Social-Skills Treatments for Children With Autism Spectrum Disorders: An Overview

http://bmo.sagepub.com/ Behavior Modification http://bmo.sagepub.com/content/31/5/682 The online version of this article can be found at: DOI: 10.1177/0145445507301650 2007 31: 682Behav Modif Johnny L. Matson, Michael L. Matson and Tessa T. Rivet Disorders: An Overview Social-Skills Treatments for Children With Autism Spectrum Published by: http://www.sagepublications.com can be found at:Behavior ModificationAdditional services and information for http://bmo.sagepub.com/cgi/alertsEmail Alerts: http://bmo.sagepub.com/subscriptionsSubscriptions: http://www.sagepub.com/journalsReprints.navReprints: http://www.sagepub.com/journalsPermissions.navPermissions: http://bmo.sagepub.com/content/31/5/682.refs.htmlCitations: What is This? - Aug 14, 2007Version of Record >> at Istanbul Universitesi on April 25, 2014bmo.sagepub.comDownloaded from at Istanbul Universitesi on April 25, 2014bmo.sagepub.comDownloaded from 682 Social-Skills Treatments for Children With Autism Spectrum Disorders An Overview Johnny L. Matson Michael L. Matson Tessa T. Rivet Louisiana State University Marked advances in the treatment of children with autism spectrum disorders (ASDs) has occurred in the past few decades, primarily using applied behavior analysis. However, reviews of trends in social skills treatment for children with ASDs have been scant, despite a robust and growing empirical literature on the topic. In this selective review of 79 treatment studies, the authors note that the research has been particularly marked by fragmented development, using a range of intervention approaches and definitions of the construct. Modeling and reinforcement treatments have been the most popular model from the outset, with most studies conducted in school settings by teachers or psychologists. Investigators have been particularly attentive to issues of generalization and follow-up. However, large-scale group studies and com- parisons of different training strategies are almost nonexistent. These trends and their implications for future research aimed at filling gaps in the existing literature are discussed. Keywords: social skills; children; autism spectrum disorders Autism spectrum disorders (ASDs) are defined by a pattern of behav-ioral deficits with one of the primary core features including severe limitations in social reciprocity and communication (Lord & Risi, 1998). In fact, it has been suggested that social impairments are the most critical ele- ment in the definition of the disorder (Stella, Mundy, & Tuchman, 1999). Furthermore, it has been argued that social excesses and deficits may have some level of independence from other symptom domains of ASDs (Charman et al., 1997). These assumptions may argue for treatments that are specific to social skills playing a central role of intervention for children with ASDs. Behavior Modification Volume 31 Number 5 September 2007 682-707 © 2007 Sage Publications 10.1177/0145445507301650 http://bmo.sagepub.com hosted at http://online.sagepub.com at Istanbul Universitesi on April 25, 2014bmo.sagepub.comDownloaded from Among the typically observed social behaviors present in this neurode- velopmental disorder are poor eye contact (Willemsen-Swinkels, Buitelaar, Weijnen, & van Engeland, 1998), failure to initiate social interactions (Matson, Sevin, Fridley, & Love, 1990), and the presence of odd manner- isms and speech (Matson & Minishawi, 2006). These symptoms are known to persist into adulthood and can be extremely debilitating for the afflicted person (Matson, Boisjoli, González, Smith, & Wilkins, in press). In fact, without effective intervention, these deficits have tended to increase rather than diminish with age (Howlin, Mawhood, & Rutter, 2000). Unfortunately, the definitions for social skills in this population are quite varied, which may be in part because of the many disciplines and theoretical orientations of researchers and practitioners who have shown interest in the area (Matson & Ollendick, 1988; Matson & Wilkins, 2007). For example, there is a marked overlap between definitions of social skills and commu- nication, whereas others have framed these target behaviors in the general developmental context of play (Stella et al., 1999; Wing, Leekam, Libby, Gould, & Larcombe, 2002). However, we have chosen to define social skills here in the broader context of behavior therapy and analysis, which has a long history relative to treatment, with a broad range of populations (Hersen & Bellack, 1976; McFall & Marston, 1970).1 However, no matter what the theoretical orientation, professional discipline, or treatment approach taken, general consensus for children with ASDs is that the prob- lem is central to the disorder and should be a primary goal in education and treatment (Torres, Cardelle-Elawar, Mena, & Sánchez, 2003; Trianes & Fernández-Figarés, 2001). Definition For the present review, the