2202_14. between children’s social and academic competence: A longi-
Matson, J. L., & Swiezy, N. B. (1994). Social skills training with tudinal analysis. Journal of School Psychology, 39, 463–481.
autistic children. In J. L. Matson (Ed.), Autism in children and Williams, T. I. (1989). A social skills group for autistic children.
adults: Etiology, assessment, and intervention. Sycamore, IL: Journal of Autism and Developmental Disorders, 19, 143–155.
Sycamore. doi:10.1007/BF02212726.
McAfee, J. (2002). Navigating the social world: A curriculum for Williams, S. K., Koenig, K., & Scahill, L. (2006). Social skills
individuals with Asperger’s Syndrome, high functioning autism development in children with autism spectrum disorders: A
and related disorders. Arlington, TX: Future Horizons. review of intervention research. Journal of Autism and Devel-
McConnell, S. R. (2002). Interventions to facilitate social interaction opmental Disorders, Online Paper #1573-3432.
for young children with autism: Review of available research Wimmer, H., & Perner, J. (1983). Beliefs about beliefs: Represen-
and recommendations for educational interventions and future tations and constraining function of wrong beliefs in young

123
J Autism Dev Disord (2009) 39:1268–1277 1277

children’s understanding of deception. Cognition, 13, 103–128. Epidemiology and classification. Journal of Autism and Devel-
doi:10.1016/0010-0277(83)90004-5. opmental Disorders, 9, 11–29. doi:10.1007/BF01531288.
Wing, L., & Gould, J. (1979). Severe impairments of social
interaction and associated abnormalities in children:

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