When children enter school, their social communication skills are developed and refined through day-to-day interactions with peers. Effective social communication interventions for preschoolers and school-age children with ASD emphasize strategies for facilitating these important peer interactions, and may include training the peers of children with ASD. Peer training packages or peer-mediated interventions aim to teach and reinforce peers for their attempts to interact with children with ASD. Although peer-mediated interventions provide more opportunities for children to interact, most children with ASD will continue to require direct and specialized interventions to learn and refine specific social communication skills. Evidence-based social communication interventions for children with ASD include published programs such as the Picture Exchange Communication System (Frost and Bondy 1994) and Social Stories^TM (Gray 1995, 2000), specific strategies such as video-based instruction and script training, as well as investigator and clinician-designed packaged interventions targeting social skills, social pragmatic skills, and social cognitive skills. “Packaged” interventions incorporate multiple procedures and strategies to teach children one or more social communication skills. A review of these interventions follows.

Inclusive preschool classrooms offer children with ASD opportunities to learn social communication skills through interactions with typically developing peers. Unfortunately, observations of peer interactions within inclusive classrooms reveal that children with high and low levels of social communication abilities do not usually initiate and sustain interactions with each other. For example, some children with ASD ignore or respond inappropriately to typically developing peers’ attempts to engage them in conversation, and in turn, typically developing peers limit their interactions with children with ASD (see reviews by Sainato et al. 2008; Strain et al. 2008).

Peer training packages or peer-mediated interventions are an evidence-based method for increasing the interactions of children with ASD and their typically developing peers (National Autism Center 2009). These interventions train peers to initiate and to persist in their efforts to interact with children with ASD. For example, Thiemann and Goldstein (2004) taught peers five social communication skills to use during interactions with children with ASD: (1) “look, wait, and listen” to allow a child with ASD to initiate an interaction with the peer; (2) “answer questions” to encourage the peer to respond to the child with ASD; (3) “start talking” to initiate an interaction; (4) “say something nice”; and (5) “keep talking” to sustain the interactions. The peers were taught each of these skills through modeling, role-play, and adult feedback. Upon completion of the peer training, each peer was paired with one child with ASD (in peer training interventions, the child with ASD is referred to as the “focus child”) during a 10-minute social activity in the classroom. Just before the social activity, the peers reviewed the five social communication skills and a visual feedback system of happy, neutral, and sad faces was introduced to encourage the peers to perform each of the social communication skills. Peers were informed that if they used each skill at least two times during the social activity with their individual focus child, they would receive a prize. The focus children also received a written text intervention comprising phrases that they could say during the social activity (script training is reviewed in a later section of this chapter). Positive changes were demonstrated in the quantity and quality of the interactions including increases in the focus children’s initiations, responses, and time spent engaged with peers. Table 14.2 provides guidelines for implementation of peer-mediated interventions in preschool and school settings.

PECS is a manualized intervention program for teaching minimally verbal children with ASD to initiate interactions with another individual. Through a series of sequential steps, the child is taught to initiate a request by giving/exchanging a picture symbol of a desired activity to a communication partner. A meta-analysis of PECS intervention studies revealed that PECS was more effective than traditional joint attention interventions for increasing the communicative behaviors of children with limited joint attention skills (Flippin et al. 2010). PECS does not require prerequisite skills such as imitation, gesture, or joint attention. As such, PECS is often introduced as an alternative communication system for children with limited verbal skills and for children who are difficult to engage in social interactions. One important clinical finding from the meta-analysis is that children with some preintervention joint attention skills had better communication outcomes with joint attention interventions than with PECS (joint attention interventions were reviewed in a previous section of this chapter).

PECS has traditionally been used to increase interactions between a child and an adult but a few studies have documented the benefits of teaching children with ASD to use PECS with classroom peers (Cannella-Malone et al. 2010; Garfinkle and Schwartz 1994; Schwartz et al. 1998). The PECS with peers protocol (Garfinkle and Schwartz 1994) uses teaching techniques similar to the original manualized training. However, environmental arrangements are implemented so that the child receiving PECS training needs to initiate the picture exchange with a peer. For example, small group activities are set up so that a peer, rather than an adult in the room, controls the child’s favorite material. If the child attempts to give the picture to the adult, the adult redirects the child’s attention to the peer who has the desired material, by stating, “I don’t have it. Ask (peer’s name).” If this verbal prompt is unsuccessful, the adult provides a physical prompt by guiding the child’s hand and picture, to the peer with the material. Some peer training is needed to increase the effectiveness of the PECS with peers’ protocol. The peer must be taught the purpose of the exchange; that is, that the child with ASD is requesting the object or activity represented in the picture and that the peer should honor this request (Cannella-Malone et al. 2010).

Social Stories^TM are a visual and text-based intervention developed by Gray (1995, 2000). The purpose of the social story^TM is to describe a social situation including what the child could say or do to appropriately manage the situation. Examples and comprehensive directions for developing social stories^TM are available in a curriculum guide (Gray 2000). Ideally, a social story^TM should be individualized for a specific child and written from a first person “child” perspective, be relatively brief, and written at the child’s comprehension level. The story should include positive statements about feelings and actions and avoid or limit negative statements (e.g., “don’t do this”). Gray (1995) recommends that the story comprises one directive statement for every two other types of statements so that the story is not a list of “should do’s” for the child. Other statements include descriptive (facts about the situation), perspective (the reactions, feelings, and responses of others), and cooperative statements (what others will do in the situation). For example, Ozdemir (2008) developed social stories^TM to decrease disruptive behaviors in three children with ASD. Examples of descriptive, perspective, and directive statements in the study’s stories included: “People talk quietly when they are in class. If I talk quietly, my friends and teachers can still hear me. I will try to use a quiet voice while I am in class.”