accepted definition in the behavior therapy and analysis literature will be used. Thus, social skills is defined as inter- personal responses with specific operational definitions that allow the child to adapt to the environment through verbal and nonverbal communication (Matson & Ollendick, 1988; Matson & Wilkins, 2007). Training may consist of the development of new skills or the establishment of a rein- forcement paradigm that will result in the display of existing skills (Kelly, 1982). Typical social-skills targets for children with ASDs and that have been the focus of treatment include eye contact, appropriate content of speech (e.g., saying please, thank you, you’re welcome; showing apprecia- tion; talking about favorite things), appropriate speech intonation, number of Matson et al. / Social-Skills Treatments Overview 683 at Istanbul Universitesi on April 25, 2014bmo.sagepub.comDownloaded from words spoken, appropriate facial affect, appropriate motor movements, ver- bal disruptions, leaving the group, unpleasant demeanor, conversational speech, number of interactions, and an overall rating of social-skill profi- ciency (Matson, Kazdin, & Esveldt-Dawson, 1980). However, by far the most frequently targeted of skills has been initiation of speech. Thus, social avoidance appears to be a particularly crucial social-skill area. These skills have been primarily trained in school settings, although clinics have been the site of intervention in some cases (Strain & Danko, 1995; Taras, Matson, & Leary, 1988). We acknowledge that many precursor skills such as joint attention are essential to adequate social-skills training (Jones, Carr, & Feeley, 2006). However, studies of this sort were not included in this analysis because they did not directly target social skills. A second issue related to the definition of social skills is the difficulty in sorting out what are socials skills versus communication skills versus behavior problems and abnormalities. The lit- erature describes procedures that overlap all three of these major domains. Given that these three areas are alternately described as the prominent domains of ASDs, being able to better define demarcating lines among the constructs has important implications for the etiology, assessment, and treatment of ASDs. An effort to more carefully parse out these groupings should therefore be a research priority. Review Procedures We did Medline and Google Scholar searches for social-skills training in children with ASDs. We also did hand searches of Research in Developmental Disabilities, Research in Autism Spectrum Disorders, Autism, Focus on Autism and Other Developmental Disabilities, Journal of Applied Behavior Analysis, Behavior Modification, Journal of Autism and Developmental Disorders, and Journal of Positive Behavior Interventions. In addition, the reference list of each article that met criteria for inclusion in our review was reviewed. Inclusion criteria consisted of children being identified as evinc- ing ASDs and at least some portion of the sample being 12 years of age or younger, thus focusing on children versus adolescents or adults. In addition, a recognized controlled experimental design, single-case design, or group design was required. Using these methods, we identified 79 studies for inclusion in our review. This list is not exhaustive but qualifies as representative (see Tables 1 and 2). Because this is the most recently completed of the social-skills 684 Behavior Modification (text continues on p. 692) at Istanbul Universitesi on April 25, 2014bmo.sagepub.comDownloaded from 685 Ta bl e 1 Su m m ar y of R es ea rc h St ud ie s St ud y Pa rt ic ip an ts Tr ai ne r Fo llo w -U p G en er al iz at io n Tr ai ni ng S et tin g M od el in g an d re in fo rc em en t A pp le ,B ill in gs le y, an d 2 A sp er ge r’s ; a ge 5 Te ac he rs a nd p ee rs N o N o Sc ho ol Sc hw ar tz (2 00 5) Ch ar lo p an d M ils te in (1 98 9) 3 au tis tic ; a ge s 6 -7 Th er ap ist N o Ye s Sc ho ol Ch ar lo p, Sc hr ei bm an ,a n d 7 au tis tic ; a ge s 5 -1 0 Ex pe rim en te r Ye s Ye s Sc ho ol Th ib od ea u (19 85 ) Ch ar lo p an d W al sh (1 98 6) 4 au tis tic ; a ge s 6 -8 N o Ye s Sc ho ol ,h om e Ch ar lo p- Ch ris ty , Le , an d 5 au tis tic ; a ge s 7 -1 1 Th er ap ist s a nd N o Ye s A fte r-s ch oo l Fr ee m an (2 00 0) st ud en ts pr og ra m Ch in a nd B er na rd - 3 au tis tic ; a ge s 5 -7 Ps yc ho lo gy st ud en t Ye s Ye s H om e O pi tz (2 00 0) Co e, M at so n, Fe e, M an ik am , 2 au tis tic ,1 Th er ap ist N o N o Sc ho ol an d Li na re llo (1 99 0) in te lle ct ua lly di sa bl ed ; a ge s 5 -6 D ra sg ow , H al le ,a n d 1 au tis tic ; a ge 3 Pa re n ts N o N o H om e Ph ill ip s ( 20 01 ) Eg el ,R ic hm an ,a n d 4 au tis tic ; a ge s 5 -7 Th er ap ist N o N o Sc ho ol K o eg el (1 98 1) G ar ris on -H ar re l, K am ps , 3 au tis tic ,1 5 ty pi ca l Pe er N o N o Sc ho ol an d K ra v itz (1 99 7) pe er s; ag es 6 -7 G en