A Systematic Review of Studies on Social Skills Development for Adolescents with Autism Spectrum Disorders

Articles Included Summary

The overall search strategy yielded a total of 2590 articles. These were all the articles that were captured using the different key words and phrase enumerated in the methodology section. Further, an additional 1013 articles were obtained through reviewing the references of the captured articles. A record for duplicates was conducted and 935 articles were removed. The next step in the results was applying the inclusion and exclusion criteria. The aspects of full versions in PDF, the publication region and timelines were applied as the study search limiters and of the remaining 2668, 69 articles fitted the criteria. Further, the articles were subjected to an analysis of their participants’ ages, inclusion of adolescents with ASD but with other conditions, and those that failed to include a relevant outcome description. The PRISMA figure for the search protocol and the outcomes is as illustrated in figure 1. The systematic review analysis remained with 11 articles that fitted the inclusion criteria and thus were used as the basis for the systematic review data analysis. A summary of the studies indicates that they were developed indifferent settings as illustrated in Table 1. The diversity of the settings enabled the creation of a diversified and all perspectives recommendation on evidence based interventions and social skills. Some of the studies were developed on a clinical setting often linked to established and recognized Teaching and Referral Universities in the USA and Canada [12, 13, 14, 15, 16, 17, 18].

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Other studies with detailed investigations evaluated social skills among autistic adolescents in school settings, such as those studies conducted by Laugeson, et al. [15], Laugeson, et al. [19] and Laugeson, et al. [14]; however, there are some that have been conducted outside the realms of school, that is, a non-public school setting, such as studies of Mandelberg, et al. [16]; Tse, et al. [12]. Also, other settings were included such as at university-based children’s hospital [20], university campus [5] and regional centres [19]. Furthermore, most of the studies evaluated SST group of adolescents with ASD which took place within the geographical domain of the US and Canada, according to the inclusion criteria in this review. Thus, various studies in accordance with the topic can be collected which would help to increase the validity of this paper about the effectiveness of learning SST among teens with high functioning ASD.

Type of Social Skills Interventions

Programme for the Education and Enrichment of Relational Skills (PEERS): The UCLA Programme for the Education and Enrichment of Relational Skills (PEERS)

is a range of social skills intervention and friendship improvements designed for adolescents with high functioning ASD, which essentially focuses on making friends in addition to managing peer rejection and conflict. It also includes the various cognitive-behavioural principles to help improve the social functioning of adolescents with ASDs [20]. The curriculum for UCLA PEERS’ is based on the principles of Children’s Friendship [21, 22], with core features of PEERS adapted for teens with ASD which is inclusive of: relevant portions of the social skills curriculum, the use of parent assistance in the treatment and structural elements of the lesson format. The UCLA PEERS intervention modified the curriculum and methods of instruction and added new modules, to be more applicable for teens with high functioning ASD [19].

The PEERS treatment includes 12-14 manualized weekly sessions, with each session lasting 90 min and typically involves a parent or caregiver [13]. Table 1 provides an overview of the 14-session intervention along with the key socialization homework assignments, and the situation five years posts the conclusion of the treatment. One of the short- term plans of PEERS intervention is to have programmes which are included with parents’ participation, as stated above. The purpose for the inclusion of parents is to help the adolescents generalize social skills to a more natural setting by parent social coaching, whereas the long-term aim is for adolescents to exhibit enhanced social competence within an independent use of appropriate social skills leading to the development and maintenance of meaningful relationships.

Three included studies evaluating PEERS used an RCT [5], and each of these studies included a wait-list control group. The two studies employed a quasi-experimental pre-post design in which participants were not randomly assigned to their conditions, and there was control group [14]. Additionally, all the studies investigated PEERS in adolescents between the ages of 11 to 19 years. Facilitators in these studies are licensed clinical psychologists wherein two coaches assisted the group leaders during the duration of the study, both of whom were psychology graduate students with experience conducting clinical treatment and possessed expertise in working with children and teens with autism spectrum. Also, they were trained in all aspects of the PEERS programme intervention.

