Autism Spectrum Disorders: Building Social Skills in Group, School, and Community Settings

Abstract

Adolescents diagnosed with autism spectrum disorders (ASD) face a variety of social difficulties as they interact with same-aged peers and adults in their schools and communities. Few empirically based interventions have been designed to increase social understanding (e.g., understanding gestures and facial expressions), social interaction abilities (e.g., initiating conversation with peers), and social competence (e.g., distinguishing between teasing and joking). This article reviews the most effective strategies for increasing social skills in adolescents with ASD and also gives examples of how to implement these strategies in group, school, and community settings.

KEYWORDS:

• autism spectrum disorder
• adolescents
• social skills
• social competence
• ASD
• group work
• school social work

My big problems came in high school. That was my terrible time. Once kids start moving through puberty into adolescence, they are no longer interested in sails and kites and bike races and board games. Attention and interest turns to all things social-emotional. For me, that spelled disaster. While I understood how to be polite, and act appropriately in different situations with other kids—that is, my social functioning skills were good—I didn't feel that sense of social bonding that seems to glue kids together in their teens. (Temple Grandin, an adult with autism, discussing her high school years, cited in Grandin & Barron, 2005, p. 19)

Although individuals with autism spectrum disorders (ASD) are continually challenged by their social impairments throughout the life span, the social demands of adolescence present a particularly difficult developmental stage. For example, adolescence often requires that individuals with ASD learn more complex social rules such as understanding humor and slang, taking the perspectives of others to understand emotions and situations, and interpreting abstract language and social cues within the context of the social environment, all areas of impairment for individuals with ASD (Kasari & Rotheram-Fuller, 2007). Despite these challenges, adolescents with ASD, like their typical peers, often have a strong desire to engage in social interaction and make friends (Mesibov & Handlan, 1997; Volkmar & Klin, 1995). The purpose of this article is to discuss various group interventions for adolescents with ASD that can be used to increase social skills and facilitate social interactions with their peers in various environments. We begin with a review of the specific difficulties experienced by adolescents with ASD and then describe empirically supported interventions and the way that we have integrated them into our clinical practice.

SOCIAL IMPAIRMENTS IN ADOLESCENTS WITH AUTISM SPECTRUM DISORDER

Researchers have examined not only social skills impairments in adolescents with ASD, but also how these social difficulties may affect interactions with others and overall quality of life. Orsmond, Krauss, and Seltzer (2004) surveyed 235 adolescents and adults with ASD and found that 46% of individuals with ASD had no reciprocal friendships. They attributed the lack of friends to poor social skills that persist into adolescence. These continued social skills impairments in adolescence were documented by Church, Alisanksi, and Amanullah (2000) through a chart review of middle school and high school students seen in an autism clinic. According to clinic records, parents believed that social skills and the ability to interact with others were their adolescents' greatest challenges. Parents reported that their adolescents with ASD continued to have one-sided conversation with peers, engaged in minimal small talk with peers, displayed inappropriate and immature behavior in social situations, experienced difficulties with peer rejection due to lack of social insight, and had difficulties interpreting nonverbal and verbal communication cues.

Despite their social skills difficulties, adolescents with ASD often desire friendships and express concerns about their lack of reciprocal friendships and difficulties maintaining and sustaining friendships (Church et al., 2000). Unsurprisingly, poor social skills in ASD have been linked to significant levels of anxiety (e.g., compulsive and ritualistic behavior, irrational fears and beliefs) and depression, (e.g., increased aggression, poor relationships with parents and teachers) (Capps, Sigman, & Yirmiya, 1995; Ghaziuddin, Alessi, & Greden, 1995; Ghaziuddin, Wieder-Mikhail, & Ghaziuddin, 1998; Green, Gilchrist, Burton, & Cox, 2000; Kim, Szatmari, Bryson, Streiner, & Wilson, 2000; Leyfer et al., 2006). However, adults and adolescents with ASD who possessed well-developed abilities to interact with others were more likely to participate in various social and recreational activities (e.g., attend weekly church services, socialize with friends/neighbors weekly) (Orsmond et al., 2004). These findings suggest that adolescents with ASD desire social interactions, and that increased social skills are likely to provide an opportunity for more successful social interactions and improved quality of life with decreased anxiety and depression.

