S.O.S.! Developing Social Skills in ASDs
Jeanne Holversto-, MS
Au9sm Spectrum Specialist Responsive Centers 913.451.8550 ext. 121
Wednesday, October 12, 2011
[email protected] www.jeanneholversto3.com Twi3er: @jholversto3
Workshop Objec9ves • Familiarity with the diagnos9c criteria for: – Au9s9c Disorder – Asperger’s Disorder – Pervasive Developmental Disorder – Not Otherwise Specified
• Recogni9on of the breadth of the impact of social impairment on the daily func9oning of individuals with ASD • Framework for developing social skills • Crea9on of a toolbox of remedia9on strategies
Wednesday, October 12, 2011
Challenge • Try to name a skill/behavior that does not have some social component: – Used for social purposes – Absence has nega9ve social outcomes – Deficit has long-‐term impact on learning future skills
• Conten9on: Every symptom/manifesta9on of ASDs has a social impact
Wednesday, October 12, 2011
The “Triad of Impairments”
THEORETICAL FRAMEWORK
Wednesday, October 12, 2011
Lorna Wing • Theore3cal Framework: – Au9sm: Wing, L. & Gould, J. (1979), "Severe Impairments of Social Interac9on and Associated Abnormali9es in Children: Epidemiology and Classifica9on", Journal of Au+sm and Developmental Disorders, 9, pp. 11-‐29. – Asperger’s Disorder: Wing, L. (1981), “Asperger’s Syndrome: A Clinical Account”. Psychol Med 11 (1): 115–29.
Wednesday, October 12, 2011
The “Triad of Impairments”
(Gould and Wing, 1979)
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Deconstruc9ng the Triad
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The Impact of Language: Global Characteris9cs • Repe33ve or rigid language – – – – – –
No meaning Seems out of context in conversa9ons Immediate echolalia High-‐pitched or singsong voice or use robot-‐like speech Stock phrases to start a conversa9on Repeat what they hear on television programs or commercials (delayed echolalia)
• Narrow interests and excep3onal abili3es – In-‐depth monologue about a topic that holds their interest, even though they may not be able to carry on a two-‐way conversa9on about the same topic.
Wednesday, October 12, 2011
The Impact of Language: Global Characteris9cs • Uneven language development: Many children with au9sm develop some speech and language skills, with uneven progress. – – – – –
Range: Nonverbal to Hyper-‐verbal Strong vocabulary in a par9cular area of interest very quickly Good memories for informa9on just heard or seen Hyperlexia Fail to respond to the speech of others and may not respond to their own names
• Poor nonverbal conversa5on skills – Lack of or limited use of gestures to give meaning to their speech – Avoid eye contact, which can make them seem rude, uninterested, or ina3en9ve – Not “seeing” and/or not understanding the facial expressions, body posture, and gesture of others – Not aware of volume and tone of voice in self and in others
Wednesday, October 12, 2011
The Impact of Language: Expressive Language • Using speech or “expressive language”
– Kanner highlighted the delay or absence of speech in his diagnosis. Use of speech varies from not at all (in 20% of cases) to a very good level of language. Common speech problems include:
• Repea9ng words spoken to them (echolalia); • Asking for things by repea9ng a phrase they associate with the ac9on e.g. 'Do you want a cup of tea' instead of 'I want a cup of tea'; • Missing linking words out of sentences such as 'in' 'on' 'because' or 'under.' For example a child may say 'go car shop' missing out the joining words; • Explaining in greater detail than is necessary; • Long replies to ques9ons spoken as if learned from a book.
