Designing Social Skills Interventions for Students With Asperger Syndrome
By Gena P. Barnhill, NCSP

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Asperger syndrome (AS) is a developmental disability that is defined by impairments in social relationships and verbal and nonverbal communication and by restrictive, repetitive patterns of behavior, interests and activities. Although controversy still exists among professionals and researchers as to whether high-functioning autism and AS are the same or two different conditions, AS is frequently considered to be part of the spectrum of autism disorders (Attwood, 1998; Tantam, 1991; Wing, 1998, 2000). Attwood contends that the major differences between AS and autism appear to be evidenced in symptom severity, with AS considered to be on the higher end of the autism spectrum. Despite the view of AS as a milder form of autism, it is "clearly, still a highly disabling social condition" (Tantam, 1991, p. 178). Furthermore, AS may cause the greatest disability in adolescence and young adulthood when social relationships are the key to almost every achievement (Tantam, 1991).

Although Hans Asperger of Austria first recognized this syndrome in 1944, the American Psychiatric Association did not recognize AS as a specific pervasive developmental disability until 1994. The incidence of AS is still uncertain, with estimates of 8.4 per 10,000 in a total population study of preschool children (Chakrabarti & Fombonne, 2001) and 48 per 10,000 in a total population study of seven-year-old children (Kadesjo, Gillberg, & Hagberg, 1999), to upwards of 71 per 10,000 children ages 7-16 years when considering suspected and possible cases (Ehlers & Gillberg, 1993). As awareness of this condition increases, many families are requesting appropriate educational services to meet their children's social, communication, academic and behavioral needs. Professionals are also now realizing that AS is not a rare disability and that more information regarding interventions in the classroom is desperately needed.

Social Skills Deficits and Need for Intervention

Individuals with AS lack appropriate social skills, have a limited ability to take part in reciprocal conversation and do not seem to understand many of the unwritten rules of communication and social conduct that their peers seem to naturally learn through observation. These characteristics significantly impact their ability to demonstrate social and emotional competence, which according to Elias et al. (1997) encompasses self-awareness, control of impulsivity, working cooperatively and caring about others. According to Attwood, individuals with AS "perceive the world differently from everybody else" (1998, p. 9). Robinson and Trower (1988) argued that social behavior is the most central and important characteristic of human beings. Gresham, Sugai and Horner (2001) contend that the ability to interact successfully with peers and significant adults is one of the most important areas of students' development. Given these statements, persons with AS are at a clear disadvantage in coping with their social world. Furthermore, recent research (Church, Alisanski, & Amanullah, 2000) indicates that social skill deficits remain the greatest challenge for intellectually bright and verbal children with AS. The impact of these deficits can range from not being able to develop or maintain friendships to not being able to keep a job because of lack of understanding of the social work culture.

What can we do to assist these individuals to understand their social environment and to be successful navigating in our complex social world?

We need to address their social and emotional learning by teaching them the skills essential to develop social and emotional competence. This includes social skills training in the following areas: problem-solving, conversational skills, identification of feelings, management of feelings, anger control, dealing with stress and organizational skills. The school psychologist can play a critical role by advocating for these services for students as well as by providing direct social skills instruction to students and by training teachers and families on various social skills strategies such as the use of social stories (Gray, 1994b), Comic Strip Conversations (Gray, 1994a) and social autopsies developed by Richard Lavoie (Bieber, 1994). In addition, directly teaching these students the "hidden curriculum," unwritten rules of conduct and "mind-reading" (Howlin, Baron-Cohen, & Hadwin, 1999) are integral parts of social skills curriculum.

Social Skills Training Groups

Currently, there are little empirical data regarding social skills training (SST) groups for students with AS. The autism spectrum disorder (ASD) research literature contains several empirical studies conducted with children and adults diagnosed with AS and autism (Barnhill, Cook, Tebbenkamp, & Myles, in press; Marriage, Gordon, & Brand, 1995; Mesibov, 1984; Ozonoff & Miller, 1995; Williams, 1989). However, only two of these studies were conducted with school-age participants specifically diagnosed with AS (Barnhill et al., in press; Marriage et al., 1995). Given this dearth of empirical data, the SST research was investigated to determine areas in need of more work to design effective SST groups.

