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Social Skill Training For Children With Aspergers Syndrome

In 1944 Dr. Hans Asperger, an Austrian pediatrician, formally described the nature of a syndrome he had observed in children. It has since become known as 'Asperger's Syndrome', abbreviated 'AS'. The syndrome is now understood to be a neuro-biological disorder within the range of autism spectrum disorder, with several similarities to high-functioning autism (HFA). An exact assessment of the prevalence of AS is yet to be obtained. However, AS appears to be a relatively rare or uncommon disorder that is more prevalent in males than in females (Solomon, Goodlin-Jones & Anders, 2004). The intelligence level of those with AS is neither unusually high nor low, falling within the range of normal intellectual capacity. The syndrome is characterized by qualitative impairments of social interactions and subtle communication skills, and a distinct set of cognitive skills that are apparent from early childhood (Rao, Beidel & Murray, 2008). The child may be incapable of establishing friendships that correspond to the child's level of development. As well, the child may not be able to make or recognize the appropriate use of non-verbal communication behaviors in social interactions. Typically, children with AS do not have difficulties with speech, and exhibit normal language fluency. They do, however, tend to have poor conversation skills and to speak pedantically with unusual word usage. They also tend to interpret everything they hear quite literally, without recognizing nuance and suggestion, sarcasm, and other inflectional manifestations. The cognitive skill set of children with AS includes unusually intense special interests in equally unusual topics, with a tendency to focus intently on errors and small details. Paradoxically, their preference for routine and consistency in their daily lives is coupled to poor organizational and time-management skills. As with HFA, those with AS may exhibit a heightened sensitivity to sound and touch, as well as impaired motor skills and clumsiness (Solomon et al., 2004).

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Current theory is that AS is a Pervasive Developmental Disorder; it does not have a specific cause, being due to effective brain development and not due to emotional deprivation or other such causative forces. Correspondingly there is no specific treatment and interventions are rehabilitational based on symptoms. This is reflected in the literature of AS.

Interventions in AS:

If one were to read between the lines of the literature of AS, the conclusion could be drawn that the all interventions that have been designed and tried have targeted the social deficits of the child diagnosed with AS. Since the cognitive skill set of AS is primarily a list of normal social abilities that do not develop or that develop poorly with AS, it should not be surprising that interventions seek primarily to alleviate or amend the severity of those associated symptoms. Social skills adjustment appears therefore to be the most significant, if not the only, direction of the various therapies and interventions that have been documented in the literature. The common feature of all such approaches has been to utilize activities and environments in which social interaction with non-AS peers is the developmental driver of behavioral change in subjects with AS. Examples range in complexity from the simple activity of using LEGO® building blocks to cooperatively assemble structures and objects, to the more complex activities of Social Stories and Video Self-Modeling (VSM). Between these extremes are approaches in which the AS individual's own siblings fulfill the roles of social models during therapy sessions designed to affect the social abilities of the AS subject.

Social Stories:

The Social Stories approach is generally implemented in the normal school environment and utilizes simple story telling methods to present normal social behaviors in a way that the AS subject can internalize (Owens, Granader, Humphrey & Baron-Cohen, 2008). The desired outcome of the approach is that the AS subject will subsequently alter his or her behavior through expression of the behaviors that have been internalized through the stories that have been assimilated. The effectiveness of the Social Stories approach is reported to be highly variable, however, which suggests that the approach may not have a suitably robust foundation for general effectiveness. That is to say, the approach does not have the same effectiveness with each case of AS. Thus, while the Social Stories approach may in fact have a consistent level of effectiveness, the variation in the nature of different cases of AS produce different effective results from the therapy. In comparison, peer-mediated approaches seem to produce more consistent results than are achieved through Social Stories approaches. This may be due to an environmental factor by which the AS subject is better able to identify with the peer mediator and therefore be more likely to assimilate the desired behavioral skills than otherwise would be the case (Owens et al., 2008).

LEGO® Therapy:

In the application of LEGO® therapies the central activity is simple and constructive. The objective is to have the AS subject work at shared construction projects with a mediator. The task of the mediator is to utilize correct social behaviors and so guide the AS subject to incorporate those behaviors into his or her own. This approach calls for the mediator to enable the AS subject to identify behaviors and non-verbal social cues, and to reinforce the utilization of those behaviors and social cures (Owens et al.,2008). It is reported that the appeal of this approach for the AS subject derives from the nature of LEGO® as an innately tactile, highly-structured, systematic toy with very predictable outcomes. These are qualities that are in excellent accord with the characteristics of children with AS in regard to order, attention to detail and enhanced tactile sensitivity.