SOCIAL SKILLS INTERVENTIONS FOR ADOLESCENTS WITH ASD

It is critical for adolescents with ASD to be instructed on various social skills so that they can develop relationships with peers, be successful in academic and vocational settings, increase their quality of life, and combat symptoms of anxiety and depression. However, there are only a handful of empirically supported interventions for social skills and the effectiveness of these interventions has been mixed (Barry et al., 2003; Bauminger, 2007a, b; Bellini, Peters, Benner, & Hopf, 2007; Charlop-Christy & Kelso, 2003; Gresham, Sugai, & Horner, 2001; Hwang & Hughes, 2000; Klinger & Williams, 2008; Krantz & McClannahan, 1993; Krasny, Williams, Provencal & Ozonoff, 2003; Lopata, Thomeer, Volker, Nida, & Lee, 2008; McConnell, 2002; Rogers, 2000; Ruble, Willis, & Crabtree, 2008; Solomon, Goodlin-Jones, & Anders, 2004; Tse, Strulovitch, Tagalakis, Meng, & Fombonne, 2007; Williams, Johnson, & Sukhodolsky, 2005). Across these studies, however, there is support for several strategies that lead to successful acquisition of social skills in individuals with ASD (see Gresham et al., 2001; Klinger & Williams, 2008; Rogers, 2000, for reviews). Klinger and Williams (2008) suggested that many successful social skills interventions utilize a “compensation” approach in which children with ASD are explicitly taught how to understand and interpret social cues and behaviors to compensate for their lack of implicit understanding of social information. Many empirically supported social skills interventions utilized similar techniques including incidental teaching, social stories and scripts, role-plays, self-monitoring, and peer-mediated activities (e.g., peer education, peer buddy). For example, Lopata and colleagues (2008) derived their social skills curriculum for high-functioning school-age children with ASD from the program Skillstreaming (Goldstein & McGinnis, 1997), which follows a specific stepwise procedure for teaching, modeling, role-playing, and feedback of a social skill. The specific rationale, details, and empirical support for several of these successful techniques are reviewed briefly prior to discussing their implementation in a group setting.

Incidental Teaching

Incidental teaching methods can be used within a social skills intervention to discuss social problems as they arise and also give constructive feedback about how to handle various social situations (McGee, Morrier, & Daly, 2001). For example, a therapist or teacher can point out when an adolescent with ASD has been talking about an intense interest (e.g., computer programming) for several minutes. This then gives the adult an opportunity to discuss how to initiate conversation about other topics people may be interested in (e.g., what people did over the weekend) and discuss how to recognize when others may be bored with a conversation (e.g., looking at their watch).

Social Stories and Scripts

Social stories (Gray, 1998, 2000) are short narratives that describe how to behave in social situations in a very explicit manner. Similarly, social scripts describe specific comments and questions that are appropriate in a given social situation (Barry et al., 2003; Charlop-Christy & Kelso, 2003; Krantz & McClannahan, 1993; Myles, Trautman, & Schlevan, 2004). Providing specific guidelines and rules for interacting with others not only explains a particular social situation, but also helps clarify the complex nature of the social environment and provides practical social solutions (Myles et al., 2004). For example, a social story or script may be utilized to explicitly instruct individuals with ASD on how to introduce themselves to others, how to ask for help in a classroom, how to initiate a conversation with a peer, and how to join a group of peers. Social stories and scripts are situation specific, and a variety of social stories and scripts are needed to address the individual social skills difficulties of each adolescent with ASD.

Role-Plays

Group role-plays provide an opportunity for the individual with ASD to practice a particular skill or strategy and observe others practicing the same skill (Barry et al., 2003; Goldstein & McGinnis, 1997; Klinger & Williams, 2008; Lopata et al., 2008; Ruble et al., 2008). Role-plays are typically preceded by the direct instruction of a skill (i.e., through a social story or script) so that adolescents have a foundation on which to then practice the skill. Examples of role-plays for adolescents with ASD might include how to ask a teacher a question during class, how to ask a friend to hang out over the weekend, how to initiate conversation with a peer about what they did over the weekend, and so on. For example, Barry and colleagues (2003) taught school-age children with ASD a social script for greeting other children and then had them role-play how to greet peers. Increased greeting behaviors were observed during interactions with unfamiliar peers in the clinic setting. However, parents did not report a statistically significant difference in greeting skills at home and school, suggesting that it is important to practice role-plays in various settings so that skills can generalize to different social environments (see Charlop-Christy & Kelso, 2003, for results that demonstrated generalization of conversational skills).