Wednesday, October 12, 2011
The Impact of Language: Expressive Language • Using speech or “expressive language” – Slow processing speed – Limited flexible use of emo9ons words – Limited self-‐advocacy – Out-‐of-‐context language – Func9onal versus pragma9c
• Not knowing “what to say”, “when” to say “it”, or perhaps even “why” to say it
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The Impact of Language: Recep9ve Language • Understanding speech or “recep1ve language” – As speech varies, so does understanding – Most people with ASD can understand some speech – Difficul:es arise in a number of situa:ons: • When objects have more than one name such as a bowl (washing up or ea9ng from?); • Confusion between the sound of a word (e.g. meet and meat); • Literal interpreta9on: Imagine if you took phrases like 'it's raining cats and dogs' or 'have you lost your tongue' literally; • Humor, especially that which relates to verbal ambiguity, can be difficult for a person with au9sm (i.e. sarcasm, puns).
Wednesday, October 12, 2011
The Impact of Language: Recep9ve Language • Overes1mated recep1ve language comprehension – High IQs – Literal – Abstract – Figures of speech – Slow processing speed – When they get it, but it’s not what we mean (and we don’t figure it out un:l later…..and they might not)
Wednesday, October 12, 2011
Deconstruc9ng the Triad
Wednesday, October 12, 2011
Impairments in Thinking and Behaving •
•
Repe99ve stereotyped ac9vi9es (Simple stereotypies may last into adulthood) –
Tas9ng, smelling, feeling or tapping different surfaces;
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Listening to mechanical noises such as washing machines;
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Switching lights on and off;
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Spinning objects;
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Head banging.
More complex stereotyped behaviors include: –
A complex sequence of bodily movements;
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Placing objects in long lines that cannot be moved;
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Extensive bed9me rou9nes;
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The family sieng in exactly the same places at meal9mes;
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A3achment to strange objects such as pieces of string or leaves; and
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Collec9ng strange objects such as 9ns of polish.
•
In more able people with au9sm, fascina9on with the weather, 9metables, train numbers, etc. may be found.
•
Many of the above do not extend into adulthood. However, fascina9on with numbers and sequences can ofen con9nue.
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Impairments in Thinking and Behaving • Wing observed a number of addi:onal features that in themselves are not universal: – Stereotyped movements -‐ such as finger flapping, arm waving, jumping, head rolling and walking on :ptoe; – Abnormali:es of gait and posture are some:mes seen -‐ where the child may not swing his/her arms properly when walking, may hold their hands out when walking or may bend their fingers or arms in unusual ways; – The person with au:sm may have marked difficul:es with physical educa:on and games. This is especially the case with team sports.
Wednesday, October 12, 2011
Impairments in Thinking and Behaving • Inappropriate, difficult behavior is frequent in children with ASD. This may manifest itself in a number of ways: – Confusion and fear of unfamiliar circumstances; – Restlessness, destruc9ve and aggressive behavior; – Screaming and temper tantrums; – People with ASD generally will not lie so if they see what they consider to be an ugly baby or a very short person.
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Impairments in Thinking and Behaving • The complex process of self-‐regula:on: Knowing when something is “wrong” 1. Recogni:on: • • • •
Understanding physical states Understanding emo9onal states Understanding behavioral paPerns Understanding cogni9ve paPerns
2. Decipher the problem 3. Select a strategy 4. Implement a strategy 5. Reassess the effec:veness of the strategy
Wednesday, October 12, 2011
Impairments in Thinking and Behaving • Sensory processing greatly impacts daily func9oning • General themes: – Hyper-‐ or hypo-‐sensi9ve: taste, smell, touch, movement, sound, visual – Inconsistent impact within a sensory system and across the sensory systems – Strategies: • Seek • Avoid
Wednesday, October 12, 2011
Deconstruc9ng the Triad
Wednesday, October 12, 2011
The Breadth of Social Impairment • “The aloof group”: Most common type of impairment – – – – – – – – –
Behaving as if other people do not exist; LiPle or no eye contact made; No response when spoken to; Faces empty of expression except with extreme joy, anger, or distress; No response to cuddling; If something is wanted, carer’s hands may be pulled towards the object; Does not ask for help; May respond to rough and tumble play well, but when this stops return to aloof paPern; Seem to 'be in a world of their own'.
