Social Skills and Children with ASD: A systematic review of occupational therapy intervention evidence. Kayla Ingram, OTS. Spalding University

Transcription

1 Running head: SOCIAL SKILLS AND CHILDREN WITH ASD 1 Social Skills and Children with ASD: A systematic review of occupational therapy intervention evidence Kayla Ingram, OTS Spalding University

2 SOCIAL SKILLS AND CHILDREN WITH ASD Ingram 2 Abstract Children with Autism Spectrum Disorders (ASD) make up a very significant percentage of the clients treated in outpatient pediatric and school-based occupational therapy settings. Children with ASD frequently display difficulty developing and maintaining meaningful social relationships due to complex issues including inability to read emotions of others and inability to understand other viewpoints. A wide variety of social skills training interventions have been developed and researched for improving various social skills in children with ASD, but which occupational therapy interventions are truly effective? The objective of this review was to analyze 7 peer reviewed scholarly journal articles to determine effective interventions for treating children with ASD. Overall, while the research articles used for this review varied in format and design, group interventions consistently yielded significant positive results for increases in targeted social skills.

3 SOCIAL SKILLS AND CHILDREN WITH ASD Ingram 3 Introduction Social skill deficiencies are found with varying degrees in all children with ASD. These issues cause problems for the individual in creating and maintaining relationships which can lead to decreased quality of life for these children and their families at times. According to AutismSpeaks.org some other common characteristics of children with ASD include not responding to their name by 12 months, no pretend play by 14 months, avoids eye contact, and difficulty understanding other s emotions. Children with ASD make up a very significant percentage of clients seen in outpatient pediatric and school based occupational therapy settings which means it should be a significant focus for practicing pediatric therapists and level II fieldwork students. Currently there are a wide variety of social skills interventions available but how can we determine which ones are effective? Through a literature review, limited occupational therapy evidence based research was found which means there needs to be much greater research conducted in this area. Narrowing specific social skills interventions will help current practitioners become more effective as well as help educate upcoming fieldwork students. According to the Center for Disease Control, 1 in 88 children have been identified with one of the autism spectrum disorders. That is an enormous number of children as well as family and friends that are being affected by this group of disorders. There is massive societal need for children with ASD to learn to function socially, even if it is not typical, in our communities. Occupational therapists are fully equipped with the skill set to help resolve this societal need but it begs the need further research and publishing to occur. If there was more evidence based research available, more children could potentially qualify for OT services. There would also be the possibility of more funding to become available for social skills programs but we must first

4 SOCIAL SKILLS AND CHILDREN WITH ASD Ingram 4 be able to prove our effectiveness as a profession. As anyone who has worked with children with ASD would know, each and every one of them is different. This makes declaring one single intervention an absolute best almost impossible, rather an individualized combination of theories to create treatment may better suit this population. The current description of Autism Spectrum Disorders for diagnosis is detailed in DSM- 5. According to the DSM-5, the individual must meet certain number of the following criteria: a. Persistent deficits in social communication and social interaction across multiple contexts b. Restricted, repetitive patterns of behavior, interests or activities. c. Symptoms present in early development period d. Symptoms cause significant impairment in social, occupational and other important areas of current functioning e. These disturbances are not better explained by intellectual disability. The above criteria makes it very evident that children with ASD could greatly benefit from occupational therapy services to increase independence and overall functioning in the community by increasing social skills. This review searched scholarly journals for peer reviewed articles that had at minimum fair evidence for the effectiveness of that specific social skill intervention. Throughout the literature review, it was determined that the definition of several key terms varied from one article to the next. The term social skills was found in all articles but referred to many different specific mannerisms including verbal communication, eye contact, relationship development, body language, etc. Also the diagnostic criteria for autism changed from the time DSM-IV was published to the DSM-V criteria which took place over the span of the research included in this review.

5 SOCIAL SKILLS AND CHILDREN WITH ASD Ingram 5 Methods The databases that were searched for this review included: EBSCO, Medline, CINAHL, psycharticles. Articles were included if they met the following criteria: published between , research study, intervention appropriate for occupational therapy, clear outcome measures, clear objective, and findings were reported. Articles were excluded from this study if they did not meet the inclusion criteria or showed no statistical relevance. Research was conducted by a master level OT student. The search terms used to find articles included: social skills, autism, autism spectrum disorder, occupational therapy, social skills training, social skills group, children, youth, adolescents. The procedures for identification and collection of articles: articles were downloaded from online database and saved to computer hard-drive for review. Quality control was insured by only including peer reviewed articles in this search. Results There were 7 studies included in this systematic review. The characteristics of these studies are shown in the table below. The level of evidence for the included studies ranged from level I to Level IV and were performed by a variety of professionals. Due to the fact that there is limited published research by the occupational therapy community on this topic, this review also included interventions published by other disciplines but that were still appropriate for occupational therapy treatment. Social Skills Groups 6 of the 7 studies included in this review involved a variation of social skills groups for different age ranges. Each of these groups contained different components such as snack time, discussion, direct teaching, role play, sensory modulation, etc. While all of the groups were a different format and targeted different social skills, all of them yielded positive data suggesting

