Social Skills Groups for Asperger’s Disorder and Pervasive Developmental Disorder Not Otherwise Specified

| January 8, 2008 | 0 Comments

by Jacqueline Countryman, MD

Dr. Countryman is from the Department of Psychiatry, Boonshoft School of Medicine, Wright State University, Dayton, Ohio; Dr. Gillig is Professor of Psychiatry, Department of Psychiatry, School of Medicine, Wright State University, Dayton, Ohio.

Editor Note

All cases presented in the series “Psychotherapy Rounds” are composites constructed to illustrate teaching and learning points, and are not meant to represent actual persons in treatment.

Key Words

pervasive developmental disorder, Asperger’s disorder, social skills group

Abstract

Pervasive developmental disorders (PDD) including Asperger’s disorder are relatively rare conditions that can be very disabling for individuals affected. This article focuses on social skills therapy, looking at research that has been completed in a group therapy format and then using composite case examples to review basic techniques that have been used to teach social skills to children with a diagnosis of PDD.

Introduction

Pervasive developmental disorders are biologically based brain disorders characterized by impairment in communication and social interactions skills and restricted repetitive and stereotyped patterns of behavior beginning in early childhood. Asperger’s disorder is a type of pervasive developmental disorder with two major areas of impairment: impairment in social interaction and impairment related to restricted repetitive and stereotyped patterns of behavior, interests, and activities (Table 1).[1]

Asperger’s disorder differs from autistic disorder in that with Asperger’s disorder there is no clinically significant general delay in language. Pervasive developmental disorder not otherwise specified (PDD NOS) is a diagnosis given when there is a severe and pervasive impairment in the development of reciprocal social interaction or verbal and nonverbal communication skills, or when stereotyped behavior, interests, and activities are present, but the criteria are not met for a specific pervasive developmental disorder.

Pervasive developmental disorders (PDDs) were thought to be relatively uncommon, with a diagnosis in approximately 2 per 10,000 children.[2] Current estimates indicate that between 2 and 6 of every 1,000 children born may have an autism spectrum disorder.[3] PDD are seen in all socioeconomic groups and is more common in males than females by a ratio of 4:1.

The etiology and pathogenesis of PDDs are not known. The main theories are that either a genetic or very early developmental disruption in brain functioning is causative, with modification of symptoms by social and environmental influences.[4]

At the present time, there is only one medication, risperidone, approved for the treatment of autism (specifically for irritability). Medication treatment for Asperger’s disorder is symptom-specific.
Presently, evidence points to the importance of appropriate educational interventions to foster the acquisition of basic social, communicative, and cognitive skills. Behavioral approaches, educational programming, and speech therapy are first lines of treatment. Higher functioning individuals can benefit from cognitive behavioral therapy, social skills groups, or psychotherapy. One of the most important items of the treatment strategy involves the need to improve communication and social competence. There is a tendency as children age for negativism and depression as the individual becomes more aware of social inadequacies and failures in interpersonal relationships.

General Principles of Therapy for Asperger’s Disorder and PDD-NOS

In general, a group setting is most effective to teach social skills as group members can learn from each other, but individual therapy can be effective.

Initially, learning how to interpret others’ social behaviors should be taught and practiced in a rote fashion. Making eye contact, tone of voice, body language, and facial and hand gestures are good starting points. Practicing these skills within the group or individual session is very important.

When working with children, having parents involved to practice new skills outside of therapy is essential to success. Studies have shown with social skills groups that often the skills taught in the group do not generalize to real world settings. Involving parents in the group process and using repetition can possibly improve success with generalization.

More advance topics, such as humor, figurative language, and sarcasm, should be taught as the individuals are felt developmentally ready for such topics. Again, teaching these skills in a verbally explicit manner and practicing is necessary. Using worksheets geared toward the developmental age of the individual is appropriate to help in the teaching process. Several workbooks are available with social skills exercises that can be used. Preplanned exercises can be used, though flexibility is needed in the group to address skill deficits noted.