Wednesday, October 12, 2011
The Breadth of Social Impairment • “The passive group”: Least common group – The child accepts social approaches; – May meet the gaze of others; – May become involved as a passive part of a game.
Wednesday, October 12, 2011
The Breadth of Social Impairment • “The ac3ve but odd” group: Make ac9ve approaches to others but make that contact in strange ways, including: – Paying no alen9on to the other party; – Poor eye contact although some9mes may stare too long; – May hug or shake hands too hard.
Wednesday, October 12, 2011
The Breadth of Social Impairment • “The over-‐formal, s3lted group”: Seen in later life, this behavior is common in the most able person with ASD. – Excessively polite and formal; – Good level of language; – Try very hard to s9ck to the rules of social interac9on without really understanding them.
Wednesday, October 12, 2011
Overarching Themes of Social Impairment • “Mindblindness” (Baron Cohen, 1997) – Predic9ng – Reading inten9ons – Understanding emo9ons – Explaining own behavior – Perspec9ve or reference – Reading and reac9ng to others’ interests – Understanding social interac9ons
Wednesday, October 12, 2011
Overarching Characteris9cs of Social Impairment • Nonverbal cues • Ini9a9ng and maintaining social interac9ons • Literalness • Perspec9ve taking • Hidden curriculum • Conveying own thoughts • May not use social e9quele • May sound more competent than they are – Expressive language more advanced than recep9ve – Say something without knowing what it means (“Bleep, bleep”)
Wednesday, October 12, 2011
Diagnos(c and Sta(s(cal Manual of Mental Disorders
CLINICAL FRAMEWORK
Wednesday, October 12, 2011
Examining the Diagnos9c Criteria • Clinical Framework: Diagnos(c and Sta(s(cal Manual of Mental Disorders, Fourth Edi9on, Text Revision (DSM-‐ IV, TR, 2000) by the American Psychiatric Associa9on
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(Overly) Simple Differen9a9on
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Qualita9ve Impairment in Social Interac9on (2 AD, 2 AS)
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Qualita9ve Impairment in Communica9on (1AD, 0AS)
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Restricted, Repe99ve and Stereotyped Behaviors, Interests, and Ac9vi9es (1AD, 1AS)
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Addi9onal Diagnos9c Criteria
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QUESTION: WHAT IS A “SOCIAL SKILL”? Answer: What isn’t? Complica+ng Factor: What are we trying to achieve?
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What’s the Difference?: Social Skills vs. Competence • Social Skills: – Discrete abili9es: • • • • •
good eye contact ability to maintain and repair conversa9on joint alen9on tone of voice word choice appropriate to audience
– Use versus outcome? • David and the floa9ng hand
Wednesday, October 12, 2011
What’s the Difference?: Social Skills vs. Competence • Social Competence: – Successful engagement in social interac9ons and rela9onships with other individuals (Odom, McConnell, & McEvoy, 1992) – Ability to ini9ate, maintain interac9ons (reciprocity), and interact appropriately, even when difficult (Guralnick, 1992)
• Complica9on: Challenging behaviors are also social interac9on
Wednesday, October 12, 2011
What’s the Difference?: Social Skills vs. Competence
• Inclusion/Integra9on alone is not the panacea: – He can handle the situa9on – He can func9on in it (socially competent)
• Knowing how and actually doing it • Bolom line: Put them to good use and get the results (i.e. a social goal)
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HOW DO WE TEACH SOCIAL COMPETENCE?