Self-Monitoring

Self-monitoring is an important tool that can be used to help adolescents with ASD keep track of their own progress in using appropriate social skills (see Lee, Simpson, & Shogren, 2007, for a meta-analysis on the use and effectiveness on self-management in individuals with ASD). Like role-plays, self-monitoring techniques are typically taught following direct instruction of a skill (i.e., through a social story or script). Self-monitoring can be used to track a variety of social skills including increased social interaction (e.g., the number of times an adolescent approached another person during a party) and increased appropriate social behavior (e.g., the number of times the adolescent asked a peer a question during a conversation). If an adolescent with ASD is able to monitor the proficiency with which they are utilizing certain skills in social situations, they will likely become increasingly successful at interacting with others and their self-efficacy in social situations will likely increase.

Because of increased symptoms of anxiety and depression and difficulty understanding and interpreting the emotions of others, adolescents with ASD benefit from strategies that help them to monitor their own emotions. Adolescents with ASD can learn to self-monitor their own emotions after basic education on emotion identification and coping. A picture of a thermometer can be used to demonstrate that different emotions are felt more intensely than others (e.g., annoyed is less intense than enraged) (Beebe & Risi, 2003). Reaven and colleagues (2007) used a similar technique for school-age children with ASD such that a stress-ometer was used to increase identification of anxiety symptoms and use of appropriate coping strategies (Reaven & Hepburn, 2003; Reaven et al., 2007). Adolescents can also write down the physical and mental cues associated with different emotional states on the thermometer, which can then help them determine how they are feeling (e.g., “When I am enraged my face is red and my thoughts race”). Last, coping strategies for different emotional states can be developed for each adolescent (e.g., “I need to listen to music when I'm enraged”). In addition, an emotion thermometer can be used to compare how other adolescents might feel in a particular situation and how their physical and mental cues and coping strategies may differ. Thus, emotion thermometers not only increase self-monitoring of emotions but also lead to an understanding of how others might feel in similar situations.

Peer Education

Peer education provides information (e.g., social difficulties, communication difficulties, repetitive behaviors, etc.) to students about their peers with ASD who may be in a general education classroom and/or special education classroom (Campbell, 2006; Campbell, Ferguson, Herzinger, Jackson, & Marino, 2004; Faherty, 2001; Swaim & Morgan, 2002). Results of peer education programs have been mixed. For example, Swaim and Morgan (2002) reported that children with typical development in third grade and sixth grade, who participated in a peer education program, rated a video of a child with typical development more favorably than a video of a child who displayed symptoms of ASD. However, children with typical development reported that they would likely participate in shared interests and activities with the child with ASD despite their unfavorable attitudes. In a replication of Swaim and Morgan's study, Campbell and colleagues (2004) found that children with typical development viewed the child with ASD more favorably when given both descriptive information (e.g., hobbies) and explanatory information (e.g., description of autism). In regards to issues that may affect the success or effectiveness of peer education, Campbell (2006) discussed the importance of factors such as source (e.g., likeability of individual facilitating peer education program), message (e.g., using descriptive information versus explanatory information), and the characteristics of the child with autism (e.g., appropriate vs. inappropriate social behavior).

Two of the most commonly used peer education programs are The Sixth Sense II (Gray, 2002) and Understanding Friends (Faherty, 2001). Both programs emphasize the ideas that individuals with ASD have similar abilities, interests, skills, and talents as children with typical development and encourage empathy and helping behavior. The curriculum in Understanding Friends (Faherty, 2001) consists of three main parts that include (1) discussing the idea that everyone has a different set of strengths and weaknesses; (2) participation in an experiential activity that gives exposure to the fine motor, visual, sensory, and auditory difficulties individuals with ASD face on a daily basis; and (3) an experiential activity that gives exposure to the receptive language difficulties that individuals with ASD face on a daily basis. The curriculum in The Sixth Sense II (Gray, 2002) does not provide a label of ASD but instead discusses the fact that some peers have an impairment of the sixth or social sense. It discusses common features that individuals with autism share with their peers (e.g., discussing how individuals with ASD have similar interests, strengths, and difficulties as children with typical development) and also discusses specific difficulties in social understanding and perspective-taking. Like Faherty's curriculum, this curriculum includes experiential activities that expose peers to some of the difficulties faced by students with ASD.