6 SOCIAL SKILLS AND CHILDREN WITH ASD Ingram 6 social skills groups are an effective intervention method for increasing social skills in children with autism. Again, because children with ASD are all so different, small social skills groups can easily be manipulated to fit the child s needs. A therapist could change components of the group to make treatment individualized and effective for each child. Since these groups are all so different, it would be difficult to create a randomized control trial with one exact protocol to further prove evidence. The most common source of evidence seems to come in the form of anecdotal evidence from parents and teachers involved with these children. While this is not the strongest form of scientific evidence, it is relevant to the quality of life that therapists can improve as a result of skilled design of treatment.

7 SOCIAL SKILLS AND CHILDREN WITH ASD Ingram 7 Evidence Table Topic: Summary of Evidence for Occupational Therapy Interventions for Increasing Social Skills in Children with ASD Author/ Level/Design/ Intervention and Year Study Objectives Participants Outcome Measures Results Study Limitations Contugno, 2009 to describe a group treatment model for children with ASD and to present data on the effectiveness of a multidimensional structure of a social skill training program. Level III Non-Randomized Before After Design N= 28 (children, youth) Treatment group, n= 18 (ASD) Control group, n= 10 Intervention: Treatment group was stage-based, group focused curriculum. Groups were formed based on age and developmental level according to the 5 stages designated in the article. Each group included an introductory session, group task, and snack/discussion time. Control group did not meet. Setting: not specified Frequency: 1 hr/wk for 30 wks Delivered by: clinician with expertise in children with ASD Outcome Measures: Collected pre and post intervention for both groups Results from the SCDS indicated significant improvement for children in the treatment group in areas of stress management, attention, and flexibility as reported by parents of participants. The WMS which was completed by teachers also indicated positive results for improvements in teacher preferred social behavior, peer preferred social behavior and school adjustment behavior. Setting not specified Data collection based off parent and teacher report, possibility of human error Small sample size Control group contained typical children of similar age but not children with ASD Ages: 6-11 y.o. Walker-McConnell Scale of Social Competence and Social Adjustment (WMS) MGH YouthCare Social Competency/Social Skill Developmental Scale (SCDS).

8 SOCIAL SKILLS AND CHILDREN WITH ASD Ingram 8 Author/ Level/Design/ Intervention and Year Study Objectives Participants Outcome Measures Results Study Limitations DeRosier, Swick, Davis, McMillen, Matthews, 2011 To test the effectiveness of a new intervention, Social Skills Group Intervention- High Functioning Autism, in improving social behaviors such as awareness, communication, and mannerisms in children with HFA disorders. Level I Randomized Control Trial N= 55 (children, youth) Treatment group, n= 27 Intervention: TX group participated in Social Skills Group Intervention-High Functioning Autism (S.S. GRIN-HFA) with didactic instruction and active participation. Parents were incorporated in sessions. CO group participated in in S.S. GRIN-HFA original protocol. Parents were not incorporated in sessions. Setting: Private practice Frequency: TX- 60 mins/wk for 15 weeks. CO- 60 mins/wk for 10 weeks. Delivered by: program developers Results indicated moderate effect size for improvements in areas of awareness, motivation, and mannerisms. Parents of children in the TX group reported improvements in self efficacy while parents of children in the CO group reported declines in self efficacy as revealed in data from SRS and ALQ. Small sample size Data based on parent/child report Demographics not diverse Control and Treatment groups received 2 different versions of same program Control Group, n=28 Ages: 8-12 y.o. Outcome Measures: Data collected pre and post intervention Social Responsiveness Scale (SRS) Achieved Learning Questionnaire (ALQ) Social Dissatisfaction Questionnaire. Significant improvement in all subscales of SRS were reported by parents for TX group including social awareness, motivation for social interaction, and social communication skills. Parents involved in treatment group but not control group