a, K ra nt z, M cC la nn ah an , 4 au tis tic ; a ge s Th er ap ist N o Ye s R es id en tia l an d Po ul so n (19 96 ) 11 -1 8 sc ho ol G on za le z- Lo pe z an d 4 au tis tic ; a ge s 5 -7 Te ac he rs N o Ye s Sc ho ol K am ps (1 99 7) 12 n on di sa bl ed pe er s; ag es 5 -8 (co nti nu ed ) at Istanbul Universitesi on April 25, 2014bmo.sagepub.comDownloaded from 686 Ta bl e 1 (C on tin ue d) St ud y Pa rt ic ip an ts Tr ai ne r Fo llo w -U p G en er al iz at io n Tr ai ni ng S et tin g H ar ch ik ,H ar ch ik ,L uc e, 4 au tis tic ; a ge s 9 -1 3 St af f Ye s Ye s G ro u p ho m e an d Sh er m an (1 99 0) H up p an d Re itm an (2 00 0) 1 PD D -N O S; a ge 8 Pa re n ts 1 ye ar N o O ut pa tie nt c lin ic In ge rs ol l a nd G er ga ns 3 au tis tic ; a ge s 2 -3 Th er ap ist a nd p ar en t Ye s Ye s U ni v er sit y cl in ic (in pr ess ) Ja hr , El de v ik ,a n d 6 au tis tic ; a ge s 4 -1 2 Te ac he rs Ye s Ye s R es id en tia l Ei ke se th (2 00 0) pr og ra m K am ps e t a l. (19 92 ) 3 au tis tic ; a ge 7 Ex pe rim en te r a nd Ye s N o Sc ho ol te ac he rs Le B la nc e t a l. (20 03 ) 3 au tis tic ; a ge s 7 -1 3 Ex pe rim en te r Ye s N o Sc ho ol Lo v el an d an d Tu n al i 13 a ut ist ic ; 1 3 D ow n Ex pe rim en te r N o N o Sc ho ol (19 91 ) sy nd ro m e M ai on e an d M ire nd a 1 au tis tic ,2 n o n di sa bl ed Pa re n t Ye s N o H om e (20 06 ) pe er s; ag es 5 -7 M at so n, Se v in ,F rid le y, 3 au tis tic ; a ge s 9 -1 1 Ps yc ho lo gi sts Ye s Ye s O ut pa tie nt c lin ic an d Lo v e (19 90 ) N ik o po ul os a nd K ee n an 6 au tis tic ,1 A sp er ge r’s ; Ex pe rim en te r Ye s Ye s Sc ho ol (20 03 ) ag es 9 -1 5 N ik o po ul os a nd K ee n an 3 au tis tic ; a ge s 7 -9 Ex pe rim en te r Ye s N o Ex pe rim en ta l (20 04 ) ro o m Sa in at o, G ol ds te in ,a n d 3 au tis tic ,3 n o n di sa bl ed Pe er s N o N o Pr es ch oo l St ra in (1 99 2) pe er s; ag es 3 -4 Sa ro ko ff, Ta yl or , an d 2 au tis tic ; a ge s 8 -9 Te ac he rs N o Ye s Tr ea tm en t c en te r Po ul so n (20 01 ) Sh ab an i e t a l. (20 02 ) 3 au tis tic ; a ge s 6 -7 Te ac he r N o N o Sc ho ol Sh er er e t a l. (20 01 ) 5 au tis tic ; a ge s 4 -1 1 Th er ap ist a nd p ee r Ye s Ye s H om e an d/ or m o de l re se ar ch la b at Istanbul Universitesi on April 25, 2014bmo.sagepub.comDownloaded from Ta ra s, M at so n, an d 2 au tis tic ; a ge s 9 -1 0 Ex pe rim en te r Ye s N o Cl in ic Le ar y (19 88 ) Ta yl or , Le v in ,a n d 2 au tis tic Te ac he rs Ye s Ye s Sc ho ol Ja sp er (1 99 9) Th ie m an n an d G ol ds te in 5 au tis tic a nd re la te d Te ac he r Ye s Ye s Sc ho ol (20 01 ) di sa bi lit ie s; ag es 6 -1 2 W er t a nd N ei sw o rt h 4 au tis tic ; a ge s 3 -5 Th er ap ist Ye s N o Sc ho ol a nd h om e (20 03 ) W ill ia m s, D on le y, an d 2 au tis tic ; a ge 4 Ex pe rim en te rs Ye s Ye s H om e K el le r ( 20 00 ) Za no lli ,D ag ge tt, an d 2 au tis tic ; a ge 4 Te ac he r N o N o Sc ho ol A da m s ( 19 96 ) Pe er m ed ia te d B ar ry e t a l. (20 03 ) 4 au tis tic ,7 n on di sa bl ed Pe er s N o Ye s O ut pa tie nt c lin ic pe er s; ag es 6 -9 B ra dy , Sh or es ,M cE vo y, 2 au tis tic ; a ge s 8 -1 0 Pe er s Ye s Ye s Sc ho ol El lis ,a n d Fo x (1 98 7) Ch ar lo p, Sc hr ei bm an , 4 au tis tic ; a ge s 4 -1 4 Ex pe rim en te r Ye s Ye s Sc ho ol an d Tr yo n (19 83 ) Ch un g et a l. (in pr ess ) 4 au tis tic ,3 ty pi ca l p ee rs ; Ex pe rim en te rs a nd p ee r N o N o U ni v er sit y cl in ic ag es 6 -7 G ol ds te in ,K ac zm ar ek , 4 au tis tic ,1 P D D -N O S, Pe er s N o N o Sc ho ol Pe nn in gt on ,a n d 10 ty pi ca l p ee rs ; Sh af er (1 99 2) ag es 3 -6 K al yv a an d Av ra m id is 5 au tis tic ; a ge s 3 -4 Te ac he r Ye s N o Sc ho ol (20 05 ) (co nti nu ed ) 687 at Istanbul Universitesi on April 25, 2014bmo.sagepub.comDownloaded from 688 Ta bl e 1 (C on tin ue d) St ud y Pa rt ic ip an ts Tr ai ne r Fo llo w -U p G en er al iz at io n Tr ai ni ng S et tin g K am ps ,P ot uc ek ,L op ez , 3 au tis tic ; a ge s 6 -8 Te ac he r N o Ye s Sc ho ol K ra v its ,a n d K em m er er (19 97 ) La us he y an d H ef lin (2 00 0) 2 au tis tic o r P D D -N O S, Te ac he r Ye s Ye s Sc ho ol ap pr ox im at el y 40 ty pi ca l c hi ld re n; ag es 5 -6 M cG ee ,A lm ei da ,S ul ze r- 3 au tis tic ,3 ty pi ca l Te ac he r a nd p ee rs Ye s Ye s Sc ho ol A za ro ff, an d Fe ld m an pe er s; ag es 3 -4 (19 92 ) M cG ra th ,B os ch ,S ul liv an , 1 au tis tic ,1 8 no nd isa bl ed Te ac he rs a nd p ee rs N o N o Sc ho ol an d Fu qu a (20 03 ) pe er s; ag es 3 -4 M or ris on ,K am ps ,G ar ci a, 4 au tis tic ,s o m e ty pi ca lly G ra du at e stu de nt s Ye s N o Sc ho ol an d Pa rk er (2 00 1) de v el op in g ch ild re n (n n o t s ta te d); ag es 1 0- 13 O do m a nd S tra in (1 98 6) 3 au tis tic ,4 n o n di sa bl ed Pe er o r t ea ch er N o N o Sc ho ol pe er s; ag es 4 -5 O ke a n d Sc hr ei bm an 1 au tis tic ; a ge 5 Pe er s Ye s Ye s Sc ho ol (19 90 ) Pi er ce a nd S ch re ib m an 2 au tis