Teachers and teacher aides assigned to the intervention were also trained and supervised in the study of [15]. This study had supervision in addition to consultation from the principal investigator. The treatment was delivered through a didactic instruction, fundamental social skills such as appropriate use of eye contact and voice volume, social initiation skills such as starting a conversation with somebody, getting along and interacts with others, including acknowledging other people and following directions and social response skills, such as reciprocity during conversations were taught. The study conducted by Laugeson, et al. [14] followed a similar protocol to Laugeson, et al. [19] but with two additional sessions of treatment and a follow-up period. These two additional treatment modules included training in the proper use of electronic communication, online security, procedures for handling cyber bullying, suitable use of humour, long term practices for changing bad characters and strategies for handling rumours and gossip.

A further study by Mandelberg, et al. [16] was described as a randomised complete block design. They assessed teens with ASD and collected outcome measures for treatment at three testing time points (T1, T2, and T3). T1 is pre- PEERS intervention as a baseline data which was collected for each measure upon initial entry into the study. T2 is a post- intervention test, wherein the assessment data was collected after the conclusion of treatment. While a T3 is a long-term follow-up assessment data which were collected during 1-5 years with an average of 29 months following the treatment? Therefore, teen members can consider as ‘blocks’ and the varying time points as ‘treatments’. The protocol intervention was described thoroughly in all the seven studies.

The study conducted by Schohl, et al. [21] was the only study which was independent of UCLA, which decreases the risk of investigator bias when compared with the other studies. In this study, additionally, to licensed clinical psychologists, there was Van Hecke, one of the authors of the study who had attended an official PEERS training workshop in Los Angeles and was certified in providing PEERS treatment. Then, she returned to the site of the current study and instructed graduate students in a clinical psychology Ph.D. programme to assist with and co-lead the PEERS adolescent and caregiver groups, and undergraduate students to serve as coaches or assistants for the PEERS group intervention. All graduate students had extensive experience in research, diagnostic, and clinical practice in ASD, and all teens group leaders had at least a Master’s degree in clinical psychology and had completed formal coursework in general aspects of group therapy. All adolescents and parent graduate group leaders received training via observing the certified Van Hecke’s sessions. Coaches in this research helped with role-play activities, behavioural rehearsal, and behavioural management. Additionally, there was a homework review of the assignment from the previous week. The didactic lesson, which was outlined in a hand-out given to the parent group and in the context of the adolescent group’s didactic lessons, they were improved by demonstrations in which the group leaders modelled the proper social skill being taught through exercises of role-playing.

The study pursued by N Lordo, et al. [20] used mixed design to examine the effectiveness of the PEERS programme as a social skills treatment. Adolescents with ASD were assessed at two-time points, before receiving the PEERS treatment and post the PEERS treatment. Multiple homework assignments were reviewed by N Lordo, et al. [20] in every group session. They also reviewed the adolescent didactic lessons, modelling appropriate behaviour and role-playing. Developing quality peer relationships and remediating social isolation, for examples conversational skills, understanding social cues, and handling socially appropriate active and behavioural responses to friend rejection and/ or bullying was investigated during the course of the study conducted by N Lordo, et al. in 2016 [20].

The seven studies used different measures to assess treatment outcome in social skills training interventions. All those studies used the Social Skills Rating System (SSRS) to evaluate the cooperation of adolescent, statement, self- control and social responsibility except the study which was conducted by Dolan, et al. [5]. The SSRS formed by parents, caregivers and teacher participants were also reviewed in studies. An improvement in adolescent’s social skills knowledge during the PEERS interventions, such as measured by the Test of Adolescent Social Skills Knowledge [22], were found in all studies with PEERS treatment study. This suggests that PEERS intervention is successful in improving the specific social skills knowledge of teens with ASD. The TASSK is the criterion-referenced measure that is developed to assess changes in the treatment associated with information for adolescents about the specific social skills taught during the programme of PEERS intervention. It contains skills acquired by the adolescents about the formulation of relationships and making friends. The test took approximate 5 minutes to be concluded and was included in statements that were related to the didactic lessons wherein the adolescents were asked to choose the best alternative among the presented answers. The themes for the questions were acquired from key elements of each of the didactic lessons.

Furthermore, the administration of the Social Responsiveness Scale was included in three of those seven studies which conducted by Laugeson, et al. [14]; Laugeson, et al. [15] and Mandelberg, et al. [16]. It is used for measuring the severity of autism spectrum symptoms as they occur in natural social settings. Studies by Laugeson, et al. 19] and Schohl, et al. [21] had an assessment on the quality of friendship by using the SST measure. Only Laugeson, et al. [19] discovered a significant time-condition interaction, which was due to a decrease from the controls’ scores. Mandelberg, et al. [16] also evaluated post-intervention improvements in friendship and observed an increase in the number of get-togethers organised with friends after PEERS, which was maintained during the follow-up period after the conclusion of the social skill intervention programs.