Peer Buddies

Peer buddies model appropriate social interaction abilities and provide feedback to adolescents with ASD regarding their own social skills (Wagner, 2001). Peer buddies can also be utilized in clinic, school (e.g., during lunch, gym class, recess), and community (e.g., during Boy Scouts) settings. In regards to choosing appropriate peer buddies, it is necessary to choose an adolescent who has well-developed social skills, has many friends, moves easily among same-age peers, has a calm personality, has a sense of humor, has empathy/helping skills, is liked by the adolescent with ASD, and is willing to be a peer buddy (Wagner, 2001). Parents or professionals should also get parental permission from the peer buddy's parents before proceeding (see Wagner, 2001, for an example of a parental permission form). Wagner (2001) recommended that a peer buddy receive peer education about ASD and suggestions about how to handle various situations that may arise (e.g., inappropriate comments, questions from other peers, etc.). The adolescent with ASD will also need an explanation regarding the purpose and function of the peer buddy (e.g., to help you make friends at Boy Scouts, to help you learn how to converse with others during drama club).

SOCIAL SKILLS GROUP INTERVENTION FOR ADOLESCENTS WITH ASD

Social skills group interventions for individuals with ASD are often conducted in a clinical setting and facilitated by psychologists, counselors, social workers, and/or therapists. Groups are also common in school settings facilitated by school counselors, special education teachers, or speech-language pathologists. There are few empirical studies examining the effectiveness of social skills groups with this population (e.g., Barry et al., 2003; Lopata et al., 2008; Ruble et al., 2008; Solomon et al., 2004) and even fewer studies that have included adolescents (e.g., Church et al., 2000; Orsmond et al., 2004; Tse et al., 2007). The authors conducted social skills groups for high-functioning adolescents (i.e., average to above-average cognitive abilities and daily living skills) with ASD in an outpatient clinic setting. Each social skills group consisted of four to six adolescents and was held bimonthly during the academic year from August through May. Therapists were graduate students earning their doctoral degrees in clinical psychology; they were supervised by a licensed psychologist. Topics that were covered in the social skills group were chosen by the adolescents with ASD or their parents and included dating, building conversation skills, making friends, managing anxiety and depression, and increasing participation in recreation and community activities. See Table 1 for a sample semester schedule. Although we don't have empirical data to support the effectiveness of our group interventions with adolescents, we used empirically supported strategies such as incidental teaching, social stories and scripts, role-plays, and self-monitoring techniques to build social skills.

TABLE 1 Sample Semester Schedule for Social Skills Group Intervention

• Session 1:	Get to Know Other Group Members
• Session 2:	Anxiety and Depression in Teens: How to Identify the Symptoms
• Session 3:	Anxiety and Depression in Teens: Using Relaxation, Visualization, and Deep Breathing to Cope
• Session 4:	Anxiety and Depression in Teens: Developing Individualized Coping Strategies and Putting Them Into Practice
• Session 5:	Friendships and Dating in High School: Learning the Basics
• Session 6:	Friendships and Dating in High School: Applying What You Know
• Session 7:	How to Apply and Interview for Part-Time Jobs
• Session 8:	End of Semester Party

Group Structure

Because individuals with ASD often experience anxiety in new and unstructured environments, we used a daily schedule to decrease anxiety and increase flexibility (see Kunce & Mesibov, 1998). At the beginning of each social skills session, the group leaders discussed the plan for that lesson and gave each participant an individual schedule. For example, a typical schedule outline included:

