Wednesday, July 11, 2018

Social Skills Intervention Improves Executive Function (EF) in Autism


             Social Skills Intervention Improves Executive Function (EF) in Autism

Social Skills

Impairment in social communication and interaction is a core feature of autism spectrum disorder (ASD). Social skills deficits include difficulties with initiating interactions, maintaining reciprocity, taking another person’s perspective, and inferring the interests of others. Social relationship skills are critical to successful social, emotional, and cognitive development and to long-term outcomes for students. Research evidence suggests that when appropriately planned and systematically delivered, social skills instruction has the potential to produce positive effects in the social interactions of children with ASD. Both the National Professional Development Center (NAC) and the National Autism Center (NAC) have identified social skills training/instruction as an evidence-based intervention and practice.  
Executive Function

Executive function (EF) is a broad term used to describe the higher-order cognitive processes such as response initiation and selection, working memory, planning and strategy formation, cognitive flexibility, inhibition of response, self-monitoring and self-regulation. EF skills allow us to plan and organize activities, sustain attention, persist to complete a task, and manage our emotions and monitor our thoughts in order to work more efficiently and effectively. Executive function and self-regulation (EF/SR) problems have been demonstrated consistently in school-age children and adolescents on the autism spectrum. Research suggests that operations and activities that require mental flexibility, including shifting of cognitive set and shifting of attention focus are impaired in children and youth with autism. This includes difficulty directing, controlling, inhibiting, maintaining, and generalizing behaviors required for adjustment both in and outside of the classroom without external support and structure from others. EF/SR skills have been linked to many important aspects of child and adolescent functioning, such as academic achievement, self-regulated learning, social-emotional development, physical well-being, and behavioral problems. Research shows that children with strong EF/SR skills are better prepared for school and have more positive social, adaptive, and academic outcomes.

Research

A study published in the open access journal Autism Research and Treatment examined potential changes in executive function performance associated with participation in the Social Competence Intervention (SCI) program, a short-term intervention designed to improve social skills in adolescents with ASD. The Social Competence Intervention-Adolescent (SCI-A) is based on cognitive-behavioral intervention and applied behavior analysis and targets EF, theory of mind (ToM), and emotion recognition as key constructs in addressing social skills impairments.

Behavioral performance measures were used to evaluate potential intervention-related changes in executive function processes (i.e., working memory, inhibitory control, and cognitive flexibility) in a sample of 22 adolescents with ASD both before and after intervention. For comparison purposes, a demographically matched sample of 14 individuals without ASD was assessed at the same time intervals. Intervention-related improvements were observed on the working memory task, with gains evident in spatial working memory and, to a somewhat lesser degree, verbal working memory. The finding of improved working memory performance for the intervention group is consistent with research suggesting that working memory represents an aspect of cognition that may be malleable and responsive to intervention.

Additional research is needed to evaluate to what extent the presently observed gains in EF performance may translate to other age ranges, levels of symptom severity, and other social skills interventions. Further research is also required to examine whether the presence/absence of comorbid ADHD symptomatology may influence the effectiveness of interventions for improving not only social skills but also underlying core EF processes such as cognitive flexibility and working memory.

Implications

Previous research indicates that EF represents an area of weakness for individuals with ASD even after accounting for comorbid conditions such as ADHD. Reviews of the existing literature suggest that cognitive flexibility, working memory, and inhibitory control are often impaired in individuals with ASD. Each of these EF component processes play an important role in the acquisition of knowledge and social skills; the better children are at focusing and refocusing their attention, holding information in mind and manipulating it (i.e., working memory), resisting distraction, and adapting flexibly to change, the more positive the social, adaptive, and academic outcomes. The aforementioned research findings contribute to the growing evidence that children with ASD who participate in social skills interventions that integrate EF skills such as working memory, cognitive flexibility, emotional recognition, and self-regulation experience not only an improvement in social competence, but also underlying core neurocognitive EF processes. Executive dysfunction places a child at-risk and is likely to have an adverse impact on many areas of everyday life and affect adaptability in several domains (personal, social and communication). Systematic social skills instruction that incorporates EF process components in program delivery can help reduce the risk for negative outcomes for children on the autism spectrum. Likewise, an assessment of EF skills can add important information about the child’s strengths and weaknesses and inform intervention/treatment planning. Best practice guidelines for assessment and intervention are available from A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).

Reference

Social Skills Intervention Participation and Associated Improvements in Executive Function Performance. Shawn E. Christ, Janine P. Stichter, Karen V. O’Connor, Kimberly Bodner,
Amanda J. Moffitt, and Melissa J. Herzog. Autism Research and Treatment
Volume 2017, Article ID 5843851, 13 pages https://doi.org/10.1155/2017/5843851

Lee A. Wilkinson, PhD is a licensed and nationally certified school psychologist, registered psychologist, and certified cognitive-behavioral therapist (CCBT).  Dr. Wilkinson provides consultation services and best practice guidance to school systems, agencies, advocacy groups, and professionals on a wide variety of topics related to children and youth with autism spectrum disorder. He is also a university educator and trainer, and has published widely on the topic of autism spectrum disorders both in the US and internationally. He is author of the award-winning books, A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools and Overcoming Anxiety on the Autism Spectrum: A Self-Help Guide Using CBT. He is also editor of a best-selling text in the APA School Psychology Book Series, Autism Spectrum Disorder in Children and Adolescents: Evidence-Based Assessment and Intervention in Schools. His latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).