9 SOCIAL SKILLS AND CHILDREN WITH ASD Ingram 9 Author/ Level/Design/ Intervention and Year Study Objectives Participants Outcome Measures Results Study Limitations Gutman, Raphael, Ceder, Khan, Timp, & Salvant, 2010 To assess the effect of a motor-based social skill intervention (role-play, sensory activities, etc) for 2 participants with high functioning autism. Level IV Single Subject Design N= 2 (youth) Intervention: 2 students participated in after school program. Weekly session sequence: sensory warm up activity, participation in activities to link motor behavior with cognitive intent and emotional understanding, role play, and last cool down sensory activity. Setting: school and surrounding community environment. Results indicated significant improvements for using facial expressions and body language to convey emotions to others. It was also indicated that participants improved abilities to recognize specific motor behaviors that indicated emotions of others. Standardized assessments not used Test-retest reliability not reported Small sample size TX= 2 Frequency: 1 hr/wk for 7 wks. Delivered by: ABA Therapy Students These improvements were maintained through 3 month follow up. Lack of follow up to report maintenance of new skills No control Group Utilized Outcome Measures: Age: 15 y.o. Data collected over 2 wk period prior to intervention, during the intervention period and then 3 months post intervention through observation of behavior in a variety of social environments. Gutman, Raphael- Greenfield, & Salvant, 2012 to assess the effectiveness of an occupational therapy roleplaying intervention on children with Asperger s Level IV Single Subject Intervention: Treatment group included after school program at specialized high school. Each session consisted of warm up (game), educational component, and role play exercises. Role play progressed Results from all three participants indicate significant effect size for increased and sustained targeted behaviors after Small sample size Effect size not reported

10 SOCIAL SKILLS AND CHILDREN WITH ASD Ingram 10 Author/ Level/Design/ Intervention and Year Study Objectives Participants Outcome Measures Results Study Limitations Syndrome. Design N= 3 (children) from simulated social situations to real life situations. Setting: Specialized high school and community settings intervention was introduced. No follow up completed after 1 month post intervention Treatment group, n= 3 Frequency: 1 hr/wk for 6 weeks Delivered by: Master Program Occupational Therapy Students Standardized assessments not used No control group Outcome Measures: Protocol was vague Ages: y.o. (2 males, 1 female) Data was collected at baseline, during intervention, and 1 month post intervention through 20 min observation sessions in which principal investigators recorded targeted behaviors. Demographics not very diverse Kroeger, Schultz, & Newsom, 2007 to investigate the effectiveness of group delivered social skills interventions for young children with autism. Level III Non-Randomized Before-After Design Intervention: TX1 was the direct teaching format and TX 2 was a play activities group format. Sessions for both treatment groups included a beginning hello circle time and ended with goodbye circle time. During the middle part of the sessions TX1 participants watched video models of socialization then engaged in free play. Results indicated increase in pro-social behaviors in both groups but a higher increase in the direct teaching group. Significant improvements were found in areas including Setting not specified Groups not randomized Only anecdotal reports of improvement from parents to

11 SOCIAL SKILLS AND CHILDREN WITH ASD Ingram 11 Author/ Level/Design/ Intervention and Year Study Objectives Participants Outcome Measures Results Study Limitations N= 25 (children) Treatment group n= 27, 2 dropouts (TX1=13, TX2=12) Ages: 4-6 y.o. TX2 included free activities only during the middle part of the session. Setting: not specified Frequency: 1hr/ 3 times per week for 4 weeks. Delivered by: Supervised by First author, facilitated by graduate and undergraduate psych students initiating behaviors, responding behaviors, and interacting behaviors. support claims of increased verbal communication Study performed over short period of time Outcome Measures: Data was collected from video recordings of the first and last group sessions in which children participated in 30 mins of unstructured play. Social Interaction Observation code Owens, Granader, Humphrey, &Baron- Cohen, 2008 To assess the effectiveness of Lego therapy and Social Use of Language Programme as interventions for social skill development in children with High Functioning Autism or Level II Non-Randomized Control Trial Intervention: TX 1- Groups of 2-3 children participated in collaborative lego play where each child had a role to complete project. Results revealed increases in socialization and decreases in maladaptive bx for both treatment groups. Small sample size Large # dropouts TX2- Children participated in group GARS results revealed

12 SOCIAL SKILLS AND CHILDREN WITH ASD Ingram 12 Author/ Level/Design/ Intervention and Year Study Objectives Participants Outcome Measures Results Study Limitations Asperger Syndrome. N= 31 (children) featuring Social Use of Language programme that included story, adult model of behavior and then practice through game play. decreases in autism specific social difficulties for the LEGO group only. Control group was not randomized Treatment group 1, n= 16 Setting: Not specified Frequency: 1 hr/wk for 18 weeks No significant changes in CO group. No follow up completed Treatment group 2, n= 15 Delivered by: First author and 1-2 undergrad volunteers Statistical significance was limited Control group, n=16 Ages: 6-11 y.o. Outcome Measures: Data measured before and immediately after intervention Setting not specified Vineland Adaptive Behavior Scale The Gilliam Autism Rating Scale (GARS) Parent rating scale. Scattone, 2008 the purpose of this study was to determine if combining Social Stories with video modeling would enhance conversation skills in a child with autism. Level IV Single Subject Design Intervention: Treatment involved 3 personalized social stories using the Gray s social story format. These stories focused on behaviors including eye contact, smiling and conversation initiation. The stories were recorded on video and printed in booklets that were Results indicate increases in specific social behaviors including eye contact, smiling, and initiation in conversation. The largest increase was evident for eye contact. 1 participant Inclusion/exclusion criteria not specified