Role playing within the therapy setting should be exercised and gradually tried outside the therapy sessions. Suggestions on role playing are included in Table 2. Parents and other close contacts with the individual should be included to reinforce the skills taught. Techniques that can help individuals become more self aware of their reactions and behavior are videotaping, tape-recording, or practicing in front of a mirror.

Social Skills Groups

Social skills group therapy is a treatment that has evidence supporting its use. The goal of social skills group therapy is to better prepare the individual to cope with social and interpersonal expectations. Individuals with PDD often are repetitious in their speech and over-focused on certain topics rather than on a dialogue.

Echolalia, pronoun reversal, and neologisms are common in the speech of those affected with PDD. Other common speech differences are concrete and poorly constructed grammar, atypical tone, pitch, and prosody.

Several examples of the use of social skills groups for children with PDD have been described in the literature. Marriage, et al., designed a social skills group for boys with Asperger’s disorder or syndrome.[5] They designed a syllabus to target specific social skills with a progression from simpler tasks to more complex tasks. Greeting a new person and making eye contact were included in simpler tasks, and deciding when a person has talked enough about a subject was included in more complex tasks. To improve having the tasks generalize to other situations, the group was moved from four different sites and staff members were rotated each week among three different persons. Methods used included role playing, video-taping, prompt cards, viewing of movies, games, and homework tasks. The group met one time per week for two hours, for 14 weeks.

The study found that progress was variable and much slower than the authors anticipated. Videotaping had questionable utility due to participants not being able to extract much information on social skills from the video. Participants interacted more with the group therapists than with group members and discipline was an issue as the group members became more familiar with each other. The pre- and post-ratings showed negligible differences. Parents, however, did note improvement in eye contact, verbalizing feelings, initiating contact with others, and being aware of others’ interests.

Nevertheless, the authors concluded that the skills learned over the 14 weeks did not generalize well to home, school, or community settings.

Williams (1989) developed an open social skills group with six children with autistic disorder that ran for four years.[6] This group met weekly for 45 minutes. The goal for the children was to discover more effective means of interacting with other people. Three methods were used to accomplish this goal: Recreational games, role playing exercises, and modeling. Role playing started simply and gradually increased in complexity. Eye contact in social situations was an initial focus. Feeling identification was later introduced and emotions were role-played.

Children practiced holding conversations. Other topics introduced in this group were voice tone, leave taking, dealing with negative emotions or negative acts of others, flexibility, and giving instructions. Group progress was evaluated by a questionnaire looking at 24 social skills items both pre and post group. This questionnaire was completed by a staff member. The results of this study were reported for seven children who completed the pre- and post-questionnaire.

Strong emotions were role played better than subtle ones by the children. All seven children showed improvement in that they made friends with other group members, and the children were more proficient in introducing themselves and starting a conversation. The author concluded that there was a need to develop better techniques to help generalize skills outside of the group setting, because the skills learned in the group did not tend to generalize.

Mesibov (1984) developed a group for 15 individuals with autistic disorder from ages 14 to 35.[7] The group ran 10 to 12 weeks for 60 minutes. Each group was preceded by a 30-minute individual session for each participant. Each session included group discussion, listening, and talking. The participants talked about emotions, starting with happy and sad and then the discussions about emotions became progressively more complicated. Role playing was used to teach specific social skills. Appreciation of humor was introduced at the end of the session.

Verbal feedback from the families was all positive. Improvement in social skills was noted. The authors concluded that role playing was effective and participants were able to improve their understanding of emotions.

Barry, et al., developed an outpatient clinic-based social skills group intervention with four high-functioning, elementary-age children with autism.[8] The group was designed to teach specific social skills, including greeting, conversation, and play skills in a brief eight session therapy format. At the end of each skills training session, the children with autism were observed in play sessions with typical peers.

