Sam Goldstein and Jack A Naglieri (eds.)Interventions for Autism Spectrum Disorders2013Translating Science into Practice10.1007/978-1-4614-5301-7_9© Springer Science+Business Media New York 2013
9. Progress for Remediating and Expanding Social Skills (PROGress)
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The Children’s Center, 350 South 400 East, 84111 Salt Lake City, Utah, USA
Abstract
Social interactions form the building blocks for much of human development. Children learn from other people and through play with peers. Their ideas, skills, and interests are shaped by these exchanges. For persons with autism spectrum disorders, interactions and friendships may be no less valuable, but they are far more difficult to establish. The ability to connect with others, participate in exchanges, learn from interactions, and enjoy relationships with others is impaired (American Psychiatric Association in Diagnostic and statistical manual of mental disorders: DSM-IV-TR, 2000; Bauminger and Kasari in Child Dev 71(2):447–456, 2000; Bauminger and Shulman in Autism 7:81–97, 2003; Daniel and Billingsley in Focus Autism Other Dev Disabl 25(4):220–229, 2010; Locke et al. in J Res Spec Educ Needs 10(2):74–81, 2010).
The better part of one’s life consists of his friendships…—Abraham Lincoln
Social interactions form the building blocks for much of human development. Children learn from other people and through play with peers. Their ideas, skills, and interests are shaped by these exchanges. For persons with autism spectrum disorders (ASD), interactions and friendships may be no less valuable, but they are far more difficult to establish. The ability to connect with others, participate in exchanges, learn from interactions, and enjoy relationships with others is impaired (American Psychiatric Association 2000; Bauminger and Kasari 2000; Bauminger and Shulman 2003; Daniel and Billingsley 2010; Locke et al. 2010).
Social difficulties are a core deficit of autism. Research has consistently documented social deficits common to autism spectrum disorders, including: difficulty understanding or deciphering subtle social cues such as facial expressions, tone of voice, and body language; deficits in joint attention; difficulty joining peer conversations or interactions; struggles with fully processing verbal and nonverbal communication; and/or uncertainty regarding expectations in different social environments (American Psychiatric Association 2000; Siegal and Blades 2003; Tager-Flusberg 1999; Wetherby et al. 1998; Wetherby and Prutting 1984). For most people with ASD, these difficulties define their most challenging experiences. Because of them, attempts at navigating peer and social settings often result in confusion, anxiety, and depression (Barnhill 2001; Bellini 2006; Myles et al. 2001; Wing 1981). Repeated failed attempts at social interaction may lead to decreased social interest, and/or an aversion or avoidance of social situations. In general, persons with ASD are often uncertain as to how to read their social environment, inappropriate in engaging in it, or excluded by peers from participating in it.
Difficulty and failure in peer social interactions are frequently experienced from a very early age. Their impact is far reaching, often negatively affecting the interpersonal relationships of persons with ASD, across their entire lifetimes (Howlin 2000; Levy and Perry 2011; McGovern and Sigman 2005; Seltzer et al. 2003). Furthermore, these negative experiences become highly difficult to impact or change (Bellini 2006; Farrugia and Hudson 2006).
Traditional behavioral interventions for children with ASD, including social skill development, are typically provided in individual therapy sessions, one-on-one with an adult. Individual skills or behaviors are often taught in isolation and outside of a social context. In these programs, intervention in peer settings does not begin until late in a child’s therapeutic program, when generalization of the isolated skills becomes the goal. More recent behavioral interventions offered within natural environments typically focus on acquisition and use of specific behaviors important in interactions. Similarly, group social skills interventions typically teach and practice specific skills using adult instruction or peer mentoring strategies. While these models are highly valuable, there are few published group curricula for young children with ASD and those reported do not commonly utilize the genuine social peer environments in which these children typically participate or wish to join. Furthermore, they tend to lack critical emphasis on the affective and/or social emotional experiences of the child. Also, lacking is a therapeutic opportunity to regularly experience natural peer groups as fun, positive, enjoyable, and successful.
