Social Skills Training for Students with Autism Spectrum Disorders: The MultiDisciplinary Way 4/16/10, Friday, 8:30-11:30

Alaine Ocampo, Mitra Sell,

Speech-Language Pathologist School Psychologist

Tyra Willis, Speech-Language Pathologist

Scope of Practice (ASHA 2006 position statement) • “Includes providing services for individuals with disorders of pragmatics and social aspects of communication” • “Individuals shall engage in only those aspects of the professions that are within the scope of their competence, considering their level of education, training, and experience” (ASHA, 2003, Code of Ethics) • SLPs “should collaborate with families, individuals with ASD, other professionals, support personnel, peers, and other invested parties to identify priorities and build consensus on a service plan and functional outcomes”

Limits to SLP-only groups • pragmatics only- limited focus • difficulty modeling 2 person conversation • disruption of the flow of group when behavior occur • missing components due to scope of practice – anxiety management – coping skills – anger management – behavior management

Overview of Presentation • Rationale for multidisciplinary team approach • IEP goals • How to select interventions • Our basic group format • Staff intervention and tools • Measuring progress • Q &A

Scope of Practice for School Psychologists According to NASP Professional Standards (2009) a school psychologist is able to "provide services that enhance academic performance, design strategies and programs to address problems of adjustment, consult with other educators and parents on issues of social development and behavioral and academic difficulties, conduct psycho-educational assessment for purposes of identifying special needs, provide psychological counseling for individuals, groups and families, and coordinate intervention strategies for management of individuals and school-wide crises."

Limits to School Psychologist-only groups • typically counseling-only groups • lack of training in pragmatics and language

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Benefits of Multidisciplinary

Research Supporting Multidisciplinary

• Consistent with IDEA in working as a team • Allows for sharing of expertise to address the core deficits found in students with ASD, thereby treating the child holistically (Language – Cognitive shifting-Behaviors)

– Treatments based on behavioral or cognitive-behavior theory appear most promising (Kehle, Madaus, Baratta, & Bray, 1998). – School psychologist’s role: May serve as a consultant to assist the speech pathologists’ delivery of services. -The school psychologist’s knowledge of behavioral and cognitive theories beneficial in collaboration with the SLP in the design of language-based treatments (Tezlow, Fuller, Siegel, Lowe, and Lowe , 1989)

Benefits (Cont)

Overview of Steps to Establishing Groups

• Alleviates growing work load and scope of practice • For SLPs: Social Skills group time can be used in lieu of an isolated “language”-based intervention group • As a Psych: Helps alleviate behaviors by addressing core deficits; decreases need for classroom behavioral interventions, bsp, bip • Keeping up with the day to day for each student

• Establish staff roles -Psychologist looks at self-regulation, social emotional reciprocity, conversational skills, cognitive shifting, behaviors interfering with establishing appropriate social skills -SLP looks at IEP goals related to language formulation/processing, auditory memory, and conversational skills. • Determine which students will participate • Establish baseline level of functioning • Establish goals • Determine types of interventions needed

Starting Groups: Group Member Criteria • Will the student benefit from a social skills group versus smaller student to staff ratio? • Does the student have enough language to participate in a social skills group? • Does the child have the cognitive capacity to benefit from a social skills group versus a language only group working on narrative skills? • Does the student’s level of behavior impede the ability to participate in a group?

Establishing a Baseline • Purpose (1) to create clearer focus for the groups (2) to know what skills to target, (3) to help you group students

• Areas assessed (see next slides) – social interaction style – level of social competence – functionality of coping skills

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Common Social Interaction Styles Found In Spectrum Kids There are several interaction styles described in research that children on the spectrum can exhibit (Wing & Gould, Kaijer and deBildt): 1. Socially aloof = the child does not or hardly notices peers 2. Passive = the child is indifferent to peers but can be led into social situations; does not typically initiate interactions with peers but will join 3. “Active-odd” = The child joins peers in a socially awkward manner 4. Adult oriented = The child is exclusively oriented towards adults. 5. Inconsistent = The child is able to inconsistently consider and join peers in activities