Results indicated that this social skills group implemented in an outpatient clinic setting was effective in improving greeting and play skills, with less clear improvements noted in conversation skills. In addition, the children reported increased feelings of social support from classmates at school following participation in the group.

Parent reports of greeting, conversation, and play skills outside of the clinic setting indicated significant improvement in greeting skills only. The authors concluded that although the clinic-based intervention led to improvements in social skills, fewer changes were generalized to nonclinic settings.

Solomon, et al., created a 20-week social adjustment group for boys ages 8 to 12 with high-functioning autism, Asperger’s disorder or PDD NOS.[9] The target behaviors were emotion identification, “theory of mind”(i.e., the concept that other people think and one can imagine their points of view, a forerunner of empathy), and problem solving. The curriculum was divided into two 10-week modules. The first module focused on group rules and developing awareness of emotions in oneself and others. The authors started with simple emotions and progressed to more complex emotions, such as pride and guilt. Receptive and expressive body language (facial expressions, body postures, and tone of voice) were taught with modeling and role-playing. The group then moved on to conversation skills. The second 10-week module included topics of friendship and conversational skills, which were reinforced. Problem solving was also taught in this module. Skills were taught and reinforced through the use of visual examples, games, and role playing. A psychoeducational group for parents of the children in the group was included and parents acted as co-teachers. Results indicated that the children improved with respect to identifying emotions, problem solving, and conversational skills. The authors could not predict whether these skills would generalize into other contexts and recommended further research to determine the answer to this question.

In general, research thus far has demonstrated that although social skills can be taught to persons with PDD, and these individuals can display these learned skills in a laboratory/clinic setting, generalization and flexible use of these skills in a natural environment continues to be a challenge.[10]

Case Example

Ben was a 10-year-old boy diagnosed with Asperger’s disorder by his psychiatrist several years previously. He struggled with making friends at school and his parents sought additional treatment due to Ben’s recent reaction to being teased. In Ben’s words, “I have no friends and the kids think I’m weird.” Ben joined a long-term social skills group for children diagnosed with Asperger’s disorder. The first topic covered with any new member in the group was working on making eye contact with others in the group. With subsequent groups, Ben learned and practiced how to start conversations and how to talk and also listen to others. Role-playing was often used within the group. Following is an example of a role playing exercise in which Ben participated:

The situation that was introduced involved “meeting a new child on the playground.” The focus was on how to introduce oneself and initiate a conversation. Prior to the role play, group members practiced skills of greeting someone with a smile and stating their names, making eye contact with the person they are meeting, asking questions of the person they are meeting and letting the person respond, and listening to what the other person says.

Ben (as new child): Hi, my name is Ben.
Peer in group (child on playground): Hi.
Ben: What is your name? (Reminded to make eye contact by group leader)
Peer: Jacob.
Ben: Do you like to play basketball?
Peer: Yes.
Ben: Do you want to play with me?
Peer: OK, do you have a ball?

The participants were praised for their good job and a discussion within in the group was initiated by the group leader on what positive conversation skills were observed by the other group members. Group leaders also can be part of the role play and as group members become comfortable with the premise, they can become the participants as group leaders observe. This technique can be taught to parents so that role playing can be done in the home setting as homework. This will help to reinforce the skills introduced.

Feedback from Ben and his parents one year after attending the group on a regular basis was that progress was slow but for the first time Ben was able to make a friend on the school bus and was reported to be much happier in general.

Practice point: Start with simplistic topics and review often

This case example illustrates that initially the topics may seem simplified, but this simplicity is often necessary so that the therapist can then build initial skills. Often topics are reintroduced when new members enter the therapy group or when the individual being treated needs a refresher on that topic. A regression to old behaviors, such as not making eye contact, is an indicator that a review is needed.

Individuals in treatment can also be taught to monitor their own speech style. Tone of voice, rhythm, naturalness, and volume should all be called to attention and practiced with different settings in mind to increase generalizability. Voice recordings can be very helpful to augment this training.