Considerations from research:

Several important considerations for conducting SST groups that are also applicable to students with AS were found in Gresham et al.'s (2001) meta-analysis of SST groups for students with or at risk for high-incidence disabilities. Based on previous narrative reviews, Gresham et al. found that effective SST strategies incorporate modeling, coaching and reinforcement procedures. One of the most persistent weaknesses of the SST literature is its failure to demonstrate sufficient generalization and maintenance of the social skills taught. Therefore, groups that specifically program for generalization and maintenance and teach social skills in natural settings must be designed. Given that social behavior is contextual, any intervention that does not take this into account will encounter major generalization difficulties. Marriage et al. (1995) also found that planning for generalization was crucial when working with pre-adolescents with AS. Although they planned for generalization by changing the staff member filling the role of group leader and varying the room and building in which the instruction was conducted, the skills taught did not generalize well to the school, home and community. This led them to recommend that, in the future, social skills training should be conducted in the natural or school setting, rather than in the clinic setting.

Other areas of consideration when designing effective SST include classification of social skills deficits and the length of training (Gresham et al., 2001). Does the student exhibit acquisition, performance, or fluency deficits? It is essential to assess the type of deficit so that the appropriate intervention can be implemented. For example, acquisition deficits refer to the absence of knowledge for carrying out specific skills under optimal conditions or a failure to discriminate which social skills are appropriate in specific circumstances. Intervention involves directly teaching the social skill through modeling, coaching, role-playing and feedback, and also explaining to the student why the skill is important. The author found that a 17-year-old male with AS was able to increase his eye contact in a SST group after being taught how and why eye contact was important to others (Barnhill et al., in press).

On the other hand, performance deficits represent skills that are in the person's repertoire but are not performed at acceptable levels in given situations. Intervention procedures such as prompting and reinforcement are used to increase performance of a social skill. Moreover, antecedents and consequences are arranged to produce the desired social behavior. However, these strategies alone would not be efficient in remediating an acquisition deficit.

Lastly, fluency skills arise from a lack of exposure to sufficient or skilled models of social behavior, insufficient rehearsal or practice of a skill, or low rates or inconsistent delivery of reinforcement of skilled performances. These students do not need the skill to be retaught, nor do they need opportunities to increase the frequency of its awkward performance. Instead, they need more practice, rehearsal, or differential reinforcement for fluent behavior performance (Gresham et al., 2001). Determining which type of deficit the student is demonstrating is a critical link in designing appropriate intervention strategies.

Based on meta-analysis results, Gresham and colleagues (2001) recommend that social skills training needs to be conducted with more frequency and intensity than it has been conducted in the past. They indicated that 30 hours of instruction over 10-12 weeks is not enough. Although it may not always be possible to adhere to this recommendation due to budget, schedule and various time constraints, the length of time needs to be seriously considered when embarking on designing a SST group, especially given the difficulty individuals with AS have in generalizing skills they learn. Teaching too many skills during SST or teaching one skill for a short period of time may inhibit generalization of the skills taught. In addition, teaching the skills in multiple settings with multiple implementers needs to be considered. Ideally, parents and teachers need to teach and reinforce the same skills.

Pilot SST group:

The author initiated an eight-week pilot SST group (Barnhill et al., in press) targeting nonverbal social skills for eight adolescents with pervasive developmental disorders, including AS. Social skills lessons from Teaching Your Child the Language of Social Success (Duke, Nowicki, & Martin, 1996) were adapted to teach facial expressions and paralanguage (e.g., tone, loudness, intensity of voice). The adolescents met for eight consecutive Saturday afternoons for a total of 3-3.5 hours each session. They first met at a local university classroom for direct social skills instruction, which incorporated modeling, role-playing and reinforcement through feedback, for approximately 45-60 minutes. Following each of these training sessions, they participated in a recreational activity within the community for approximately two to three hours. During the recreational activity they were reminded to be sensitive to the nonverbal communication that others were conveying and were reinforced for appropriate responses to peers' nonverbal expressions. Parents received a summary of the skills taught and suggestions to reinforce these skills at home. After the seventh session, the adolescents participated in a 13-hour sleepover in order to prepare for a sleepover summer camp experience several were planning to attend. For many, this sleepover was the first time they had been asked to spend the night with peers.

Social scripts:

Although the adolescents were often able to identify the emotion others exhibited following the eight-week intervention, they frequently were unable to reply appropriately to these emotions. For example, one participant recognized that a peer seemed sad, but he did not possess the social script or ability to respond to his friend's grief. Perhaps, providing these adolescents with a brief 2- or 3-statement social script card that they could use with a communicative partner in specific situations would be helpful. These scripts could be printed on small index cards and kept in an unobtrusive place, such as the student's pocket, so that they could easily be accessed and used as response cues in specific situations. These scripts would not be considered social stories because they would only contain the specific statements to be repeated. McClannahan and Krantz (1999) reported that data from the Princeton Child Development Institute's preschool and school suggested that, for children with satisfactory language, several examples of communication (e.g., scripts) may expand language. Intervention strategies for individuals with AS appear to need to go beyond teaching the recognition of nonverbal behavior.