tic ; a ge 1 0 Pe er s Ye s Ye s Sc ho ol (19 95 ) Pi er ce a nd S ch re ib m an 2 au tis tic ,8 ty pi ca l Pe er tr ai ne rs Ye s Ye s Sc ho ol (19 97 a) pe er s; ag es 7 -9 Pi er ce a nd S ch re ib m an 2 au tis tic ,8 ty pi ca l Pe er s Ye s Ye s Sc ho ol (19 97 b) ch ild re n; a ge s 5 -8 at Istanbul Universitesi on April 25, 2014bmo.sagepub.comDownloaded from R oe ye rs (1 99 5) 3 au tis tic ; a ge s 5 -1 3 Te ac he rs Ye s N o Sc ho ol R oe ye rs (1 99 6) 85 a ut ist ic o r P D D -N O S, Te ac he rs N o N o Sc ho ol 48 n on di sa bl ed p ee rs ; ag es 5 -1 3 Sh af er , Eg el ,a n d N ee f 4 au tis tic ,1 6 ty pi ca l Ex pe rim en te r N o Ye s Sc ho ol (19 84 ) pe er s; ag es 5 -6 St ra in ,K er r, an d Ra gl an d 4 au tis tic ; a ge s 9 -1 0 Te ac he rs Ye s Ye s Sc ho ol (19 79 ) R ei nf or ce m en t s ch ed ul es o r ac tiv iti es Ch ar lo p an d Tr as o w ec h 3 au tis tic ; a ge s 7 -8 Pa re n t N o Ye s Sc ho ol (19 91 ) D aw ph in ,K in ne y, an d 1 au tis tic ; a ge 3 Te ac he r N o N o Sc ho ol St ro m er (2 00 4) G rin dl e an d Re m in gt on 5 au tis tic ; a ge s 5 -1 0 Te ac he r Ye s N o Sc ho ol (20 04 ) In ge nm ey a nd V an H ou te n 1 au tis tic ; a ge 1 0 Ex pe rim en te r Ye s Ye s H om e (19 91 ) M cE vo y et a l. (19 88 ) 3 au tis tic ; a ge s 4 -7 Te ac he r Ye s Ye s Sc ho ol Sh ea re r, K o hl er , B uc ha n, an d 3 au tis tic ; p re sc ho ol a ge Te ac he r Ye s N o Sc ho ol M cC ul lo ug h (19 96 ) Ta yl or a nd L ev in (1 99 8) 1 au tis tic ; a ge 9 Te ac he r Ye s N o Sc ho ol Za no lli a nd D ag ge tt (19 98 ) 1 au tis tic ,1 la ng ua ge Te ac he r N o N o Pr es ch oo l de la ye d; a ge s 2 -6 St or ie s a nd sc rip ts A da m s, G ou vo u sis ,V an Lu e, 1 au tis tic ; a ge 7 Ex pe rim en te r N o N o Sc ho ol an d W al dr on (2 00 4) (co nti nu ed ) 689 at Istanbul Universitesi on April 25, 2014bmo.sagepub.comDownloaded from Ta bl e 1 (C on tin ue d) St ud y Pa rt ic ip an ts Tr ai ne r Fo llo w -U p G en er al iz at io n Tr ai ni ng S et tin g B ak er , K o eg el ,a n d Ko eg el 3 au tis tic ; a ge s 5 -8 Te ac he rs N o N o Sc ho ol (19 98 ) Ch ar lo p- Ch ris ty a nd 3 au tis tic ; a ge s 8 -1 1 Ex pe rim en te r N o Ye s Th er ap y ro om K el so (2 00 3) D el an o an d Sn el l ( 20 06 ) 3 au tis tic ,6 n on di sa bl ed Ex pe rim en te r Ye s Ye s Sc ho ol pe er s; ag es 6 -9 K ra nt z an d M cC la nn ah an 4 au tis tic ; a ge s 9 -1 2 Te ac he r Ye s Ye s Sc ho ol (19 93 ) K ra nt z an d M cC la nn ah an 3 au tis tic ; a ge s 4 -5 Te ac he r N o Ye s Sc ho ol (19 98 ) K u o ch a nd M ire nd a (20 03 ) 3 au tis tic ; a ge s 3 -6 Ex pe rim en te r N o N o H om e or s ch oo l N or ris a nd D at til o (19 99 ) 1 au tis tic ; a ge 8 Ex pe rim en te r N o N o Sc ho ol Sa ns os ti an d Po w el l-S m ith 3 A sp er ge r’s ; a ge s 9 -1 1 Pa re n ts Ye s N o Sc ho ol (20 06 ) W o o ds a nd P ou lso n (20 06 ) 2 au tis tic ,1 o th er h ea lth Ex pe rim en te r N o Ye s Sc ho ol im pa ire d; a ge s 5 -6 N ot e: PD D -N O S = pe rv as iv e de v el op m en ta l d iso rd er , n o t o th er w ise sp ec ifi ed . 690 at Istanbul Universitesi on April 25, 2014bmo.sagepub.comDownloaded from 691 Ta bl e 2 M isc el la ne ou s St ud y Pa rt ic ip an ts Tr ai ni ng M et ho d Tr ai ne r Fo llo w -U p G en er al iz at io n Tr ai ni ng S et tin g B au m in ge r ( 20 02 ) 15 a ut ist ic ; a ge s 8 -1 7 So ci al -s ki lls Te ac he rs N o Ye s Sc ho ol cu rr ic ul um Ch ar lo p- Ch ris ty , 3 au tis tic ; a ge s 3 -1 2 PE CS Th er ap ist Ye s N o O ut pa tie nt c lin ic Ca rp en te r, Le , Le B la nc , an d K el le t ( 20 02 ) In ge rs ol l, Sc hr ei bm an , 6 au tis tic ,3 ty pi ca l In cl us iv e cl as sr oo m Te ac he r N o N o Pr es ch oo l an d St ah m er (2 00 1) ch ild re n; a ge s 2 -3 m o de l K o eg el ,K o eg el ,H ur le y, 2 au tis tic ; a ge s 6 -1 1 Se lf- m an ag em en t Ch ild N o N o Cl in ic ,c o m m u - an d Fr ea (1 99 2) n ity , ho m e, sc ho ol M ah on ey a nd P er al es 20 a ut ist ic ; a ge s 3 -5 Pa re n t t ra in in g Pa re n t Ye s N o Sc ho ol (20 03 ) M at so n, Se v in ,B ox , 3 au tis tic ; a ge s 4 -5 Ti m e de la y Th er ap ist Ye s Ye s U ni v er sit y ou t- Fr an ci s, an d Se v in pa tie nt c lin ic (19 93 ) Sc he pi s, R ei d, B eh rm an n, 4 au tis tic ; a ge s 3 -5 Co m m un ic at io n Ex pe rim en te r N o N o Sc ho ol an d Su tto n (19 98 ) tr ai ni ng Th or p, St ah m er , an d 3 au tis tic ; a ge s 5 -9 Pi v o ta l r es po ns e Ex pe rim en te r Ye s Ye s H om e, cl in ic , Sc hr ei bm an (1 99 5) tr ai ni ng sc ho ol N ot e: PE CS = P ic tu re E xc ha ng e Co m m un ic at io n Sy ste m . at Istanbul Universitesi on April 25, 2014bmo.sagepub.comDownloaded from treatment reviews, it also covers more studies than did previous reviews. However, there are a number of previous reviews and commentaries that warrant the reader’s attention. We direct the reader to DiSalvo and Oswald (2002), Krantz (2000), McConnell (2002), Parsons and