Skills including topic management, shifting topics, and expanding on a variety of different topics typically of interest to the individual’s peer group are important. Often individuals with Asperger’s disorder will expand on a certain topic to the point of alienating themselves from others. Helping the person with Asperger’s achieve some awareness of this within the group setting is important, so that the person can modulate this behavior.

Case Example, Continued

When a new child named Ryan entered the group, he often would discuss robots with the group members. He would spontaneously bring up this topic in each group and would seem to ignore the body language of several of the group members that they were tired of hearing about Ryan’s robots. At one point, Ben, who had now been in the group for more than one year, told Ryan he was “sick of hearing about the robots,” and “what do robots have to do with what we are talking about?”

Group Leader: Ben, what do you think Ryan could do differently?
Ben: We were talking about his (referring to another group member) day at school, not about robots!
Group Leader: So what could he do instead of talking about the robots?
Ben: He could listen to him and ask him a question about his day.
Group Leader: That is a good suggestion and those are some of the skills we talked about with getting to know others and start a conversation. Why don’t we practice being good listeners today?

At such a point, the group leader can introduce a preplanned exercise of working on listening skills. These skills include looking at the speaker, not interrupting others, asking questions of others, and repeating what the speaker is saying. After these skills are introduced, the group can do a role play paying attention to working on each of these topics. Each group member can be assigned a skill to watch for in the role play and this can prompt a discussion on the importance of each of these skills and what would happen if they didn’t use these skills. At the end of the group the members are sent home with a worksheet describing the skills they worked on during that group so that family members can practice between groups.

Summary

Studies completed in the past with children having Asperger’s disorder or a pervasive developmental disorder have shown that group settings can be effective to improve basic communication skills in the clinic setting; generalization has been difficult to achieve. Nevertheless, the techniques described in this article have had some success in teaching and reinforcing basic communication skills to individuals with deficits in these areas. Improvement in social skills typically is a slow process that takes a team approach that includes the clinician, the patient, and caregivers. The goal of teaching social skills is to improve the quality of life, because clinical experience and research have confirmed that social skills impairment affects optimal functioning in all other areas of life for persons with pervasive developmental disorders including Asperger’s disorder.

References
1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington DC, American Psychiatric Association, 2000.
2. Fombonne E. Epidemiology of autistic disorder and other pervasive developmental disorders. J Clin Psychiatry 2005;66(suppl 10):3–8.
3. Centers for Disease Control and Prevention. Autism Spectrum Disorders Among Children. February 03, 2006. Available at: www.cdc.gov/ncbddd/dd/documents/autism_factsheet020306.pdf. Access date: December 17, 2007.
4. Freitag CM. The genetics of of autistic disorders and its clinical relevance: a review of the literature. Mol Psychiatry 2007;12(1);2–22.
5. Marriage KJ, Gordon V, Brand L. A social skills goup for boys with Asperger’s syndrome. Aust NZ J Psychiatry 1995; 29(1); 58–62.
6. Williams TI. A social skills group for autistic children. J Autism Dev Disord 1989;19;143–55.
7. Mesibov G. Social skills training with verbal autistic Adolescents and adults: A program model. J Autism Dev Disorder 1984;14:395–404.
8. Barry TD, Klinger LG, Lee JM, Pet al. Examining the effectiveness of an outpatient clinic-based social skills group for high-functioning children with autism. J Autism Dev Disorder 2003;33(6):685–701.
9. Solomon M. A social adjustment enhancement intervention for high functioning autism, Asperger’s syndrome, and pervasive developmental disorder NOS. J Autism Dev Disord 2004;34(6):649–68.
10. Williams White S, Keonig K, Scahill L. Social skills development in children with autism spectrum disorders: A review of the intervention research. J Autism Dev Disord 2007 Nov;37(10):1858-68.

Category: Asperger's syndrome, Pervasive development disorder, NOS, Pervasive Developmental Disorders, Psychiatry, Psychology, Psychotherapy Rounds

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