Individual Social Skills Instruction

Mind-Reading: Howlin et al. (1999) recommended that interventions for individuals with autism spectrum disorders target improving social understanding rather than attempt to change specific behaviors in specific situations. These interventions focus on teaching "theory-of-mind," or "mind-reading," which is the ability to infer other people's thoughts, beliefs, desires and intentions, and then use this information to interpret what they say, make sense of their behavior and predict what they will do next. By four years of age, normally developing children are able to mind-read. However, individuals with AS possess varying levels of this ability. A deficit in mind-reading or theory-of-mind can produce the following social challenges: an insensitivity to others' feelings, an inability to take into account what other people know, an inability to read and respond to others' intentions, an inability to deceive or understand deception, an inability to understand the reasons behind other people's behavior, an inability to understand misunderstandings and an inability to understand unwritten rules. The curriculum Howlin et al. (1999) designed, based on the results of empirical study, includes teaching the understanding of emotional states and informational states through the use of photographs, pictures and schematic drawings. In addition, pretence, or pretend play, is taught through direct instruction.

Mind-reading can also be taught in a small group setting as Ozonoff & Miller (1995) did with five normal-IQ adolescents with autism. The first module of seven sessions addressed basic interactional and conversational skills and the second module focused on teaching perspective taking and theory-of-mind skills. Perspective taking was first introduced physically by having group members lead a blindfolded trainer through a maze. The children were taught how to take the blindfolded person's physical perspective by providing a good description of obstacles without assuming that the blindfolded person could see what the child could see. First-order and then second-order cognitive perspective taking were introduced and practiced through role-playing. First order perspective-taking refers to inferring the thoughts of another person, and second-order perspective taking involves predicting what one person thinks another person thinks. Meaningful change was found on several tasks that assessed perspective taking in the five adolescents, and no change was found in the control group. However, no changes were found in parent and teacher ratings of social competence for either group. Again, this highlights the importance of building generalization into any intervention. In the clinical setting, these students evidenced change but apparently not in the home and school settings.

Social Stories:

Social stories (Gray, 1994b) are short stories or minibooks usually written by the adult in the child's environment to help answer questions that autistic children or adults may need to know to interact appropriately with others – the "who, what, when, where, and why" in social situations. They are personalized for each child, often motivating and serve as a visual cue that targets one behavior for improvement. The student's age, reading and comprehension ability, and attention span directly influence the content and format of each story. For instance, a story for a preschool student will have a few simple words on each page accompanied by pictures, photographs, or icons, and can be read to the child by a parent or teacher. Each story provides two to five descriptive and perspective sentences for each directive sentence. Descriptive sentences give information about the child, setting and actions. Perspective sentences highlight possible feelings and reactions of others. Directive statements illustrate the appropriate behavioral response. Social stories provide the student with accurate and specific information about what occurs in a situation and why. They are designed to bring predictability to a situation that from the perspective of the student with AS is confusing, scary, or difficult to understand (Gray, 1998).

Comic Strip Conversations:

Gray (1994a) describes a Comic Strip Conversation (CSC) as "a conversation between two or more people which incorporates the use of simple drawings" (p. 1). These drawings are used to illustrate ongoing communication by providing additional support to individuals who struggle to understand the quick exchange of information that occurs in a conversation. Individuals with AS are often visual learners who require more processing time than their peers. Comic Strip Conversations turn an abstract conversation into a concrete representation that allows for reflection and understanding. The teacher or paraprofessional facilitates or guides the CSC without assuming the lead in order to allow the child to have control during the session. Simple symbols, stick drawings and color are used. Color helps some students identify the emotional content and the motivation behind a statement. Attwood (1998) stated that the speech and thought bubbles used in these conversations, as well as the choice of color, can visually demonstrate hidden messages. Each CSC visually depicts what people do, say and think. These conversations can be conducted with the use of a blackboard and chalk, laminate marker board and markers, or with paper and pencil or crayons.