1. Socialize with other group members

2. Review homework assignment

3. Teach new skill

4. Practice new skill

5. Break: Eat snack and socialize with other group members

6. Role-play new skill

7. Assign homework

8. Parent time

The above schedule was used as an outline, and more specific details and activities were added depending on the topic being discussed or the skill being taught. For example, a schedule that outlined the topic of dating might have included items such as a worksheet that discussed the advantages and disadvantages of dating and a role-play on how to ask someone on a date (see Table 2 for an example of a detailed schedule used for a session focused on dating). Homework assignments were used to review topics discussed in group or to encourage the adolescents to think about upcoming topics. For example, the homework assignment for the session on dating was to write down what would be most rewarding and most challenging about dating. The adolescents then discussed their thoughts in the group setting and were free to comment or ask questions about the responses of the other group members.

TABLE 2 Daily Schedule for Social Skills Group on the Topic of Dating

1.	Socialize with other group members
2.	Review homework assignment (Write down what you think would be most rewarding and most challenging about dating.)
3.	Complete worksheet: “Thinking About Dating”
4.	Complete worksheet: “Advantages and Disadvantages of Dating”
5.	Break: Eat snack and socialize with other group members
6.	Complete worksheet: “How to Let Someone Know You're Interested in Them”
7.	Role-play how to show interest in members of the opposite sex
8.	Discuss how to ask someone on a date and write a social story about the topic
9.	Role-play how to ask someone on a date
10.	Parent Time

When learning and also practicing new skills, written worksheets were commonly used because we found that they increased concentration and attention on the topic, increased the likelihood of remembering what was discussed, and allowed for parents to discuss the topic with the adolescent at home. Worksheets were completed as a group, with the leader reading the questions aloud and asking for comments before the adolescents wrote down their answers. Group leaders used the questions and responses from the adolescents with ASD to teach a skill or provide guidance about how to handle a particular activity.

We used popular books, movies, television shows, and articles to emphasize session content and to provide examples from which the adolescents could model behavior. For example, group members read and discussed sections from an autobiography written by Luke Jackson, an adolescent with ASD. This book, Freaks, Geeks, and Asperger Syndrome: A User Guide to Adolescence (Jackson, 2002), contains chapters on topics such as dating, making friends, and disclosing one's diagnosis. We used these chapters to facilitate group discussion. For example, in his chapter on dating, Luke discusses tips such as “Try to talk to the person's friends and find out what they are interested in,” and “If the person you fancy is talking to you, try to listen and not interrupt them” (Jackson, 2002, p. 175). We also used video clips from several popular teen movies (e.g., The Breakfast Club, Mean Girls) to practice identification of other people's emotions using verbal, nonverbal, and situational cues. This was a particularly successful strategy and allowed us to evaluate the abilities of group members to not only identify emotions, but also to develop possible coping strategies that related to the particular emotion the teens in the movies displayed.

At the conclusion of each social skills session, parents were asked to join the group to discuss what topics, skills, and strategies had been discussed. The group members were encouraged to share their new skills or knowledge with their parents.

Adapting Empirically Supported Social Skills Intervention Techniques for a Group Setting

Incidental teaching

Group members were encouraged to frequently socialize with one another. The group leaders used incidental teaching methods (Wagner, 2001) to not only model appropriate conversation skills (e.g., commenting during a conversation, ending a conversation appropriately), but also to give the group members feedback about their own conversational skills in a constructive manner (e.g., how to initiate conversation about shared interests, transitioning to new topics, etc.). Group leaders also utilized incidental teaching to discuss perspective taking. For example, if an adolescent made an inappropriate comment (e.g., “Your haircut makes your ears stick out”) the group leader used this as an opportunity to discuss how the comment influenced another adolescent's feelings and how to use nonverbal cues (e.g., facial expressions, body posture, eye contact, sighing) and verbal cues to understand those feelings. Group leaders also used these opportunities to discuss the subtle differences between teasing and joking around or the difference between sarcasm and humor.