In conjunction with LEGO® therapy, the curricular methodology of the Social Use of Language Program (SULP) has also been employed. The focus of the SULP methodology is the development of social cues such as direct eye contact, the ability to 'take turns' during activities, listening skills and oral language skills. It is thus a less tactile, more aural approach than LEGO® therapy, and provides complimentary reinforcements and training for the improvement of social skills. The application of the SULP methodology seems to require the use of reward incentives in order to maintain a level of commitment from the subjects; without such incentives the sessions tend to become progressively more disorganized as the participants lose focus on the tasks at hand (Owens et al.,2008).

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Carried out with subjects aged 6 - 11 years, the combined methodologies of LEGO® therapy and the SULP are reported to have produced significant improvements in the social skills and abilities of both AS and HFA subjects.

Social Adjustment Enhancement and Social Skills Training Programs:

The majority of studies carried out seem to have employed various social adjustment enhancement programs. Such programs typically take the form of a structured program spanning a specific period of time. Subjects generally experience a group session and an individual session once per week for a specific number of weeks during the course of such a program. Social Skills Training (SST) programs have been reported in the literature spanning periods ranging from 6.5 weeks to a full academic year in duration, involving anywhere from 3 to 46 subjects in specific age groups (Rao et al., 2008).

SST or Social Adjustment Enhancement (SAE) programs are designed around a curriculum that targets specific hypothesized social deficiencies in AS subjects. These have been reported as the recognition of emotions in self and others, recognition of facial expressions, theory of mind and perspective, various executive functions such as individual and group problem solving, and basic conversational skills.

Central to the successful execution of any study is the means to assess quantitatively the outcomes achieved in the study. In an SST or SAE program, this translates into the ability to measure changes in the nature of the specific attributes being tested and the direction in which those changes have occurred. Accordingly, a restriction is placed on the design of any such program in that the valid means of measurement must already exist or can be developed and validated in the course of the study in question. In cases for which the attribute can be numerically identified, as for example with the yes-or-no identification of emotions in facial expressions, quantification is not difficult. On the other hand, in cases in which assessment of the AS subject's change of social ability rests on subjective opinion quantification and subsequent analysis becomes very difficult. Adding to the difficulty in determining whether an intervention has produced a significant result is the low number of participants in any one study. In studies with very low numbers of participants quantitative results relate well to the individual participant, but not necessarily to the group as a whole. As the number of participants increases, quantitative results of statistical analysis become more relevant to the group as a whole, while individual results retain their value for assessment on a case-by-case basis. The results from larger study groups are apparently more readily extrapolated with a higher degree of reliability to the general population. The key to obtaining good usable results in SST and SAE studies is to ensure that extensive logs of behaviors and their changes are kept by the study leaders so that assessments can be as accurate and quantitative as possible (Rao et al., 2008).

One other important consideration in studies that take place over an extended period of time is that of maturation of the individual subject. In monitoring the changes in social and cognitive abilities of subjects, the assessment tools that are utilized must be able to identify and account for changes that can be ascribed to a naturally higher level of maturity in the appropriate subjects. Failure to account adequately for such changes has the potential to skew interpretation of the results to the point of being entirely inconsistent with actuality

Video Self Modeling:

Video modeling is a technology-based method used primarily with autistic subjects, but which is nevertheless amenable for use with SA subjects. The technique involves the preparation of video specific to a characteristic that is to be adjusted. For example, video footage of an individual or group carrying out or exhibiting a desired behavior is shown to a target subject group. The desired outcome of the method is internalization and subsequent expression of the behavior by the subjects of the intervention, and in this the method has a commonality with the Social Stories method. Video self modeling is a more advanced version in which the video footage is edited so that it shows the subject of the intervention performing the actual behavior, rather than some other person. The theoretical basis for VSM is that the subject will more readily identify the behavior and comprehend that this is the behavior that he or she is to assimilate and express (Litras, Moore & Anderson, 2010). The results obtained with VSM are contentious and subject to different interpretations by different researchers in regard to their significance and validity. It is reported that the efficacy of behavior change was the same regardless of which video method was employed, though VSM has been shown to be effective in improving language and social initiations, verbal response to questions, and spontaneous requesting.

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