This chapter will discuss a group social skills intervention model that aims to change the cycle of social failure often experienced by children with ASD by creating an environment that fosters successful peer engagement. In this model, a positive peer environment is created within which children with ASD experience a sense of belonging, joy, and excitement at attending, as well as satisfaction and success in engaging with peers. This environment sets into motion a completely different and far more facilitating experience than is usually experienced by children with ASD in group peer settings. By creating an environment that fosters natural and successful peer engagement and interactions early on, young children with autism spectrum disorders can experience, learn, and succeed in peer play much as their typical peers do. As a result of these early positive experiences, children with ASD can develop positive social foundations with which to learn needed skills, seek continued friendships, and experience social successes. Furthermore, by providing environmental supports such as structure, predictability, language scaffolding, and visual instruction, described later in this chapter, the participants are supported in and freed from the typically confusing and anxiety-producing elements that usually challenge them. They are then “freed up” to recognize, practice, and experience success with social interactions and needed skills. In such an environment, the children can experience the natural and often unpredictable social elements of peer group interactions. They can learn what to do, how to do it, and with whom. They can develop motivation to engage with peers, learn to seek interactions, perceive peer social experiences positively, and establish genuine friendships. Support and structure can help them understand and manage the situations as they arise. Ultimately, they can experience success in authentic and intrinsically motivating peer interactions, and can experience the joys of friendship and interaction often achieved by their typical peers.
The PROGress Model and Curricula
The PROGress Model (PROGram for Remediating and Expanding Social Skills) described in this chapter is designed for early school-age children, ages 4–9, with autism spectrum disorders. The concepts presented incorporate intervention strategies demonstrated as effective in clinical and research literature. This model can be easily adapted for children and young adults of varying ages and abilities. Furthermore, while this model has been implemented with hundreds of children in an after-school clinical setting, it can also be easily adapted for school settings as well. Adaptations to the model described are discussed later in the chapter.
The PROGress Model is designed as a 25-week curriculum, consisting of up to five units that each last for 5 weeks. The first 4 weeks of each unit introduce and build skills, while the fifth week is designed as a generalization session, typically involving a community outing. This format is designed to parallel a typical school year, giving children an opportunity to settle into their classroom settings prior to beginning the group. Similarly, the sessions run weekly and thus end just before the school year also ends. The 25-week curriculum is successful in providing needed time for genuine friendships and relationships to develop, as well as ample time for the basic skills to be repeatedly practiced and honed, while additional skills can be added and developed.
Each session typically lasts for 75–90 minutes. This provides adequate time to include organized opening and closing routines, skill development and practice, and snack time to further enhance social skills and generalization. The PROGress Model also utilizes a 1:3 or 1:4 adult to child ratio within the groups, with a maximum of 12 children enrolled. Both the group size and the adult child ratio are dependent upon the needs of the participants. Groups with children needing more individualized support are often grouped in smaller configurations of six to eight children, with a 1:3 adult to child ratio. Groups of children with more independence and self-regulation typically benefit from a larger peer group and a 1:4 adult to child ratio is provided to support their success.
Group and Curricular Planning
In this section, features, factors, and elements critical to forming groups and determining curriculum will be addressed.
Forming Groups
Many aspects of group social skills intervention require careful attention and planning. First and foremost in the planning process is the careful determination of the group and the peers with whom a child is placed. Social skills group placement in the PROGress Model requires different consideration than is often applied to classroom placements.
In most school settings, academic placements typically group children with same-age, same-grade peers, based upon their emerging skills. This allows children to perpetually work on skill acquisition. In the PROGress Model, skill use, rather than acquisition, is the primary emphasis and focus. A child’s social ability and use is highly dependent upon his personal willingness, desire, and comfort in interacting. Regardless of what social skills a child possesses, he can only truly be successful with them when he is willing to utilize them. Thus, placement in a group where a child can experience comfort, ease, and enjoyment in social interactions is a critical first step to both the planning of the group and to the child’s social success. Social interest, motivation, and skills are all primary placement concerns. An unstructured social play observation by a skilled clinician is generally adequate for assessing this. First, the child’s social use and comfort with peers is carefully determined. Only after that should consideration be given to the developmental, cognitive and language abilities, and age of the group participants. This careful matching and placement results in the greatest social fit for participants, and the greatest ability to adapt the group format, expectations, and instruction. This careful matching of social comfort and individual skills maximizes engagement and success. Once social comfort and skill use is achieved, further skill development can then be addressed.