Social stories and scripts

Social stories (Gray, 1998, 2000) and scripts (Barry et al., 2003; Myles et al., 2004) were used to help adolescents with ASD learn new skills by explicitly writing down how to behave in a particular social situation. For example, during the session on dating, group members wrote their own social story about how to ask someone on a date after the topic had been discussed in the group setting. We found that social stories for adolescents were often longer than typical social stories developed for younger children so that the necessary details can be adequately covered. An example of a social script or story that we wrote to explain how to ask someone on a date is described below:

How to Ask Someone on a Date. When I am interested in dating a girl, I should do things to let her know that I like her. For example, I can talk to her about things she likes, compliment her, and get to know her friends better. If I decide that I want to ask the girl on a date, I should first ask my parents for permission. My parents can help me decide where I can take the girl on a date (e.g., movies) and when we can go on the date. Next, I can call the girl on the phone to ask her for a date. If she is not at home when I call, I will politely leave a message with my name and phone number so that she can call me back. If she is home when I call, I will ask her how she is doing and make small talk about things she likes to talk about for 1-2 minutes. Then, I will ask her if she would like to go to the movies with me this weekend and tell her that my parents can drive us to the movies. If she says YES, we will decide which movie to go to and the exact date and time of the movie. I will then let her know that I think we will have a fun time and that I will see her at school tomorrow. If she says NO, I will politely say that maybe we can go to the movies together another weekend and that I will see her at school tomorrow.

This social script makes the process of asking someone on a date very explicit for adolescents with ASD. For example, it discusses the steps that need to occur before asking someone on a date (i.e., talk to your parents about the specific details of going to a movie) and provides guidelines for how to respond if the girl is available to talk on the phone (i.e., ask her to go to a movie) and if the girl is not available to talk (i.e., leave a detailed phone message).

Role-plays

After creating social stories or scripts, each group member role-played the social scenario that was discussed. Our goals for using role-plays included the opportunity for group leaders to observe how proficient an adolescent has become at a skill and the opportunity for other group members to observe others implementing the skill. For example, after learning the dating script described above, each group member role-played how to ask someone on a date over the phone while a group leader played the part of the individual being asked out. Each group member was given the opportunity to practice how to leave a message when the girl he wanted to ask out was not home, how to respond when the girl did want to go on a date to the movies, and how to respond when the girl did not want to go on a date. For the session on applying for and interviewing for part-time jobs, the adolescents with ASD role-played how to ask for a job application (“I noticed that you are hiring cooks and bus boys. I am interested in these positions and was wondering if I could please have an application to fill out?”), how to clarify questions about the job application (e.g., “I have three references, but I notice you only have room for one reference. Would you prefer a previous employer?”), and how to respond to common questions that a job interviewer may ask (e.g., “My strengths are that I am a very organized person and always show up to appointments on time”). Following each role-play, constructive and positive feedback was provided by group leaders and other group members.

Self-monitoring

During sessions that focused on anxiety and depression, group members utilized an emotion thermometer to identify different intensities of an emotion, symptoms of that particular emotion, and how to cope with that emotion (see Figure 1 for an example of a completed emotion thermometer). Further, group leaders encouraged self-monitoring within sessions. For example, if an adolescent with ASD stopped participating in the discussion, put his head down on the table, and began picking his fingernails, a group leader might point out that these were the symptoms he had identified for feeling depressed on his emotion thermometer. The group leader could then discuss what coping strategies the adolescent could use to increase his mood (e.g., taking a few deep breaths, talking to a friend, etc.).

FIGURE 1 Emotion thermometer worksheet for feeling depressed.

In addition to monitoring their own emotions, we found that it was important to provide adolescents with coping skills to use when they were upset. Each adolescent was encouraged to identify individualized coping strategies (e.g., drawing, cooking, reading, taking a bath, playing a board game, etc.) for dealing with anxiety and depression. After thinking of coping strategies, the adolescents with ASD then constructed their “emotion toolbox” (see Attwood, 2004) by collecting objects (e.g., stress ball, picture of a family member), drawing pictures, cutting out magazine pictures, or writing the coping strategies on index cards, and then placing them in a box. Each adolescent was encouraged to keep his or her “emotion toolbox” in the bedroom where it would be seen frequently and was easy to find when the adolescent was upset.