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Treatment Methodology • Instruc9on • Interpreta9on • Coaching
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TREATMENT METHODOLOGY: INSTRUCTION “If we don’t teach it, they don’t learn it”
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Instruc9onal Strategies • Lack of incidental learning • Direct Instruc9on – Scope and Sequence – Controlled Exercises – Video Modeling
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Direct Instruc9on: Scope and Sequence • A lis9ng of skills in developmental order of acquisi9on • Helps to target objec9ves (school and clinic) • Assists in providing instruc9on in a systema9c manner • Some include assessments best completed in a social situa9on
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Scope and Sequence: Examples • Super Skills by Judith Coucouvanis • Space Travelers by Josie Santomauro • Skills Streaming by Arnold Goldstein and Ellen McGinnis • Naviga+ng the Social World by Jeannele McAfee • Social Skills Training by Jed Baker • Social Thinking by Michelle Garcia Winner
Wednesday, October 12, 2011
Direct Instruc9on: Controlled Exercises
• Step 1: Describe the skill • Step 2: Provide a ra9onale • Step 3: Describe general situa9ons in which to use the skill • Step 4: Teach using role play • Step 5: Iden9fy social rules
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Step 1: Describe the Skill • • • •
Defini9on Verbal: What children say Nonverbal: What children do (body basics) Cogni9ve: What children think
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Step 2: Provide a Ra9onale • Explain why • Discuss how the skill will benefit the child • Provide posi9ve and nega9ve ra9onale statements
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Step 3: Describe Situa9ons in which to Use the Skill • The idea is to communicate appropriateness or inappropriateness • Increases likelihood of generaliza9on
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Step 4: Using Role-‐Play to Teach • Par9cipa9on • Describe a real-‐life situa9on, assign a main actor, and a suppor9ng actor • Conduct role play • Provide feedback (clinician, peers)
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Step 5: Iden9fy Social Rules • Rules: – Govern socially acceptable behavior – Guide students in using a skill
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Direct Instruc9on: Video Lessons • • • •
Show a videotaped program without sound Have students videotape themselves Use silent movies to teach facial expressions Using media with over exaggerated ac9ng
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TREATMENT METHODOLOGY: INTERPRETATION “Teaching to the Loophole”
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The Challenge of Competence • “We’ve given him all of the tools. He just needs to use it.” – Prac9ce – Role of failure – Need for pa9ence
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Interpreta9on Strategies • Scales, Numbers, and Categories (Oh My!) • Social autopsies • SOCCSS • SODA • Power Cards • Social Stories • Cartooning
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Scales and “Things” • Overarching Goal: Quan9fica9on – Omnipotent Problem: Abstrac9on versus Pragma9cs
• Categories, Scales and Things: – Create structure and “rules” – Provide basis for comparison – Quan9fies the unquan9fiable
• Examples: – – – –
“Love, Like, Hate Scale” “Just the Facts” “Aspie Target” “Fault Form”
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Five Point Scale (Buron, 2003)
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Social Autopsies (LaVoie, 2001) • Adult-‐assisted • Joint analysis of child social errors – Iden9fies error – Pinpoints damage to others and self – Outlines strategies to correct damage – Teaches new strategies
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SOCCSS (Roosa, 1995) • • • • • •
Situa9on Op9ons Consequences Choices Strategies Simula9on
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SODA (Bock, 2001) • Stop – What and where should I observe?
• Observe – Doing, saying, conversa9on length, arer talking?
• Deliberate – What would I like to say or do? – How do I know to keep talking or stop?
• Act – Approach, greet, listen, ask related ques9ons, look for cues (con9nue or stop), and end conversa9on
Wednesday, October 12, 2011
Power Card Strategy • The Power Card is a visual aid that incorporates the child’s special interest to teaching appropriate social interac9ons including rou9nes, behavior expecta9ons, the meaning of language and the hidden curriculum (Gagnon, 2001). • Not a stand alone interven9on: – Part of an interven9on strategy package – Strategies suggested are usually strategies concurrently being worked on
• Not a teaching tool: – Most effec9ve to augment a skill already taught to a child
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Power Card Strategy: Components • A short scenario describing how the hero solves a problem similar to the one experienced by the child (reader) – Describes how this hero places a value on the expected behavior
• A short paragraph recapping the strategy – Encourages the child to alempt the new behavior
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Social Stories (Gray, 1999) • Describe how to use and why to use a specific skill in a story format – Favorite character – Favorite items
• “Buy in”
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Social Stories (Gray, 1999) • How To: – Disclaimer – Op9on 1: Describe the situa9on not working, describe the skill to be used, describe the situa9on working – Op9on 2: Describe the use of the skill in the situa9on
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Social Stories: Examples • “School is Hard” • “Leave it on the Table”
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Cartooning • Visual Representa9on • Thought Bubbles AND Talking Bubbles • Benefits: – “On the fly” – No Van Gogh here!