Anthony is 5½ years old and has a diagnosis of autism. He uses one- and two-word utterances to communicate. He typically plays and works in isolation but often watches his peers when he is in a group activity. Anthony will initiate to a peer only when given a physical prompt and a verbal model.
Eric is 4 years old with a diagnosis of High Functioning Autism. He can spontaneously engage with adults using complete sentences in one-on-one interactions. He enjoys many toys and activities with adults or at home and can follow simple directions and sequenced play activities. When Eric is in a peer group setting, he covers his ears, runs around the room, and will not join in group activities.
In the PROGress Model, both these boys would be placed in the same group. While they are in different grades at school, and their verbal and cognitive skills differ, both are working on maintaining regulation and simple engagement with peers in a group setting.
Evan is 6 years old and has a diagnosis of PDD-NOS. He is highly verbal at home but is very reserved and quiet outside of his home and rarely engages verbally in any other settings. He is in a half-day regular education kindergarten and has age-appropriate cognitive and receptive language skills. In class, he follows all classroom instructions and engages in all activities, albeit nonverbally.
Jacob is 7 years old and has a diagnosis of autism. He is in a special education classroom at his neighborhood school. His academic skills range in ability from first grade (language) through third grade (math). Jacob is friendly with peers and adults and is willing to join in teacher-led classroom activities but he has no friends in the class. He often plays alone at recess and sits alone at lunch.
In the PROGress Model, both these boys would be placed in the same group. They are a year apart in school, are in different academic settings, and have very different abilities. Both boys can follow simple directions and participate in structured, concrete activities. They both need significant assistance and support in engaging successfully with peers.
Group Levels
Once children are matched based upon their social comfort and use, the appropriate curriculum level and focus must be determined. The PROGress Model is designed with four different levels of curricular focus. Each level is intended to meet the general social and developmental needs of the group. That noted, however, each grouping of children brings with it its own issues, balance, and flow. Thus, each group of children must be carefully observed and assessed, and adaptations to each group’s schedule, activities, and curriculum must be made. These adaptations will be discussed in the next section.
The four curricular levels of PROGress Model include:
Play-based
High structure
Low structure
Thematic activities
Each level addresses different social and developmental needs that are described below.
Play-Based
This curriculum is designed for children with ASD who exhibit an interest in engaging with peers but who are primarily challenged to remain calm and regulated when in a group of peers. The activities within this curriculum are play-based in nature, allowing the participants to engage in motivating activities and materials at the level of engagement with which they are most comfortable. Once engaged in play, the goals within the curriculum should include playing in close proximity of peers, participating in activities with others, using a common set of materials, attending to peers, imitating peers, initiating and responding to simple requests, and playing together with peers.
High Structure
This curriculum is designed to meet the needs of children with ASD who demonstrate interest in interacting, who have at least some spontaneous language abilities, and who can participate in and follow structured, concrete activities. This curriculum is intended to provide needed scaffolding to children who require structure and support to process language, to participate in activities, and/or to interact with peers.
Low Structure
This curriculum is intended to support the social interactions of children who have both the interest and ability to interact spontaneously with peers, but who may need some guidance and support in understanding the most appropriate ways to do so. This curriculum provides opportunity for independent interactions and supports the practice and use of skills in semistructured or natural social opportunities.
