Table of Contents
Approaches to Social Skills Training
Parent-Assisted Social Skills Training
Social Skills Group Training (SSGT)
Recommendations for social skills training
Introduction
Children with autism spectrum disorder (ASD) have a substantial social impairment, which negatively affects their cognitive and language functioning (Hodges et al., 2020). The social challenges are unlikely to resolve if the appropriate interventions are not applied (Park et al., 2022). Placement of autistic children in inclusive places where there are neurotypical peers is increasingly being propelled as the solution to the improvement of social interaction difficulties among autistic children (Latorre-Cosculluela et al., 2022). However, proximity to neurotypical peers alone is not likely to enhance the social functioning of autistic children (Park et al., 2022). Targeted interventions comprising training and supporting autistic children are necessary to prepare them to experience the benefits of interacting with their neurotypical peers.
Social skills training is among the therapeutic approaches that can be applied to teach autistic children the fundamental skills they need to maneuver routine social situations (Park et al., 2022). This paper will explore how social skills training can benefit children with autism based on personal learning. The objective will be achieved by reflecting on independent learning activities, applying the acquired information, and critically evaluating related evidence. Cognizant of the fact that there are multiple approaches to social skills training in the management of ASD, theory and research evidence on the various approaches will be critically analyzed and synthesized to identify, evaluate, and recommend the most appropriate social skills training strategies for autistic children.
Search Strategy
The PEO (population, exposure, outcome) strategy was applied to search for articles that would fulfill the objectives. It helped to maintain focus during the search process. The PEO elements used are presented in table 1 below:
Table 1: PEO Elements of the Research Topic
| PEO Elements | |
| Population | Children with autism spectrum disorder |
| Exposure | Occupational therapy interventions |
| Outcome | Social skills training |
MEDLINE, EMBASE, and Cochrane Library databases were searched to identify articles that would fulfill the objectives. Some articles were identified from the reference lists of the relevant articles retrieved from the search. The keywords, search terms, and search strategy applied to identify articles relevant to the research topic are shown in table 2 below.
Table 3: Search Strategy to Identify Relevant Articles to Address the Research Topic
| Keywords | Search terms | Search Strategy |
| Children with autism spectrum disorder | Children with autism spectrum disorder; children with ASD, autistic children | “Children with autism spectrum disorder” OR “children with ASD” OR “autistic children” |
| Occupational therapy interventions | Occupational therapy interventions; social skills interventions; peer mentoring; social skill group; video modelling; social stories | “Occupational therapy interventions” OR “social skills interventions” OR “peer mentoring” OR “social skill group” OR “video modeling” OR “social stories” |
| Social skills training | Social skills training; social behavior; SST, SSGT | “Social skills training” OR “social behavior” OR “SST” OR “SSGT.” |
Only articles published in the past five years were included in this paper to ensure that only recent evidence is analyzed. The inclusion criteria were a population comprising children aged 0-18 years, assessing an occupational therapy intervention and measuring a social skills training aspect. The exclusion criteria were articles not published in English, opinion articles, and non-peer reviewed studies.
The selection of articles was balanced to ensure that diverse occupational therapy interventions were covered. The selected articles include Park et al. (2022) addressing parent-associated social skills training; Zhang et al. (2022) tackling peer-mediated intervention; Dekker et al. (2018) investigating social skills group training; Beaumont et al. (2021) focusing on video modeling; and Hanrahan et al. (2020) assessing social stories. Information from the articles was synthesized to obtain advanced knowledge of how social skills training can benefit autistic children. Additionally, it was critically analyzed to evaluate various research-based interventions including parents-associated social skills training, peer-mediated intervention, social skills group training, video modeling and social stories.
Considering the evidence-based from the studies, recommendations for occupational therapy practice to administer social skills training to children with autism are presented. The critical analyses of the approaches are presented reflexively considering the population in the practice setting – the autistic children. Based on the strengths of evidence presented, interventions that can be adopted in the practice setting to improve social skills training to children are recommended.