Basic Social Skills The Mental Health Foundation of Australia (2005) identified the following building blocks in social competence: - “Basic interaction skills (e.g., smiling, making eye contact, listening) -Entry/approach skills (how to approach an individual socially or join a group) -Maintenance skills (e.g., how to share, take turns, follow rules, co-operate etc.) -Friendship skills (e.g., how to show appropriate affection, involve others in decision making, be inclusive, etc.) -Conflict resolution (how to manage disagreements in a socially acceptable manner) -Empathy -Communication of needs and ideas -Sense of humor -Assertiveness (how to say no to engaging in dangerous or antisocial behavior, stand up for oneself, etc.)”

Additional Components • Bellack et al (2004) identified the following components in social skills: -expressive behaviors including speech content, paralinguistic features (voice volume, pitch, intonation, and speech rate); -nonverbal behaviors (eye contact/gaze, posture, facial expression, proximity); -social perception or receptive behaviors (attention to and interpretation of relevant cues, emotion regulation); -interactive behaviors (response timing, use of social reinforcers, turn taking); and -situational factors (social intelligence, ie., knowledge of social mores and demands of the specific situation).

Coping Skills -How does the student cope with problems? -Are the student’s coping skills: -functional (doing what they should do to alleviate behavior) -age and gender appropriate -What behaviors does the student exhibit that impede his/her ability to interact with others?

How to Develop IEP Goals • Address core deficits in by breaking things down • Importance of collaborating on goals • Sample areas of IEP goals: – – – – – – –

emotion regulation topic maintenance initiation of conversation on non-preferred topic anger management skills anxiety management eye gaze conversation taking

Key Components in Goals • • • •

Measurable Age appropriate Attainable Connect to state standards – Language Arts: Standards that are connect language to narratives and pragmatics (Listening & Speaking Strategies and) Speaking Applications

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Samples of Collaboratively Developed IEP goals Conversational Skills •

•

By 12/09, During structured class activities, XX will use appropriate comments/remarks and facial/bodily gestures as judged by the teacher or clinician when presented with a communicative interaction from a peer or adult in 3/5 opportunities when provided with 3 prompts. By 1/09, during a small structured setting, XX will participate in a group discussion with 2-4 peers as demonstrated by asking at least one question to gain new information, answering one question, and making one related comment in 4/5 trials when given visual cues/instructions and no more than 2 verbal prompts across 2 consecutive sessions.

Review of Basic Components of Groups • • • • • • •

1 SLP, 1 School Psych Number of students: between 4-6 depending on age Once a week for 30-45 minutes each session. Structured format Consistent use of behavior management strategies Group rules Creating a group language or lingo

Teaching Relaxation • Purpose: self regulation to be used anywhere at anytime • Teaching relaxation via – deep breathing – muscle relaxation – counting

Continued Self-Regulation By 1/1/10, In a large group setting, when becoming excited, XX will use self-regulation strategies (i.e., deep breathing, muscle relaxation) while staying in the conversation/interaction in 3/4 opportunities when given no more than 4 prompts.

Initiation, Proximity, Body Language : By 1/07, during a small semi-structured group activity, XX will appropriately begin an interaction with a peer by demonstrating appropriate proximity (at least 1 arm length away and with feet facing the front of the person), looking at a person’s face and acknowledging person’s body language (social referencing) and verbalizing the persons name in 3/5 trials when given visual cues and no more than 1 verbal prompt.

Our Group Format Step 1: Relaxation (deep breathing, muscle relaxation) Step 2: Check-in (small talk) Step 3: Feedback Step 4: Activity (lesson of the day) Step 5: Practicing and processing the activity (feedback can also be given here) Step 6: Saying good-bye (termination skills)

Format of “Check-in” • Purpose: teaches students the format of a conversation; also gives them something to fall back on when stuck • Provides students with a basic script for small talk – “how are you feeling” – “what did you do at lunch” – “what did you do over the weekend”

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Feedback • who gives feedback

The “Activity” How to select an activity

– staff first, then add peers.