© 2018 Lee A. Wilkinson, PhD

Saturday, June 30, 2018

Social Communication Skills and Autism

Social Communication Skills and the Autism Spectrum

The DSM-5 diagnostic criteria for autism spectrum disorder (ASD) include persistent deficits in social communication and social interaction across multiple contexts. Poor pragmatic/social use of language or impairment in the ability to understand and use language in social-communicative contexts is a core feature of ASD. Pragmatic skills involve: (a) using language for different purposes; (b) changing language according to the needs of a listener or situation; (c) understanding non-literal language; and (d) following rules for conversations. 

There are many unwritten rules in society that govern our behavior. While most of us intuitively understand these rules, individuals with ASD have not automatically learned the conventions and nuances that make up their social environment. These unspoken or “hidden” social standards can make the world a confusing place and result in life-long challenges. For example, social expectations such as “it is not polite to interrupt others while they are talking,” “take turns in conversation” and “discuss other topics besides only those you are interested in” are not taught and are assumed to be known and understood. We seem to have an “unconscious” navigator that allows us to make intuitive sense of the unspoken rules in society and adjust to the social demands of our everyday lives.
Figurative Language

The unspoken rules of social engagement involve the use of the pragmatic, social communicative functions of language (e.g., turn taking, understanding of inferences and figurative expressions) as well as nonverbal skills needed to communicate and regulate interaction (e.g., eye contact, gesture, facial expression). This includes body language and idioms, metaphors, or slang – phrases and meanings that we intuitively assimilate or learn through observation or subtle cues. Individuals with ASD tend to interpret language literally and may be puzzled by the common everyday expressions used by a typical peer or adult. Consider how idioms such as “how the cookie crumbles,” “curiosity killed the cat,” and “when it rains, it pours” might have a totally different meaning and result in confusion if taken literally. In order to understand language, we must understand what the idioms in that language mean. If you try to figure out the meaning of an idiom literally (word by word), you will be bewildered. While the typical individual might understand that the phrase “that’s the way the cookie crumbles,” and accompanying body language (e.g., voice, body) communicates to the listener that something unfortunate has happened, to someone with a pragmatic social-communication problem, this idiom will have a completely different meaning and be confusing. The following are but a few of well over 3,000 idioms in the English language.
  • Bite off More than you can chew  
  • Cross that bridge when you come it
  • Everything but the kitchen sink 
  • Get up on the wrong side of the bed 
  • Have a bone to pick with you 
  • Have your cake and eat it too 
  • Kill two birds with one stone  
  • Put all your eggs in one basket 
  • Raining cats and dogs 
  • Run circles around someone 
  • Till the cows come home
Assessment

Because social communication deficits are among the core challenges of ASD, a best practice student assessment should include an evaluation of pragmatic competence and not be limited to the formal, structural aspects of language (i.e., articulation and receptive/ expressive language functioning). As a group, more capable students with ASD tend to demonstrate strength in formal language, but a weakness is pragmatic and social skills.  As a result, they often fail to qualify for speech-language services because they present strong verbal skills and large vocabularies, and score well on formal language assessments. Particular attention should be given to the pragmatic, social communicative functions of language (e.g., turn taking, understanding of inferences and figurative expressions) as well as to the nonverbal skills needed to communicate and regulate interaction (e.g., eye contact, gesture, facial expression, and body language). 

Assessments to identify pragmatic language deficits tend to be less well developed than tests of language fundamentals. There are fewer standard measures available to assess these skills in children with ASD. Valid norms for pragmatic development and objective criteria for pragmatic performance are also limited. Among the standardized instruments that focus on the social communicative functions of language are the Comprehensive Assessment of Spoken Language (CASL; Carrow-Woolfolk, 1999), Test of Pragmatic Language, 2nd Edition (TOPL-2; Phelps-Terasaki & Phelps-Gunn, 2007), Social Language Development Test-Elementary (SLDT-E; Bowers, Huisingh, & LoGiudice, 2008), Children's Communication Checklist, Second Edition (CCC-2; Bishop, 2006) and Pragmatic Language Skills Inventory (PLSI; Gilliam & Miller, 2006). 
Significant and severe deficits in the ability to communicate and interact with others can limit students' participation in mainstream academic settings and community activities. Moreover, pragmatic deficits tend to become even more obvious and problematic as social and educational demands increase with age. Because pragmatic language is a critical part of everyday social interaction, it is imperative that speech/language services for children with ASD include a focus on social communication skills. Students with pragmatic language deficits who do not meet the DSM-5 ASD criteria for restricted, repetitive patterns of behavior should be evaluated for social (pragmatic) communication disorder (SCD). 


Lee A. Wilkinson, PhD, NCSP is a licensed and nationally certified school psychologist, registered psychologist, and cognitive-behavioral therapist. He is author of the award-winning book, A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools, published by Jessica Kingsley Publishers. He is also the editor of a best-selling text in the APA School Psychology Book Series, Autism Spectrum Disorder in Children and Adolescents: Evidence-Based Assessment and Intervention in Schools and author of the book, Overcoming Anxiety and Depression on the Autism Spectrum: A Self-Help Guide Using CBT. Dr. Wilkinson's latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition). 
© 2018 Lee A. Wilkinson, PhD

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