Approaches to Social Skills Training
The strategies applied in the delivery of social skills training to children with ASD have been increasing in the past two decades. Examples of the strategies include learning through play activities, modeling and prompting, and behavioral practice and rehearsal. According to Moody and Laugeson (2020), social skills can be reinforced by modeling them and having autistic children view and practice the modeled skills.
Some approaches leverage technology to deliver social skills training considering the increased ease of access to smartphones and the internet (Soares et al., 2021). Strategies such as video modeling are thus pivotal especially when access to a therapist is a challenge. Nevertheless, most interventions remain face-to-face due to challenges of doubts by practitioners on the translation of technological interventions into real social interactions (Soares et al., 2021). On the other hand, the liking of technology by young ASD patients has resulted in proposals to integrate it in social skills training programs (Valencia et al., 2019). Therefore, there is a need to analyze both face-to-face and technological interventions for social skills training targeting children with ASD.
Parent-Assisted Social Skills Training
Active parent training can be incorporated into SST as a social intervention to increase effectiveness. Involving parents is associated with more successful learning opportunities, better therapy outcomes, and long-term gains from treatment (Chaidi & Drigas, 2020). Parent-assisted social skills training (PASST) is ideal for young children since parents can directly teach them and supervise their play activities while observing developmental appropriateness. PASST is a modification of PEERS®) in which social skills are customized for appropriateness among young children, parents are more greatly involved, and play-based activities are leveraged to deliver behavioral strategies (Park et al., 2022).
Park et al. (2022) conducted a two-part study to assess the outcomes of treating young children with ASD by applying parent-assisted social skills training. Part I of the study was an open trial in which five autistic children received 16 once-weekly sessions of the PEERS® for Preschoolers intervention and were assessed for changes in social skills using multiple measurement tools rated by their parents. They found that the intervention improved several outcomes including social cognition, motivation, and responsiveness, and decreased repetitive interests and problem behaviors.
Although the statistical power of trial I was low due to the small sample size (CASP, 2020), the differences in pre- and post-intervention measures were clinically significant (Park et al., 2022). For example, social skills scores improved by an average of 5.4 standard score points, which is clinically substantial. According to Serdar et al. (2021), attaining a sample size that would give the statistical power to detect significant changes in outcomes when the clinical issue is rare would substantially delay the completion of the study and increase the cost of the project. A small sample size can be justified if the number of individuals that can participate in a study is very small (Lakens, 2022). ASD is a rare disease; hence, it can be sometimes difficult to recruit enough individuals to reach the sample size estimated using statistical formulae or software. Therefore, the findings of research studies should not be dismissed for lack of statistical power until the pertinent clinical considerations are made.
In part 2 of the study by Park et al. (2022), 11 of the 19 autistic children recruited completed the treatment and assessments. The treatment comprised a modification of the PEERS® for Preschoolers intervention applied in trial I to include the parents’ suggestions and consensus by the treatment team. Comparison of pre-test and post-test social skills measures revealed statistically significant changes in restricted interests and repetitive behaviors (p = 0.015, d = 0.879), social motivation (p = 0.007, d = 1.03), and social cognition (p = 0.003, d = 1.20) (Park et al., 2022).
The study design used by Park et al. (2022) is quasi-experiment since it neither entails randomization nor controlling, which are the key attributes of randomized controlled trials. The credibility of their findings may have been reduced by internal validity threats (Maciejewski, 2020). However, applying randomization and controls is difficult when researching rare conditions such as ASD. Thus, the study that Park et al. (2022) designed is optimal considering the challenges in researching ASD.