Thematic Activities
This curriculum is designed for children who have already benefited from and mastered participation in the Low Structure Groups and/or for children who function fairly well in typical peer activities but need some support to understand appropriate interaction skills or with negotiating social problems. This curriculum offers multisession thematic activities that involve social peer skills such as negotiation, cooperation, compromise, acceptance, and joint planning and participation. Support, coaching, and teaching is provided and practiced within the context of the activities, as needed.
It is vital to the success of the children in the group that they are following the curriculum level at which they are most able and comfortable engaging, rather than at a level that requires abilities they have not yet mastered or are not at ease using in peer groups.
Ryan is a 6-year-old boy with autism who has spontaneous, independent language that he uses at home with his siblings and family. Ryan is considered very shy and demonstrates significant anxiety when in social peer groups. Upon enrolling in the social skills group, Ryan was willing to participate in activities, but required his mother to remain in the room, and refused to verbally engage with peers. Although he had language skills consistent with the children in the Low Structure group, that group required him to use his language abilities in order to participate. This social demand was not consistent with his social comfort and typical engagement. Thus, Ryan was placed in a High Structure group. His mother remained in the room for the first 5 weeks, until a planned exit at the predictable snack time was implemented. Three weeks later, he told his mother she could leave after the opening Hello Song. Ryan participated in this group for the 25-week session, becoming increasingly more comfortable with his peers as the weeks progressed. By the end of group, he was both at ease with his peers and was independently using his spontaneous language skills in all activities. The following session, Ryan participated in the Low Structure Group and was able to independently engage with peers while practicing and learning new skills throughout the session. By the end of this second group, Ryan considered the Thematic Activity Group (called “The Kids’ Club”) but felt he no longer needed to attend the social skills groups and began inviting peers over to his house for play dates. He was highly successful in these small, planned social opportunities and his classroom teacher also reported that he was engaging in small groups of peers spontaneously at school.
Determining the Curriculum
Relevance to ASD
Children with ASD are often unable to recognize or understand the subtle social cues that their peers intuitively use and depend upon when engaging with each other. For example, cues from peers that signal such subtleties as interest, disinterest, openness, and engagement are frequently missed by the child with ASD. Failure to recognize these cues often results in the child with ASD being unaware of whether peers are engaged or interested. As a result, the child with ASD may experience difficulty joining in, may be unaware of when to stop a behavior or conversational topic, or may lack understanding of what the social expectations are. Ultimately, this can lead to personal confusion, peer rejection, social isolation, and/or group exclusion commonly experienced by children with ASD.
Although autism-specific curricula such as the PROGress Model are being developed and offered, most commercially available social skills curricula designed to meet the needs of children with social difficulties often do not adequately address these underlying social difficulties that make social interactions so challenging for children with ASD. In a social skills intervention specifically aimed at meeting the social needs of this population, it is imperative that the goals addressed are salient, relevant, and central to the underlying deficits common in autism. For children without ASD such goals may seem foolish and obvious, but for children with ASD the goals addressed and skills developed must help these children to recognize and understand the present and at times subtle social information that often eludes them.
Research has demonstrated that skill awareness and daily use is facilitated when children understand the importance and relevance of the skill and its use (Gray 1995). Thus, it is also important that information about not only the behaviors but the variables critical to appropriately using those behaviors is embedded in the teaching and rehearsal opportunities provided within the groups. Children with ASD must learn more than just how to perform the targeted skills. If simply teaching a behavior or skill was sufficient to change the social deficits commonly seen in autism, this chapter would be unnecessary and the social skill deficits of children with ASD would be easily remediated. Rather, it is commonly understood that these deficits are complex and difficult to eliminate. Perhaps that is because learning a skill is only the first part of what needs to be taught. Children with ASD must learn not only what they need to do and how to do it, but also why they need to do it, with whom they should and should not use a skill, when and when not to use the skill, and why. Taught in the context of the interactions, the relevance of the instruction is authentic and motivating. The likelihood of the skill becoming a part of the child’s social repertoire is enhanced.