(1) Determine what you are going to target (start with key foundational skills we talked about earlier). (2) Focus on a couple key deficits at a time until students have internalized the skill(s) (3) Determine the type of staff intervention needed (next slide) and level of intervention needed for each student (which may vary day to day, session to session) (4) Determine the tools you will need

• for what – pick 2-3 target skills ex: eye contact, staying on topic,

• purpose – teaching how others perceive us, how we effect others

• scales – good job, needs work on…(be specific!)

Level of Prompting

Types of Staff Intervention • providing scripts (of varying lengths from full to minimal) • verbal and physical prompts (to facilitate formulation of questions/comments)

• • • • •

shadowing scaffolding direct instruction prompts to initiate /self-monitor relaxation techniques counseling techniques (including redirecting, normalizing feelings and thoughts, confronting thought distortions with reality, reframing thoughts and perceptions) • direction correction (then and there)

• full script (high level of prompting) • occasional interjection • fading back or shadowing (lowest level)

Practicing and Processing: the Progression of Social Interaction

Tools of Intervention • • • • • • • • •

Behavior charts Word of the day (a psuedo-lesson plan) Social stories or comic strip stories Video modeling Wordless books Book of rules Role plays Social scenario cards Facial expression pictures

• • • • •

Staff to student Student to staff student to student on preferred topics student to student on non-preferred topics group conversations

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The Progression of Group: Moving from Instruction to Process • Starts out with introducing the routine of group and managing behavior • As student behavior decreases, begin to work on one skill at a time • Begin to expand check-in – moving beyond a script – introducing here and now topics of interest (preferred and non-preferred) – introducing bonus points to work on listening comprehension and social emotional reciprocity – encouraging students to facilitate check-in

Video Clips • Confidentiality review • Example of students during “check-in” • Example of students doing relaxation exercises • Example of here and now group

Managing Group Behavior •

Visual behavior chart (next slide) – Review how to earn points (behavior mgmt. piece) – Review how students can earn warnings and consequences to warnings (3 warnings= going back to class, consultation with teacher

• • • • • •

positive reinforcement for appropriate behavior frontloading reviewing expected behavior teaching anxiety management teaching anger management visual or written schedule of routine (to encourage attention and decrease behaviors due to predictable format)

about behavior, time-out, extended time)

Behaviors to Expect & What to Do Expect • tantrums • resistance • physical aggression • verbal aggression

More Intervention Ideas: Breaking Core Deficits Down

Sample Behavior Chart RELAXATION

STUDENT 1

STUDENT 2

CHECK-IN

EYE/ BODYLISTENING

STAYING ON TOPIC

Suggestions • behavior chart • positive reinforcement • frontloading • reviewing expected behavior • teaching anxiety management • teaching anger management

• • • • •

Social skills Communication skills Behavior and emotions Narrative skills and sequencing Play Skills

STUDENT 3

STUDENT 4

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Social and Communication Skills • Defining what a conversation is and is not – monologue versus dialogue – types of conversations

• • •

Staying on topic (“topic maintenance”) How to end a conversation appropriately How and when to share interests with others

• •

How to learn about the interests of others How to look and act interested in others

– reading body cues

• parallel versus joint

• Defining what is a friend

– verbalizations – body language – facial expressions

– how to be a good friend – benefits of having a friend

• How to start a conversation – how to join a conversation already in progress (physical proximity, what to say, and when to say it)

• Using eye and body listening (the role in a conversation) – two person versus group conversations

Behavior, Thoughts, and Emotions • Emotions – – – –

Labeling emotions Recognizing emotions on people Recognizing emotions in picture scenes Discussion of ways to deal with feelings

• Theory of Mind (knowing that we each have our own thoughts and feelings) – reading body cues – reading facial expressions – looking at the social situation

• Self-Regulation • Shifting perspectives (CBT)

Sequencing • Sequencing pictures, toys, social scenes, etc., telling a story with the cards, asking the child to retell the story, and then with skill mastery asking the child to tell a story of the pictures without any prompting.

• This can be done with toys as well, starting at first with more functional types of activities, such as cooking spaghetti, making pizza, scooping ice cream, etc.