Mitchell (2002), Reynhout and Carter (2006), Rogers (2000), Solomon, Goodlin-Jones, and Anders (2004), Terpstra, Higgins, and Pierce (2002), and Weiss and Harris (2001). These reviews focus more on descriptions of the treatments, whereas our review primarily focuses on trends in the data. Types of Interventions All the published literature could best be described as operant or social learning in theoretical orientation. We did not find any studies with an acceptable research method that could be described as psychodynamic or humanistic. Different authors of reviews have used several methods of orga- nizing the available treatment literature. Weiss and Harris (2001), for example, used the categories of scripts, social-skills training, self-management training, and classroom interventions. DiSalvo and Oswald (2002) reviewed methods they described as peer mediated, and Reynhout and Carter (2006) provided an entire review on social stories. Rogers (2000) took a different approach including more categories. These procedures included techniques such as peer- mediated approaches, peer tutoring, social games, self-management, pivotal response training, video modeling, direct instruction, visual cuing, circle of friends, and social-skills groups. Obviously, at this point, many different pro- cedures have been used. We wished to keep the list simple, so we settled on five groups. These categories were determined by the number of studies pub- lished on given topics in the 79 treatment studies surveyed. Even so, some variability within categories was clearly evident. These categories were mod- eling and reinforcement (33 studies), peer-mediated interventions (20 stud- ies), reinforcement schedules and activities (8 studies), scripts and stories (10 studies), and miscellaneous (8 studies). Modeling and Reinforcement This method is the progenitor of social-skills training. Modeling is typi- cally done by an individual and confederate (either an adult or child preschooled in how to respond). They present a social situation that results in eliciting a response from the target child. Discrete target behaviors such as eye contact, voice volume, and contact in speech are rated. Feedback on the 692 Behavior Modification at Istanbul Universitesi on April 25, 2014bmo.sagepub.comDownloaded from Matson et al. / Social-Skills Treatments Overview 693 accuracy and appropriateness of the child’s response are given, along with suggestions for further improvement. Additional practice attempts often fol- low this feedback. Social and edible reinforcement for appropriate respond- ing are also used. This procedure is efficient and effective but may be best for older children with better mental skills and experiences and the ability to gen- eralize these skills to other settings with minimal additional training. Peer-Mediated Interventions The notion that generalization should be programmed into social-skills treatments is perhaps best exemplified by the employment of peers as train- ers. Theoretically, the skills developed with normal developing peers will generalize to various environments and activities in the school setting. Methods vary, but typically an experimenter, therapist, or teacher works to teach peers to model and/or prompt appropriate social behaviors for children with ASDs. The substantial number of studies using this method points to its popularity. This approach also reinforces the notion of “inclu- sion” models of education for children with ASDs. The approach is limited by the setting (generally would need to occur in the school) and age of the child. Preschool-age children would likely be able to serve in such a capac- ity in limited ways. Also, the ethical issue of whether children should serve as “trainers” for other children, although rarely addressed, should be con- sidered. The cost–benefit to the peer tutor, relative to other school activities, deserves attention. Also, the potential for subtle coercion, even if unin- tended, to participate is always present in an adult–child learning situation. The opportunity to not participate or to end participation should be closely monitored. Having noted these concerns, the method certainly has merit and is likely to continue to be used and studied. Reinforcement Schedules and Activities This procedure appears to show considerable promise, for young children in particular. We say this because the treatment is fairly basic, with reinforcement and, in some instances, prompts or time delays between prompts and reinforcement (Ingenmey & Van Houten, 1991). No particular advanced conceptual skills are required, as is the case with modeling or most peer-mediated interventions. Similarly, edible reinforcers are commonly employed and, for ASD children, may be more effective in many instances at Istanbul Universitesi on April 25, 2014bmo.sagepub.comDownloaded from given the fact that social avoidance and aversion to physical contact and praise can be symptomatic