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Wednesday, October 12, 2011
TREATMENT METHODOLOGY: COACHING “Prac9ce makes perfect or, at least, be3er.”
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Social Competence: Coaching • Feed the language • Conversa9on starters • Scripts
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Coaching: Feeding the Language (Collins, n.d.)
• Jump start • Verba9m or paraphrased verbal prompt • Can be used to – Point out a playmate who is alone – Provide a topic – Provide an opening sentence
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Coaching: Conversa9on Starters • List of topics – Eavesdropping – Asking high-‐status peers
• Wrilen on business card • Can be overtly displayed when used
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Coaching: Scripts • Provides verba9m (or close to it) structure • Uses child/adolescent-‐friendly language • Targets one social situa9on: – Predictability – Stress
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Final Thoughts on Treatment Methodology • Instruc9on à Interpreta9on à Coaching – Progression from individual to group format
• Social competence as part of a comprehensive treatment package • Making it Work: We are the P.R.O.S. – – – –
Prac9ce Repe99on Opportunity Sabotage
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Dispelling Myths • “Individuals on the spectrum are happy to be alone.” • “Individuals on the spectrum are aggressive and violent.” • “Au9sm is more severe than Asperger’s.” • “Eye contact is always bad.”
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When was the last 9me you threw a hammer away?
SMALL GROUP APPLICATION
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Ac9vity • • • •
Pick two or three classmates Select 1 case study Select 1 strategy for how to work on “goal” Iden9fy possible shortcomings with selected strategy
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Case Study: Alex (19) • •
•
DX: au9sm Relevant Strengths: well-‐ mannered, no significant externalized behaviors, able to engage in rudimentary small talk Relevant Weaknesses: lack of knowledge about how his DX impacts him socially; accep9ng his lack of interac9on; “video games are my friends”; “I don’t know what else to say”
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• •
Goal: Increase peer communica9on at school Plan:
Case Study: Joe (8) • DX: Asperger’s Disorder • Relevant Strengths: well-‐ mannered, very intelligent, capable of assessing if a strategy will work for him, wily, interacts with peers with some success • Relevant Weaknesses: policing and anger management
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• Goal: Reduce impulsive reac9ons with peers when upset • Plan
Case Study: Patrick (14) • DX: Asperger’s Disorder • Relevant Strengths: well-‐ mannered, mo9vated to interact with peers, ar9culate about himself • Relevant Weaknesses: mindblindness, literalness, puberty
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• Goal: Increase more socially appropriate interac9ons with same-‐aged females • Plan:
Recommending Reading • • • • • •
Scope and Sequences Gray, C. (1995). Social stories unlimited: Social stories and comic strip conversa9ons. Jenison, MI: Jenison Public Schools. Jackson, Luke. (2002). Freaks, geeks, and Asperger Syndrome: A use guide to adolescence. London: Jessica Kingsley Publishing. Myles, B.S., Trautman, M.L., & Schelvan, R.L. (2004). The hidden curriculum: Prac9cal solu9ons for understanding unstated rules in social situa9ons. Shawnee Mission, KS: Au9sm Asperger Publishing Company. Packer, A.J. (1997). How rude: The teenagers’ guide to good manners, proper behavior and not grossing people out. Minneapolis, MN: Free Spirit. Robison, J.E. (2007). Look Me in the Eye: My Life with Asperger’s. New York: Crown.
Wednesday, October 12, 2011