Social story^TM intervention sessions usually comprise two parts. First, the story is presented to the child by an adult who remains near the child as the child reads the story or listens to the story if the child is unable to read it. Stories can also be presented via audio recordings or computers. Then the child is placed in the situation described in the story. For example, if the social story^TM is about using a quiet voice in class, the story is presented to the child just immediately before the child is to sit in the class. The story can be introduced several times a day across several weeks. When the child begins to demonstrate a stable change in the desired behaviors, procedures to fade the presentation of the story can be initiated. Fading procedures include reducing the number of times that the story is read to the child or reducing the number of directive sentences in the story (Wallin 2004). If changes in the targeted social behaviors are not observed after several weeks, Gray (1995) recommends rewriting and reintroducing the story. Once the skills of a story are mastered, the stories can be kept in a binder so that the child can review them as needed. Social stories^TM should be a “team” intervention. All the child’s teachers and caregivers should be aware of the specific social communication targets in the story so that they will reinforce those behaviors when they observe them.

Story-based intervention packages including the use of social stories^TM as described here are classified as established evidence-based interventions for children with ASD (National Autism Center 2009). A recent meta-analysis of six controlled trial social story^TM dissertation studies revealed positive changes in children’s game-playing skills, story comprehension, labeling of facial emotions, social communication skills, and reduction of aggressive behaviors (Karkhaneh et al. 2010). The intensity of the social story interventions varied from two presentations of the story during a single intervention session to ten presentations across the school day with the duration of the interventions lasting from 2 days to 1 month. Studies that demonstrated the most positive outcomes were those that presented the stories in highly structured and predictable settings with well-controlled environments and well-trained personnel.

Script training interventions comprise verbal, pictorial, and/or written scripts of explicit statements or questions to be used in a small group in vivo activity or a role-play. Scripts for role-play have also been called sociodramatic scripts (see Goldstein et al. 2007 for review). Scripts are usually introduced and practiced repeatedly just before the child with ASD and his or her peers will engage in the activity or the role-play. An important component of a comprehensive script training intervention is systematic procedure for fading the use of the script so that the child’s production of the statements and questions becomes independent of script availability. Fading can be accomplished by systematically omitting parts of the script.

Krantz and McClannahan (1993) introduced script training to four children, ages 9–12, with ASD. The intervention was implemented because the children did not spontaneously initiate interactions with peers unless verbally prompted to do so by their teachers. Written scripts of ten statements and questions to be used during classroom activities were developed in collaboration with the children’s teachers. As the scripts were written, the children’s oral reading accuracy for the scripts was tested prior to the start of the intervention. The scripts were introduced during classroom art activities when talking among students was allowed. As children began the art class, they were prompted nonverbally (via pointing by their teacher) to read instructions posted at their desks: “Do your art.” and “Talk a lot.” These statements were followed by the script statements such as “{Name—the names of children in the group activity} do you want to use my {pencils/crayons/brushes}?” “{Name} won’t it be fun to go to the {park/store/farm} on Fun Friday?” “{Name} I like your picture.” No verbal prompts were used to encourage the children to read the script. Instead, the teacher stood behind the child and manually guided the child to pick up a pencil, pointed to a scripted statement or question, and then moved the pencil word-by-word below the text. If the child did not read or say the statement/question within 5 seconds, the manual guidance procedure was repeated. In some cases, the teacher also manually guided the child’s head to face the peer who was being addressed. If the child did read the script, the child placed a check mark next to the statement or question each time he or she produced it. Manual prompts were eliminated as soon as the children began to read without the prompts (across the four children, 15–27 intervention sessions were needed before the prompting was discontinued). As soon as the manual prompts were eliminated, script-fading procedures were initiated. Scripts were faded word-by-word beginning with the end of the statement or question (e.g., “{Name} won’t it be fun to go to the {park/store/farm} on …..?”) until the statement was reduced to {Name} and quotation marks. By the end of the intervention phase, children were producing scripted and unscripted spontaneous initiations to peers. Children’s responses to the initiations of their peers also increased.

Script training interventions have recently been classified as emerging evidence-based interventions (National Autism Center 2009). Effective script training requires a collaborative effort among children’s teachers, speech-language pathologists, and other service providers. Script development requires this team effort so that script statements and questions are individualized and appropriate for multiple situations to facilitate generalization of statement and question use across settings and partners. A potential disadvantage of script training interventions is that children can become dependent on the script if systematic fading procedures are not programmed within the intervention. McClannahan and Krantz (2005) provide practical guidelines, scripts templates, and script-fading techniques to assist with the implementation of script training.

Video-based instruction (VBI) is an intervention strategy that involves the demonstration of one or more social communication behaviors. Alternative names for this intervention strategy include video instruction, video modeling, and video-taped modeling. A video-based intervention session usually consists of the child watching a short video of himself or herself (i.e., self-modeling) or others (peer modeling) performing a sequence of social communication behaviors. After watching the video, the child is given immediate access to an identical set of materials, communication partners, the activity, and the setting that were presented in the video. Little, if any, verbal explanation is provided; rather the expectation is that the child will imitate the words and actions that he or she has just observed.