of the disorders. Similarly, using activity sched- ules can be a very effective procedure that can be provided as part of a rein- forcement schedule. The need for sameness can make schedules particularly salient and effective with this population. Scripts and Social Stories The reader is referred to Reynhout and Carter (2006) for a detailed description of this method. In effect, this approach to social-skills training is a form of school-based curriculum or study plan. The content involves various lessons on socialization presented by reading from a book, through presentation on a computer, via music, or by visual symbols. Generally, several stories are used (e.g., three or four). They may center on one theme such as social interactions. Other researchers have addressed multiple themes, including socialization, communication, or aggression. Exercises are often included and can involve taking social stories home to be read by the parents or practicing behaviors described in the stories. This format is particularly adaptable to school settings because the format is similar to what is employed in many other classroom activities. Miscellaneous Several interventions defy categorization into one of the previously reviewed main topics. Social-skills curriculums have received limited atten- tion. Similarly, efforts to borrow well-researched treatment strategies for ASD children, typically used to teach communication and other viable skills, have been tested. Pivotal response training, Picture Exchange Communication System, and inclusion in classrooms with typically developing, same-age peers are examples of these methods. Self-management has also been tried. However, this procedure’s practicality is markedly limited with young children, particularly where intellectual disability co-occurs. We found only one instance of parent training. This procedure is woefully understudied in our view. Obviously, parents are a great source of support and learning for their child. Parental skills that can be transported to the home and other natural environments appears to be an area where much greater resources should be invested with respect to the treatment literature. 694 Behavior Modification at Istanbul Universitesi on April 25, 2014bmo.sagepub.comDownloaded from Matson et al. / Social-Skills Treatments Overview 695 Selection of Target Behaviors A particularly concerning issue was the haphazard manner of target behavior selection. In almost every instance, no rationale was provided for the selection of target behaviors; they were just described. It is highly likely, given the complexity and number of social skills and the substantial number of deficits these children with ASDs exhibit, that many other social skills require remediation. We argue for more-systematic methods of identifying these behaviors to ensure that the skill most likely to bene- fit the individual is targeted for intervention first. For example, a social- skills measure, such as the Matson Evaluation of Social Skills with Youngsters (Matson, Rotatori, & Helsel, 1983), might be administered. Next, deficit skills might be ranked based on ease with which the skill might be trained and its overall impact on the child’s improved adaptabil- ity. Furthermore, some skills naturally group together and could be grouped into clusters. Some skills the child already uses might be suc- cessfully added in with skills with which the child is deficient, using a behavioral momentum model. In addition, functional assessment might be important to include. Some social behaviors might be replacement behav- iors for stereotypes, self-injury, aggression, and property destruction. Example social skills that might serve this role include initiating com- ments, securing attention, and initiating requests. The assessment litera- ture on social skills and replacement behaviors has advanced to a point where these technologies should be incorporated into social-skills training paradigms (Matson & Wilkins, 2007). Social Validation Social validity as a construct for evaluating the social significance and desirability of interventions has been available for several decades. Having said this, precious few studies we reviewed, less than 10%, used such pro- cedures. We strongly encourage researchers to incorporate these methods in future research on social-skills treatment of children with ASDs. Several methods were used in the studies reviewed. In one study, a focus group of knowledgeable people evaluated target behaviors for greatest functional improvement in the natural environment. In addition, they selected social skills used in previous research (Laushey & Heflin, 2000). In another study, 10 parents of nonhandicapped elementary-age children rated pre–post videotapes of ASD children interacting with a therapist to assess social at Istanbul Universitesi on April 25, 2014bmo.sagepub.comDownloaded from 696 Behavior Modification importance of treatment effects (Charlop & Milstein, 1989). Gena, Krantz, McClannahan, and Poulson (1996) had participants’ parents and graduate psychology students rate videotaped scenarios of children. The raters’ task was to identify the scene of each vignette where the participants’ behavior was the most socially appropriate. Other methods, such as questionnaires aimed at client satisfaction, could also be used along with these measures of social validation of target behavior selection (conducted prior to inter- vention) and at the conclusion of treatment. Thus, it is important to note that social validation procedures have an important role to play prior to and at the conclusion of therapy. Experimental Design and Setting Single-case experimental designs constituted more than 90% of the stud- ies. Typically, 3 or 4 children participated. Multiple baseline designs were the most common, and multielement procedures were used in a substantial number of the studies. It was common to see some form of generalization and of follow-up. The latter measure was typically in weeks or months ver- sus years. Most studies were school based, with either teachers or experi- menters or therapists (usually graduate students, we would deduce) serving as instructors. There is plenty of room for additional small-N studies. However, at this point, there is a particular need for group research designs. These methods could be used to further establish the viability of given interventions while demonstrating if large-scale intervention programs for social skills are both practical and effective. Second, testing different treatment methods against one another is overdue. Of course, these studies take more resources and are often harder to conduct. However, even if, as has occurred in many treat- ment studies, behavioral methods produce similar effects, that would be very valuable to know. Additional measures about practical issues in imple- mentation, such as length of time needed to learn the strategy, the attitude of staff toward specific procedures, the resources needed to implement a training model, and so on, would be invaluable. Thus, if two methods were nearly equal in effectiveness but one method required far fewer resources, it might prove to be more preferred. Experimenters were consistently aware of the need to program for generalization. These issues are particularly salient for young children and persons with intellectual disabilities (ID) and/or ASDs. Thus, it is laudable at Istanbul Universitesi on April 25, 2014bmo.sagepub.comDownloaded from Matson et al. / Social-Skills Treatments Overview 697 that such efforts have been so frequently made in the ASD social skills lit- erature. However, given the often intractable nature of social deficits in this population, longer treatment phases, with much longer follow-ups and using a broader, more comprehensive set of social behaviors, would be of great value in future research. Although early treatment studies on social-skills training were con- ducted by clinical psychologists, often in clinic settings, children with ASDs receiving social-skills training has largely been the domain of the school and has been planned by educators. It is good that these individuals have been so active. However, those in the mental health disciplines have, to some extent, dropped the ball. Efforts to develop parent-training models, in-home programs, and programs that address comorbid psychopathology of ASD children in the context of social-skills training are greatly needed. Participant Characteristics Almost without exception, the children studied are autistic; therefore, studies on related ASDs are required. Of particular concern for many of the studies is that the methods of classification are often poorly described or sorely lacking. Thus, the validity of diagnoses in the bulk of the studies is questionable. Often no reliability data on diagnoses are present. Frequently, the diagnoses were not done for the study, and thus we are left with vague references to diagnoses made by a psychologist, psychiatrist, educator, or multidisciplinary team. It is suggested that diagnoses be provided for given studies using evidence-based assessment scales. Interrater data with two independent diagnoses for at least some subset of diagnosed children would be optimal. Other related participant characteristics that require evaluation in the context of different social-skills treatments and their effectiveness are level of intellectual disability if present, severity of ASD symptoms as a group and individually, presence of comorbid psychopathology, and type of comorbidity. Krantz (2000), in an interesting commentary, noted that children with ASD should have intervention for social skills well before age 5. She noted that most children have already developed rudimentary social behavior in the first 2 years of life and that marked deficits in such skills after 5 may be in large part because of the absence of early