• • • •

How to take turns talking in a conversation How to talk about non-preferred topics How and when to change the topic How to use nonverbal body language to express thoughts and needs

Narrative skills • The use of stories to address both story retell and to introduce theory of mind concepts via probing questions (such as what is the character thinking and feeling, how do we know that, etc.) • As a multidisciplinary format, specific language goals concurrently addressed with TOM

Measuring Progress • Can monitor same areas inside AND outside of the classroom • Feedback from teachers • Assistance from trained paraprofessionals • Provides intervention targets/program planning and monitoring

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Tips for Lower Functioning Students

Information that can be collected on playground Student A

Student B

Student C

Student D

• • • •

Initiated a conversation with peer Faced the person during verbal interaction Spoke only about his/her topic of interest

Narratives and story retell Simple toy play Sequencing activities Perspective taking activities with visual supports

Parallel Play Played Jointly

Initiated Play

Tips for Preschool Teams

Tips for Junior High and High School Teams

Important: Know the stages of child development. When working with preschoolers, you are helping them learn the stages they have not developed. Suggested authors: Dr. Stanely Greenspan, Dr. Pamela Wolfberg, Piaget, Vgotsky

• focusing on skill deficits and social emotional functioning

Suggested areas for intervention: • work on narrative skills

• getting to know each student to know what problems they are encountering • moving into here and now to teach coping skills, creating a safe place to talk • helping students find a peer group or creating a peer group where natural friendships will be established

– teaching specific coping skills – read work by Dr. Lauren Franke – use sequencing cards, wordless picture books

•

work on play skills – read Peer Play and the Autism Spectrum by Dr. Pamela Wolfberg – teaching students how to play via: • • • • •

sequencing play activities direct instruction directed or guided play (hand over hand) play groups art activities

Parent Involvement • Why parent involvement is necessary – generalization of skills • Research suggests that the greatest effects of any direct treatment are reflected in the generalization of learning achieved by working with parents and classroom personnel (NRC, 2001)

– everyone being on the same page – listening to the parent’s perspective

• Ways to involve parents – – – –

phone calls IPT meetings newsletter having an open door policy

Cultural Sensitivity • Work with family to better understand child’s ethnic identity and social customs • Stay aware of family’s culture • Know how to appropriately interact with others of a different culture • Understand social rules of society as a whole

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ASHA and NRC: Overall Recommendations • Service Delivery should be flexible and dynamic • Adapt to changing needs, preferences, and priorities of the individual with ASD and family • Delivery options sensitive to culture and language

Additional Obstacles • how to convince administration • how to convince teacher of importance • how to convince school psychs and SLPs the importance of social skills groups led by both professions in order to stay within our scope of practice

Questions & Answers • Mitra Sell, LCSW, LEP Email: [email protected] • Alaine Ocampo, M.A. CCC-SLP Email: [email protected] • Tyra Willis, MCD Email: [email protected] Our website: TBA Look for our workbook in the near future.

Areas of Frustration for Teams • Behavior, behavior, behavior • Are we seeing progress? • Feeling overwhelmed with what skills to teach • Are the kids getting this? • How do I make time for this? • The student is not responding to interventions

Recap: Benefits of MultiDisciplinary Format • Collaboration • Sharing of expertise

• Demonstration of strategies by each professional • Promote generalization in a variety of contexts and environments

References American Speech-Language-Hearing Association (2006). Guidelines for speech-language pathologists in diagnosis, assessment, and treatment of autism spectrum disorders across the life span [Position Statement]. Available from http://www.asha.org/policy. American Speech-Language Hearing Association (2003). Code of Ethics (Revised). ASHA Supplement, 23, 13-15. Barnes, P. E., Friehe, M. J., Radd, T. R. (2003). Collaboration between speech-language pathologists and behavioral psychologists . Communication Disorders Quarterly, 24 (3), 137-142. Bellack, A., Mueser, K., Gingerich, S., Agresta, J. (2004). Social skills Training for Schizophrenia: A Step by Step Guide. The Guilford Press. New York: NY.