SOCIAL SKILLS INTERVENTION IN A SCHOOL SETTING

Although our social skills groups are implemented within an outpatient clinic setting, social skills groups can be implemented in a school setting with school counselors, special education teachers, or speech-language pathologists serving as group leaders. However, many middle and high schools may not have enough students with ASD to form a group. In this situation, individual instruction might be necessary. Regardless of whether skills are taught in a group or individual setting, these skills need to be practiced outside of the therapy group in “real-world” environments. This is particularly important for adolescents with ASD who have difficulty generalizing social skills learned in a clinic setting to other environments (see Barry et al., 2003). Regardless of whether the adolescent with ASD is included in the regular education classroom, receives resource services while included in the regular education classroom, or is in a special education classroom, the school setting provides opportunities for additional contact with same-age peers so that social skills can be learned, maintained, and generalized.

The success of social interactions in the school setting benefits from the inclusion of typical peers through the use of peer buddy programs, incidental teaching, and peer education (see Klinger & Williams, 2008; Wagner, 2001, for a description of each). In our clinical work, we have utilized Gray's (2002) peer education curriculum, The Sixth Sense II, to educate a middle-school classroom about a classmate with ASD who was in their general education classroom full-time. The student had a diagnosis of high-functioning ASD, was doing well academically, and participating in various extracurricular activities with his peers. However, the student with ASD was frequently teased for his intense interest in a particular book series and had difficulties comprehending when his peers were joking rather than teasing him. In this particular example, the student did not want to be identified as having autism or having difficulties with his social sense during the peer education, but did remain in his classroom during the presentation. Thus, The Sixth Sense II curriculum (Gray, 2002) seemed most appropriate as it does not label a particular child. Using this curriculum, we discussed a fictitious student named “Jack” with middle-school students:

Jack is in 7th grade and doesn't have many friends. He seems really shy and has trouble speaking up in class and does not like to answer questions that the teacher asks. He has trouble speaking up during group projects, and while he wants to have a group of friends, he has difficulties joining in because he gets nervous he will make a mistake. However, Jack is really good in science and knows a lot about topics such as animals, space, and airplanes/jets. Lots of people make fun of Jack because he doesn't talk much, and because he seems “weird,” no one ever sits with him at lunch.

Following this scenario, we asked students to describe the parts of the social sense that are hard for Jack, to identify the things that Jack is good at, and to identify ways that they could help Jack. After the peer education, the adolescent with ASD felt that his classmates understood him more and were friendlier to him than they had previously been. He also began eating lunch with two peers when he had previously eaten lunch by himself.

We conducted a similar peer education for a middle-school student with ASD who also had moderate intellectual disability and engaged in occasional motor tics when he was in the special education and general education classrooms. In this case, the adolescent's parents and teachers felt that some autism-specific peer education would be important to helping peers understand the adolescent's unusual behaviors. Thus, we adapted The Sixth Sense II (Gray, 2002) curriculum to educate the student's peers about autism and the student's specific autism symptoms. More specifically, classmates were informed that many people who had difficulties with the social sense also had a diagnosis of autism. The symptoms of autism were discussed in detail, and various examples were given. We then disclosed the name of one of their classmates who had autism and discussed the particular symptoms of ASD he displayed (e.g., poor eye contact, intensely interested in maps, vocal and motor tics) and specific ways to interact with him. As a result, this adolescent's classmates were more accepting of his unusual behaviors and also increased their attempts to include him in classroom activities.

SOCIAL SKILLS INTERVENTION IN A COMMUNITY SETTING

Although individuals with ASD will undoubtedly benefit from social skills interventions in the clinic and school settings, it is also critical that they receive instruction in how to engage in social interaction within the community. Research has demonstrated that participating in outside social activities leads to increased social skills and daily living skills in adolescents with ASD (see Orsmond et al., 2004).

There are many opportunities for individuals with ASD to participate in extracurricular activities through school and the community, and they should be encouraged to participate in any interesting social and recreational activities when possible. In particular it may be most beneficial to encourage participation in an activity that is related to the adolescent's intense interest or hobby, which often requires creativity and planning on the part of the parent or professional. For example, if an adolescent enjoys reading about basketball and memorizing the stats and scores of his favorite basketball players and teams, he can be encouraged to join the school's basketball team. However, because adolescents with ASD often have difficulties with fine and gross motor coordination, it may be more beneficial and enjoyable if the adolescent could assist the coach with managing the team (e.g., helping out with drills, getting necessary equipment ready, being in charge of keeping track of players' statistics, etc.). Other examples of matching adolescents' interest with a particular activity include encouraging the adolescent to join a band if they enjoy music or to join the art club if they enjoy painting and drawing. Thus, the adolescent will get the opportunity to participate in something he enjoys and will be placed in a situation where he will be interacting with adults and peers.