Social Skills Training Group

A study by Tse, et al. [12] evaluated a Social Skills Training (SST) Group which consisted of sessions lasting for approximately one hour, weekly for 12 weeks. This study by Tse, et al. [12] stated social skills were covered in the groups such as; “Awareness and expression of feelings Making eye contact, Recognition of non-verbal communication Politeness, Introducing oneself to others Listening to others, Starting a conversation Maintaining a conversation, Ending a conversation, Making small talk, Negotiating with others Responding to teasing and bullying Hygiene Dining Etiquette Dating Etiquette”. The group consisted a mixture of psycho- education and experiential techniques that taught social skills and included the elements of role-playing and didactic. The content of the group that has many of such exercises used to teach new skills adapted from the book which was based on ‘Skillstreaming the Adolescent’ by Goldstein, et al. (2000). According to this book of Skill streaming the Adolescent, there are many exercises that can be used to teach new social skills, apart from role-playing and didactic elements. Additionally, various other skills training manuals are available.

The study was quasi-experimental pre-post designs without a control group and participants had a mean age of 14.6 years. The SST group led by the social worker and psychologist was working with teenagers in the setting of psychiatric units. For one group, there was a psychiatric resident as the third co-leader. Two hours per week for each clinician for 14 weeks was required by the group leader, and included assessments, planning and preparation, group time and feedback sessions. Mix psycho-education and experiential exercises were used. Also, participants’ parents were asked to complete three questionnaires post- and pre- the 12-week group: the Social Responsiveness Scale, the Aberrant Behaviour Checklist. The authors noted small but significant improvements in social competence, as measured by the SRS and N-CBRF-PS. Also, as measured by ABC, there was notable reduction in problem behaviours of the individuals with developmental disabilities.

A further study was developed by Jonsson, Olsson, Coco, Gorling, Flygare, Rade, Chen, Berggren [18]. It targeted participants aged above 10 years but below 17 years. This is a category within which teenagers fall within. The study had a sample base of 50 teenagers with ASD with 15 females and 35 male teenagers. The primary outcome tool for the study was the Responsiveness Scale-Second edition (SRS-2) rated by parents and blinded teachers for the respondent included in the clinical trial. The analysis was longitudinal with assessment developed at baseline and a follow-up done after 3 months with the application of social skills training. The analysis established that the parents rating on social skills had a higher score post treatment as compared to the baseline scores. However, the teachers and other secondary outcomes did not reach statistical significance. The findings were a demonstration that the social training skills were mainly focused on enhancing and promoting the teenagers social skills. Unfortunately they have a low impact and significance on their learning capabilities and functionality. Nevertheless, since they enhanced their social wellbeing, the strategy was considered as successful and valuable.

Implications and Study Limitations

The developed systematic review analysis has the benefits and implications on literature, research and clinical practice in handling adolescents with ASD related disorders. The main findings are on the strategies applicable in improving the adolescents’ social skills and integration with peers. The practice implications are on the emphasis on adopting the Peers based social group strategies as a basis of promoting peer learning. On research and literature, it paves way for the development of additional studies on the context. It is evident that there is a literature gap on studies targeting the adolescent category, thus creating a feasible basis for formulating future reviews and studies hypothesis on adolescents with ASD social and psychological well-being evidence based improvement and enhancement strategies.

On Limitations, despite evidence of the benefits of social and communication skills interventions for adolescents with ASD, there are significant limitations to the current evidence base. While the authors conducted an extensive search of the literature available on SST interventions for adolescents with ASD and HFA in the United State and Canada, only nine studies were found. Due to the limited number of the studies on autistic adolescents, the current study was a systematic review, not the meta-analysis research. As a consequence, clear measures of effect size for various types of social skills interventions are not available. Effect sizes should also be perceived with caution, particularly for studies with limited sample size, which was an element of the majority of the studies reviewed for the current study. Additionally, the samples in included research studies were a mostly Caucasian male, which makes the findings less generalised to diverse sample. Therefore, in future studies, a larger, more diverse sample including females should be examined.