Social Autopsies:

Richard Lavoie (Bieber, 1994) developed social autopsies to assist students with learning and social problems develop an understanding of social mistakes and learn to problem solve alternative solutions. This intervention is particularly helpful for students with AS because it helps them to see the cause and effect relationship between their behavior and others' reactions. When a social mistake occurs, the child meets with the adult to discuss and dissect it. In a nonpunitive manner, the mistake is jointly analyzed, and they determine who was harmed by the error. A plan is then created to avoid making that mistake in the future. Social autopsies provide practice, immediate feedback and positive reinforcement. They can also be used to analyze successful social interactions. All of the adults in Lavoie's residential school for children with learning disabilities were taught how to conduct social autopsies, and they conducted them as needed with each student several times throughout the day. Currently, the effectiveness of social autopsies with students with AS is based on anecdotal records (personal communication, B. S. Myles, October 5, 2001). Further research to support these records is needed.

Hidden Curriculum:

Hidden curriculum refers to the unwritten, unspoken rules of the school that almost everyone, except the student with AS, takes for granted. It is the culture that makes your school different than others (Bieber, 1994). Children with AS violate these rules and frequently are not even aware that they have done so. For example, most students figure out in a matter of days which middle school teachers will tolerate missing homework and being late to class and which teachers will not. The student with AS typically does not intuitively pick up these unspoken rules and needs to be taught them directly. Furthermore, teacher expectations, teacher pleasing behavior, teacher likes, students to interact with and students to avoid, safe and unsafe places in the school, and what the "cool" kids do and do not do are all part of the hidden curriculum that must be explicitly taught to the student with AS. Students must also be taught that the hidden curriculum varies across settings, people, situations and cultures. For example, the hidden curriculum for behavior in a library is certainly very different than the hidden curriculum for behavior in a bowling alley.

Lavoie (Bieber, 1994) cited a study in which 1500 mainstream teachers were asked to list the three most important skills for students with learning disabilities to have in order to be successful in the mainstream. The teachers listed the following seven skills: listening, following directions, staying on task, knowing how to ask for help, getting started on a task, finishing a task on time and word attack skills. The first six skills are hidden curriculum skills that need to be taught. Many of our students are failing in the regular education class because of a lack of hidden curriculum skills, not academic skills. Therefore, it is imperative that special educators talk to the school support staff (e.g., secretaries, maintenance workers, bus drivers and cafeteria staff) to determine the hidden curriculum of their school and teach it to their students.

Conclusion

Interventions for students with AS need to focus on teaching social skills that will assist them in successfully navigating the complex social demands of today's world. Social skills training (SST) groups and direct individual instruction using social stories, Comic Strip Conversations and social autopsies are suggested intervention strategies that can be used to help students understand the social nuances that were previously out of their awareness. In addition, direct teaching of the hidden curriculum and how to mind-read need to be considered when developing the student's curriculum. These techniques can assist the adults working with students to understand the student's behavior as well as to share accurate and specific social information with the student. Finally, it is important to keep a sense of humor when working with these students. Hans Asperger (1944) wrote that even though these students can be difficult, even under optimal conditions, "they can be guided and taught, but by people who give them true understanding and genuine affection, people who show kindness to them and, yes, humor" (p.48).

References

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Marriage, K. J., Gordon, V., & Brand, L. (1995). A social skills group for boys with Asperger's syndrome. Australian and New Zealand Journal of Psychiatry, 29, 58-62.

McClannahan, L. E., & Krantz, P. J. (1999). Activity schedules for children with autism: Teaching independent behavior. Bethesda, MD: Woodbine House.

Mesibov, G. B. (1984). Social skills training with verbal autistic adolescents and adults: A program model. Journal of Autism and Other Developmental Disabilities, 14, 395-404.

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

Robinson, P., & Trower, P. (1988). Social skills training. In G. M. Breakwell, H. Foot, & R. Gilmour (Eds.), Doing social psychology (pp. 172-184). New York: Cambridge University Press.

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Wing, L. (1998). The history of Asperger syndrome. In E. Schopler, G. B. Mesibov, & L. J. Kunce (Eds.), Asperger syndrome or high-functioning autism? (pp. 11-28). New York: Plenum Press.

Wing, L. (2000). Past and future research of research on Asperger syndrome. In A. Klin, F. R. Volkmar, & S. S. Sparrow (Eds.), Asperger syndrome (pp. 418-432). New York: Guilford Press.

For further information on Asperger syndrome contact: ASC-U.S. (Asperger Syndrome Coalition of the U.S., Inc.) (866)-4-ASPRGR; www.asperger.org or MAAP (More able autistic persons), (219)-662-1311

Gena P. Barnhill, Ph.D., NCSP, author of Right Address ... Wrong Planet: Children with Asperger Syndrome Becoming Adults, is a special education coordinator and autism consultant for the North Kansas City School District in Kansas City, MO and parent of a young adult son with Asperger syndrome. E-mail: genabarnhill@hotmail.com.