Peer-mediated intervention
Peer-mediated intervention (PMI) or peer mentoring entails preparing typical children to help their autistic counterparts to actively engage in social interactions (Zhang et al., 2022). It is considered an evidence-based approach to address challenges in social interactions and communication (Kent et al., 2018). It is implemented in naturalistic environments for the involved children to understand the rhythm and nature of the interaction (Kent et al., 2018). However, therapists have to sometimes engineer environments for predictability and consistency when applying PMI. A school environment is considered appropriate for the implementation of the PMI (Zhang et al., 2022).
Zhang et al. (2022) conducted a randomized controlled trial (RCT) to test the effectiveness of PMI among autistic children aged 4-12 years. They applied the stratified random sampling method to assign 55 children to either the experimental group (n = 29) that received PMI or the control group (n = 26) that received behavioral therapy based on applied behavior analysis (ABA). They measured the social performance of the children before and after the intervention to determine if the interventions imparted any significant changes (Zhang et al., 2022). The researchers found that PMI increased social motivation, reduced undesirable behavior patterns, enhanced social communication, and improved overall social skills. The Social Responsiveness Scale (SRC) score decreased significantly in the intervention group compared to the control group (t= −3.918, P = 0.0001), d = −1.043).
The RCT by Zhang et al. (2022) was validly designed since it addressed a clearly focused research question: “Among children with ASD (population), what is the effectiveness of PMI (intervention) compared to behavioral therapy (comparison) on social skills (outcome)? Secondly, it applied stratified randomization since the envelop method with random allocation sequence was used to allocate the children to either the PMI or EIBI group, which sufficiently eliminated systematic bias. The RCT was methodologically sound because blinding was optimal (CASP, 2020). Only therapists that assessed the participants, data entry assistants, and data analysts could be blinded considering the nature of the intervention. Additionally, there were no significant differences between the demographic characteristics and baseline SRS scores between the PMI and EIBI groups, which shows that the study groups were similar at the start of the RCT (CASP, 2020). Besides, the results of the study were comprehensively presented with confidence intervals and p-values reported. The precision and significance of the statistical results could be assessed. Therefore, the evidence provided by Zhang et al. (2022) can be considered level 2 and leveraged to recommend practice changes.
Social Skills Group Training (SSGT)
SSGT is an intervention in which behavioral modification principles and socially instructive techniques are applied in group settings to improve social communication skills (Dekker et al., 2019). Autistic children are the main beneficiaries of SSGT since it is used to clinically manage them (Jonsson et al., 2019). The content and structure of SSGT can be customized to address the specific needs of the targeted children. Optimizing the delivery of SSGT through strategies such as lengthening the sessions can increase its benefits (Jonsson et al., 2019). Parent-teacher involvement (PTI) is also a viable optimization strategy (Dekker et al., 2018).
Dekker et al. (2018) conducted a randomized clinical trial among autistic children aged 9-13 years to assess the effectiveness of SSGT on social skills such as socialization, cooperation, assertion, and self-control. Their sample comprised 122 high-functioning autistic children randomized into three arms namely the SSGT group (n = 47), the SSGT with parent involvement group (n = 51), and the care-as-usual group (n = 24). They observed that 15 sessions of both the two SSGT approaches significantly improved socialization (SST: Cohen’s d = 0.39; SST–PTI: d=0.43) and cooperation (SST: d=0.43; SST–PTI: d=0.45) (Dekker et al., 2018). Although the PTI did not result in significant additional effects, it intensified treatment.
The main strength of the RCT by Dekker et al. (2018) is that participants were followed up post-treatment to ascertain the sustainability of the treatment effects. Secondly, the sample size was considerably large (n = 122) since ASD is a relatively rare condition. Moreover, the stratified random sampling employing a computer-generated allocation algorithm ensured balanced assignment to treatment groups and concealed the allocation sequence. The use of the hierarchical linear modeling to analyze the effect of the interventions on each of the outcomes facilitated accounting for measurement occasion, condition, and interaction. Among the weaknesses of the study is the failure to blind parents and teachers during post-treatment measures, hence an increase in the risk of biased measurement (CASP, 2020). Secondly, the imprecision of most of the results coupled with small effects makes it challenging to confidently apply the findings albeit positive in practice settings.