Although it is important to increase social interaction through participation in social and recreational activities, adolescents with ASD will likely benefit more if they are provided with the opportunity to build their social skills and learn how to interpret various social cues in different contexts. More specifically, the use of peer buddies who are also participating in the same social activity would allow the individual with ASD to benefit from the modeling of social interaction abilities and also receive feedback regarding their own social skills from the peer buddy.

In our clinical experience, we have assisted with the development of a peer buddy program for an adolescent with ASD who was involved in her church's youth group. The youth group met on Sunday mornings and Wednesday evenings but also had frequent outings such as scavenger hunts, going out to eat, going bowling, watching a movie at the group leader's house, etc. The adolescent with ASD was very reluctant to participate in any of these social activities and frequently demonstrated symptoms of anxiety and anger when her parents encouraged her participation. When the adolescent with ASD did attend these various youth group events she rarely initiated conversation, was unlikely to respond to the conversation attempts of others, and sat by herself whenever possible. Despite the fact that the adolescent had been taught these specific skills in our social skills group, she was not implementing these skills in a real world setting. The authors first decided to conduct a peer education with the youth group that the adolescent with ASD did not attend. More specifically, the authors utilized The Sixth Sense II (Gray, 2002) but also disclosed the adolescent's diagnosis and discussed the specific symptoms that the adolescent often displayed. The participants in the youth group had many questions, and these were addressed in great detail with the focus on how to facilitate social interaction with the adolescent with ASD (e.g., call her on the phone to invite her to social activities, etc.).

After the peer education had been completed, the mother of the adolescent with ASD expressed interest in also choosing a member of the youth group as a peer buddy. One particular girl stood out as a good candidate for a peer buddy because she was very friendly, socialized with several adolescents in the youth group, had expressed empathy and concern for the adolescent with ASD during the peer education, and had well-developed social skills. In addition, the adolescent with ASD also liked the potential peer buddy because they shared an interest in the same television show. When permission was obtained from the peer buddy and the peer buddy's parents, the authors trained the mother of the adolescent with ASD on how to provide guidance, education, and support for the peer buddy. More specifically, the authors discussed that the mother should review common social difficulties her adolescent with ASD encountered and give specific examples of how to appropriately model or give feedback about these social difficulties. For example, the adolescent with ASD rarely made eye contact when conversing with others, and the peer buddy could help increase this skill by gently reminding the adolescent with ASD to look at her when talking or give her feedback about her eye contact after she had conversed with others. The mother was encouraged to check in with the peer buddy to ensure that she was effectively modeling appropriate social skills and felt comfortable working with the adolescent with ASD. The authors also encouraged the mother to provide the peer buddy with occasional reinforcement for her effort (e.g., book, gift certificate to the movies).

Thus far, the adolescent has benefitted immensely from the peer education at her youth group and the peer buddy. The adolescent with ASD frequently attends various youth group activities and also occasionally talks to her peer buddy on the phone. Her parents also reported that she seems to be experiencing less anxiety and anger regarding attending youth group.

SUMMARY AND CONCLUSIONS

Adolescents with ASD are faced with increasingly complex social situations that require them to decipher a variety of social cues despite their social impairments. In addition, though adolescents with ASD often experience anxiety, depression, and low self-esteem as a result of their social deficits, those adolescents with ASD who have increased social skills are more likely to have reciprocal friendships and participate in social and recreational activities (Orsmond et al., 2004). Thus, it is necessary for social skill interventions to be implemented in the clinic, school, and community settings to increase learning, maintenance, and generalization of social skills so that adolescents can successfully transition to other developmental stages including secondary education and employment. Despite the clinical need for providing social skills interventions for adolescents with ASD, there is a dearth of empirical literature supporting the effectiveness of these interventions. Future research is clearly needed to develop and assess the efficacy of social skills interventions for adolescents with ASD.