13 SOCIAL SKILLS AND CHILDREN WITH ASD Ingram 13 Author/ Level/Design/ Intervention and Year Study Objectives Participants Outcome Measures Results Study Limitations N= 1 (children) Treatment group, n=1 reviewed in clinic and at home with parent. Setting: medical center. Frequency: Delivered by: licensed psychologist Outcome Measures: Not reported if participant was randomly selected Procedure method vaguely described Age: 9 y.o. Data was collected at baseline and post intervention through observation probes in which the author recorded target behaviors for intervals of 10 secs then calculated percentage of intervals in which targeted behaviors occurred. Note. [ TX= treatment; CO=control; y.o.= years old; wk= week; hr=hour; ASD= Autism Spectrum Disorder; bx=behavior]

14 SOCIAL SKILLS AND CHILDREN WITH ASD Ingram 14 Conclusion Based on the results of the articles included in this research, social skills groups proved to be effective for increasing specific socials skills in a variety of groups of children. With that said, it warrants the need for more research. If more clinics began to record data based on already existing social groups then we would have more evidence that this is an effective form of treatment that should be reimbursed by insurance companies. With the current lack of actual research published on the topic it is hard to prove to patients and their families as well as funding sources that this is a skilled treatment worthy of reimbursement. More research should be completed to narrow the specific components of social skills groups that are more effective. There are so many options but what are the better options for these children? The strengths of this study include positive parent report that indicated improvement at home for these children which means skills are being carried over from the clinic to home/school. This research also supports that treatment for ASD cannot be 1 set regime for therapy but rather it needs to be customized to fit the needs of this specific population. That is where the skilled therapist part of the process becomes key. Limitations of this review include limited demographics, various ages, various targeted social skills and very small sample sizes. It was difficult to find relevant research related to one specific age group that targeted the same social skills. Implications for Occupational Therapy Practice More research needs to be completed to determine effective components of social skills groups. Research needs to be published so that OT is recognized as a skilled therapy for treating ASD.

15 SOCIAL SKILLS AND CHILDREN WITH ASD Ingram 15 We need to advocate for our clients with ASD to get the accommodations and funding needed to help them be successful.

16 SOCIAL SKILLS AND CHILDREN WITH ASD Ingram 16 References Autism spectrum disorders- data & statistics. (2013, December 26). Retrieved from speaks Cotugno, A. J. (2009). Social competence and social skills training and intervention for children with autism spectrum disorders. Journal of Autism & Developmental Disorders, 39, doi: /s DeRosier, M. E., Swick, D. C., Davis, N., McMillen, J., & Matthews, R. (2011). The efficacy of a social skills group intervention for improving social behaviors in children with high functioning autism spectrum disorders. Journal of Autism & Developmental Disorders, 41, doi: /s Dsm-5 diagnostic criteria. (2014). Retrieved from Gutman, S., Raphael, E., Ceder, L., Khan, A., Timp, K., & Salvant, S. (2010). The effect of a motor-based, social skills intervention for adolescents with high-functioning autism: two single-subject design cases. Occupational Therapy International, 17, doi: Gutman, S. A., Raphael-Greenfield, E. I., & Salvant, S. (2012). The effect of an occupational therapy roleplaying intervention on the social skills of adolescents with asperger's syndrome: a pilot study. Occupational Therapy in Mental Health, 28, doi: / x Kroeger, K. A., Schultz, J. R., & Newsom, C. (2007). A comparison of two group-delivered social skills programs for young children with autism. Journal of Autism & Developmental Disorders, 37, doi: /s x

17 SOCIAL SKILLS AND CHILDREN WITH ASD Ingram 17 Owens, G., Granader, Y., Humphrey, A., & Baron-Cohen, S. (2008). LEGO therapy and the social use of language programme: an evaluation of two social skills interventions for children with high functioning autism and asperger syndrome. Journal of Autism & Developmental Disorders, 38, doi: /s Scattone, D. (2008). Enhancing the conversation skills of a boy with asperger s disorder through social stories and video modeling. Journal of Autism & Developmental Disorders, 38, doi: /s