Video Modelling
Video modelling is one of the technological innovations that have been developed to address the geographical and financial barriers that families face when seeking services for children with ASD (Beaumont et al., 2021). It leverages the fact that ASD children are substantially drawn toward new technologies such as personal computers, smartphones, and tablets. Social skills programs can be administered using computer games in which video modeling teaches competencies such as communication, independence, and play activities (Frolli et al., 2020). Examples of video modeling strategies that can be applied in SST include peer video modeling and self-video modeling.
Beaumont et al. (2021) conducted a randomized controlled trial to test the effectiveness of a parent-supported video gaming-based social skills program called Secret Agent Society (SAS). The intervention comprised partaking SAS for 10 weeks. The control was a 10-week caregiver-supported cognitive skills training game (CIA). The sample size was 70; each arm had 35 participants. The subjects were autistic children aged 7-12 years. The researchers measured teacher-rated social skills and parent-rated social skills and problem behaviors before and after the interventions. The SAS group improved better than the CIA group in all the measures.
Beaumont et al. (2021) conducted their RCT to address the limitations of a previous RCT by Sofronoff et al. (2015) that had observed large effect sizes when a videogame-based social skills program is used to improve the social skills of children with ASD. The limitations they addressed include the absence of teacher report data and the lack of controlling. Therefore, their RCT was more pragmatic (CASP, 2020). The findings that video modelling improves social skills can thus be considered credible evidence since they were reported in a pilot RCT and confirmed in a more pragmatic extension of the RCT.
Social Stories
Social stories are used in the educational setting to help children with ASD improve their social skills and communication across various contexts (Hanrahan et al., 2020). They are promising interventions in addressing maladaptive behaviors among children with autism (Aldabas, 2019). Teachers consider them acceptable, hence they are likely to support their implementation. The feasibility of social stories can be enhanced using technology to address the barriers that limit their application (Hanrahan et al., 2020).
Hanrahan et al. (2020) conducted a pilot RCT to address the lack of methodological rigor in the delivery of social stories. It entailed administering a digital social stories intervention to nine autistic children and comparing their outcomes to six autistic children that concurrently received a simple poem of comparable length. They observed that the intervention group scored significantly higher in the goal-based measure compared to the control group in weeks three, four, five, and six (Hanrahan et al., 2020). However, the difference in effect was not significant after one or two weeks of intervention.
Hanrahan et al. (2020) avoided selection bias by using the online random number generator to allocate the participants into the intervention and control groups. The class teachers involved in the study were blinded to the interventions the participants were receiving to prevent observer bias (CASP, 2020). However, the strength of the study to provide level 2 evidence was limited by the low power considering the small sample size. Since the study was a pilot, a more pragmatic study is expected to increase the reliability of the findings.
Recommendations for social skills training
Social skills training delivered through the various approaches emerges as a promising intervention in the management of children with ASD. Both face-to-face and technology-based approaches to social skills training can be successfully used in practice. Evidence from critical analysis of literature regarding social skills training approaches revealed that some strategies are supported by strong evidence and others require additional research.
Peer-mediated interventions can be applied in occupational therapy practice to improve social skills in autistic children since their effectiveness is supported by a pragmatic RCT. The evidence on SSGT and video modeling is also strong since the RCTs supporting them are well-designed and comprehensive. Parents-associated social skills training can be applied to improve the management of children with ASD. Since it was a modification of the Program for the Education and Enrichment of Relational Skills (PEERS®, which is commonly applied in occupational therapy, other modifications should also be explored to diversify effective interventions for children with ASD. PEERS® is an evidence-based SST program for the management of ASD among adolescents and young adults (Park et al., 2022). Similarly, the evidence from the pilot study on social stories ought to be supplemented with findings of a larger RCT for the intervention to be considered evidence-based.
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