intervention or ineffective treatment to that point. It is not uncommon for early-intervention programs to begin at age 2 or 3 (Matson & Minishawi, 2006). However, a review of at Istanbul Universitesi on April 25, 2014bmo.sagepub.comDownloaded from 698 Behavior Modification the social-skills training literature shows that treatment at such early ages rarely happens. The bulk of the intervention studies targeted children from 6 to 9 years of age, well past the periods now recommended for the initia- tion of such interventions. This factor is most likely in large part because of the lack of substantial numbers of programs (Matson, Nebel-Schwalm, & Matson, 2007). However, in instances where early-intervention programs are in place, they rarely feature social skills as one of the primary compo- nents for training. Furthermore, early-intervention programs tend to be through clinics, schools, residential organizations, or other private organi- zations. They are not typically linked to the school system and therefore do not afford continuity in programs as the child grows older. Given the chronic nature of ASDs, a reformulation of service provision may be war- ranted. For example, Gabriels, Ivers, Hill, Agnew, and McNeill (in press) note that based on their follow-up data of 5 years post–early intervention, it may be necessary to continue the intervention, targeting communication for below-average cognitive groups while emphasizing social skills for higher functioning children. Given that skills tend to degrade if not prac- ticed, particularly in populations with special needs, protracted intervention strategies should be considered. “Cure,” although a debated topic in the early-intervention literature on ASDs, may be possible (Matson & Minishawi, 2006). However, even if that occurs, it would be in a subset versus all ASD children, thus making long-term social-skills training a priority for children with ASDs. The notion of a chronic condition that can be improved versus eradicated appears to be more in line with the conventional wisdom at this time (Howlin et al., 2000). Trends in Treatment Figure 1 represents the number of treatment studies published each year that we reviewed. The most obvious finding here is that the number of stud- ies has been increasing during the past 25 years. This trend is fairly consis- tent, and, based on these data, one could expect this trajectory to continue. The data are broken down a bit further into each of the five treatment cate- gories in Figure 2. The variety of treatments has increased with time as well. Thus, not only is the greatest number of studies on social skills with ASDs in the 2001 to in-press time block, but more variability in the types of procedures is available now than ever before. Again, this may underscore the need for studies that better define what treatments are best for what at Istanbul Universitesi on April 25, 2014bmo.sagepub.comDownloaded from Matson et al. / Social-Skills Treatments Overview 699 children under what conditions. Having said this, modeling and reinforcement has been and continues to be the most popular intervention strategy in the published research. These results would suggest the viability of this particular method. However, more clearly establishing comparative studies using social validation criteria, which has been infrequent in this literature to date, might help to better determine optimal treatment models. Most researchers, by the nature of the interventions they describe, assume a skill deficit on the part of the child. We caution the reader not to quickly conclude that this is always the nature of the deficit. Another possibility is that the child has the skills, but the nature of his or her disability or inade- quate natural reinforcement in the environment may impede the person with an ASD from evincing the requisite social behaviors. Thus, systematic assessment of social skills, which can help illuminate the etiology of social- skill deficits, should be used as a component of case formulation (Matson & Wilkins, 2007). The issues noted above await future examination. However, clinical, public, and research interest in ASDs has never been greater. 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Matson is a professor and distinguished research master in the Department of Psychology at Louisiana State University. His research interests are in developmental disabil- ities and autism spectrum disorders. He is the author of 450 publications, including 32 books. Michael L. Matson is a student at Louisiana State University. His research interests are in developmental disabilities and autism spectrum disorders. He is the author of two books and eight journal articles on the topic. Tessa T. Rivet is a doctoral student in clinical psychology at Louisiana State University. Her research interests are in developmental disabilities and autism spectrum disorders. 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