Carly is a 7-year-old girl with ASD who enjoys being with peers and is easily engaged in social activities. She easily enters the group each week and will willingly interact with adults and peers. Carly is very soft-spoken, however, and is barely audible when she interacts. In group, activities are designed to require initiating, requesting, and responding to peers in highly motivating activities. When Carly first began spontaneously engaging her peers, she was reminded “Justin can’t hear you. You need to change your voice to a ‘medium voice’ so he knows what you want.” (Note: this was only offered after voice volumes were concretely defined and taught). Following repeated practice, Carly is now only reminded “this room is pretty noisy!” or “Do you think he heard you?” to which she is able to independently problem solve and change her volume to one that is more audible and successful.
Group Goals and Skills
The goals identified for a group must be dependent upon many factors: the abilities of the children within the group, the rate and pace at which they can understand and acquire skills, and the amount of time available in the group to learn, practice, and gain skills. In the PROGress Model, the goals for each of the groups are included below.
Play-Based
Interaction basics
Learning peers’ names, greeting, observing others.
Communication basics
Greeting, initiating, showing, asking, listening.
Play and friendship skills
Playing alongside and with, using materials together, sharing space, taking turns.
High Structure
Interaction basics
Learning peers’ names, using an appropriate volume, maintaining an appropriate distance, and observing and listening to others.
Communication basics
Commenting or “telling,” questioning or “asking”; commenting and questioning with peers, “checking in” with peers in a conversation; initiating a conversation, participating in a peer’s conversation topic, maintaining a conversation, ending a conversation, staying on a conversation topic, switching a conversation topic.
Play and friendship skills
Defining a “Friend” versus “Not a friend,” joining in play, sharing materials and equipment, taking turns, compromising, negotiating, following group rules, fairness, winning and losing.
Emotions and feelings
Developing an emotional vocabulary, recognizing varying emotions in others, recognizing varying emotions in self, understanding what causes emotions and feelings, dealing with emotions, taking others’ perspective, and developing and showing empathy.
Self and others awareness
Identifying unique and important characteristics of self and of others, recognizing similarities and differences in people, playing and working cooperatively, sharing different interests, cooperating and compromising.
Low Structure
The first four units described above are also addressed with the Low Structure groups, although it is done so in ways that facilitate and utilize greater independence and spontaneous engagement. In addition, because these children experience and are able to understand and negotiate greater abstract social issues, the following unit is also included:
Social problem solving
Being told “no”; dealing with things you don’t like, feeling left out, being teased, saying or being told “I don’t know,” and self-advocating in social situations.
Thematic Activities
The children in this group work on skills needed as they work together on thematic units such as science experiments, building projects, cooking, games, etc. Although the goals may vary, dependent on each particular group of children, they commonly work on maintaining a conversation topic, checking in with and engaging peers, negotiating, decision making, consensus building, cooperating, compromising, self-advocating, winning and losing, and dealing with disappointment.
Sequential and Progressive Instruction
It is commonly known that repetition and practice are critical to skill mastery. However, it is perhaps all too common that children are taught social skills as a series of isolated behaviors with little ongoing reinforcement or skill coordination. In planning social skills interventions, it is important to consider the order in which activities and skills are introduced and rehearsed to maximize the opportunities for coordinated skill development and use. A fluid and connected learning continuum should be provided in which the most relevant skills needed are continually addressed and practiced. As described below, this sequential and progressive programming should occur for each session, for each set or unit of lessons, and across the entire skill content provided. It is important to teach basic skills first, then continue to practice them as later skills are introduced and practiced. Activities and skills should build upon each other and be interrelated. Intervention should intentionally utilize a natural context within which the authentic social motivation and learning can occur. By doing so, one can carefully ensure that not only are the appropriate skills addressed, but also that they are taught in a coordinated manner that supports, reinforces, and builds upon earlier skills. Such programming promotes social awareness and skill development, ensures necessary practice and repetition needed to develop mastery, and increases the likelihood of maintenance and use of the skills. Below, a description of how the PROGress Curricula planfully accomplishes this is provided.
Curricular Sequence
Within each set of skills or skill unit, the way in which the skills are presented and taught must also be considered and carefully planned so that the earliest and most fundamental skills are practiced with greatest frequency and repetition, while new skills are added. The Introductory, Skill Development, Integration and Generalization Phases detailed below can also be built in to the design of skill units within a curriculum. In the PROGress curricula for the High and Low Structure Groups, the first 2 weeks of a 5-week unit comprises the Introductory Phase. In these sessions, the basic concepts and skills of the unit are introduced and practiced. The next two sessions make up the Skill Development portion of the unit. During these weeks, the skills from the first 2 weeks continue to be practiced while additional skills are added. In the fourth week of the unit, all the skills are combined and integrated into typical, semistructured, age-appropriate activities and games that require the coordinated use of those skills previously taught. The fifth and last week of the unit is dedicated to generalization of the skills. A community outing is scheduled at a location or event that requires the use of the skills addressed in the unit just completed.
In the High Structure Group of the PROGress curriculum, the Conversation Skills Unit begins with activities that teach and reinforce greetings, using peers names to engage them, and initiating a topic or interaction. Next, “telling” and “asking” are practiced individually. This is followed by coordinating the acts of telling a designated number of comments and then engaging or asking a peer to join in. Next, strategies and tools to blend these together into a conversation are taught and rehearsed. For the final week, we meet at a pizza restaurant to eat and talk with each other.
Finally, the coordination of all sessions and units should be considered in a sequential manner when determining the flow of instruction for the entire curricula. The sequence of skills taught across the entire group curriculum should also be carefully determined so that those concepts and skills taught first are prerequisite to the subsequent skills addressed. With such planning, the earlier skills addressed at the beginning of the curriculum continue to be practiced and used as the next skills are introduced and learned.
In the Low Structure PROGress Curriculum, the children focus on learning peers’ names in the first and second weeks in the group curriculum so that when in the sixth week of the curriculum they address Conversation Skills they learn to say the person’s name and then initiate a topic.
If skills are carefully planned, then those taught first are practiced as needed throughout the course of the group. Skill development and mastery can thus be planfully designed.
Learning the concept of “friend” versus “not a friend” is addressed in the 13th week of the Low Structure PROGress Curriculum. Awareness of whether someone’s social attention is intended as friendly or not and mastery of recognizing and evaluating these advances must be learned before the participants can be expected to use self-advocacy strategies, to apply, for example, when someone is not being a friend. This is addressed in the 21st week of the curriculum in the Social Problem-Solving Unit.
Children learn to identify other people’s emotions and their own emotions in weeks 17 and 18 of the Low Structure PROGress Curriculum. A child must be able to identify that he is becoming frustrated, before he can be expected to implement a skill or strategy to deal with frustration. In the Social Problem-Solving Unit, taught in weeks 21 through 24, the children then learn strategies for what to do when they feel frustrated.
Session Sequence
Within a group session, it is important to consider and plan the sequence and progression of the many activities and experiences to be provided. The order of activities and events should carefully assist the participants in both learning and practicing skills. Thus, each session should be designed to include the greatest structure and adult input at the beginning of the session, when the skill is first being introduced and taught. This would be an Introductory Phase. Activities are designed to provide clear and concrete instruction and examples of the skills being introduced. Practice is incorporated in natural and age-appropriate activities to enhance understanding, awareness, and skill development. As the session progresses, the activities are designed with decreased instruction and structure as well as increased practice so that the participants can learn to use the skill more independently with each other. This is the Skill Building Phase. Group leaders provide assistance as needed or identify the importance of the skill within the activity or interaction. As the session progresses, the children use the skills within a familiar game, event, or routine, such as snack. This is the Integration Phase. Natural opportunities to practice must be designed, incorporated, and encouraged. Last, the children practice the skill in a semistructured game or event that closely resembles typical peer activities but is adapted to include, emphasize, or highlight the skill for the day. This is the Generalization Phase. Throughout this session, the use of skills previously taught and relevant to the interaction are reinforced, highlighted, and encouraged as well.
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