Bellini, S. (2006). Building Social Relationships: A Systemic Approach to Teaching Social Interaction Skills to Children and Adolescents with Autism Spectrum Disorders and Other Social Difficulties. Shawnee Mission, Kansas: Autism Asperger Publishing Co. Franke, L. (2006). Coaching Comprehension Creating conversation. OCDE S.U.C.S.E.S.S. Training workshop. Gutstein, S. E., & Sheely, R. K. (2002). Relationship development intervention with young children : Social and emotional development activities for asperger syndrome, autism ,PDD, and NLD. London, England: Jessica Kingsley Publishers Ltd. Howlin, P., Baron-Cohen, S., & Hadwin, J. (1999). Teaching children with autism to mind-read: A practical guide. New York, NY: John Wiley & Sons. Individuals with Disabilities Education Act of 2004, Pub. L. No. 108-446, 118 Stat. 2647 (2004).

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References (cont) Kehle, T.J., Madaus, M. M., r., Baratta, V.S., & Bray, M. A. (1998). Augmented self-modeling as a treatment for children with selective mutism. Journal of School Psychology, 36,(3), 377-399.

Licciardello, C., Harchik, A., Luiselli, J. (2008). Social Skills Intervention for Children with Autism During Interactive Play at a Public

References (continued) Schwartz, H., & Drager, K. D. R. (2008). Training and knowledge in autism among speech- language pathologists: A survey. Language, Speech, and Hearing Services in Schools, 39, 66-77.

Elementary School. Education and Treatment of Children. 31 (1), 27-37. Linder, T. (1993). Transdisciplinary play-based intervention: Guidelines for developing a meaningful curriculum for young children. Baltimore, MD: Brookes.

Telzrow, C.F., Fuller,A., Siegel, C., Lowe, A., & Lowe, B. (1989). Collaboration in the treatment of children’s communication disorders: A five-year case study. School Psychology Reviews, 18, 463-474.

Mental Health Foundation of Australia (2005). Social Skills: The Building Blocks of Social Competence. Available on: http://www.embracethefuture.org.au/resiliency/index.htm?http://www.embracethefuture.org.au/resiliency/social_skills.htm

Weiss, M., Harris, S. (2001). Teaching Social Skills to People with Autism. Behavior Modification, Vol. 25, No. 5, 785-802 (2001)

Montgomery, E., & Turkstra, L. (2003). Evidence-based medicine: Let's be reasonable. Journal of Medical Speech Language Pathology, 11(2):ix-xii.

Whitmire, K. A. & Eger, D. L. (2003). Issues brief on personnel preparation and credentialing in speech-language pathology (COPSSE Document No. IB-5). Gainsville, FL: University of Florida, Center on Personnel Studies In Special Education. Retrieved July 23, 2008 from http://www.coe.ufl.edu/copsse/docs/IB-5/1/IB-5.pdf

National Research Council (2001) Educating Children with Autism. Committee on Educational Interventions for Children with Autism. National Association of School Psychologists (2009) Professional Standards. Available from: http://www. nasponline.org Olswang, L. B., Coggins, T. E., & Timler, G. R. (2001). Outcome measures for school-age children with social communication problems. Topics in Language Disorders, 32(4), 50-73. Ozonoff, S., & Miller, J. N. (1995). Teaching theory of mind: a new approach to social skills training for individuals with autism. Journal of Autism and Developmental Disorders, 25(4), 415-433. Prelock, P. A. (1995). Rethinking collaboration: A speech-Language pathology perspective. Journal of Educational and Psychological Consultation, 6(1), 95-99.

Winner, M. (2002). Thinking of you thinking of me. Michelle Winner, Self-Publisher: San Jose. Wolfberg, P. (2003). Peer Plan and the Autism Spectrum: The Art of Guiding Children’s Socialization and Imagination. Kansas. Autism Asperger Publishing Company: Woodruff, G., & McGonigel, M. (1988). Early intervention team approaches: The transdisciplinary model. In J. Jordan, J. Gallagher, P. Hutinger, & M. Karnes (Eds.), Early childhood special education: Birth to three (pp. 163-181). Rustin, VA: Council For Exceptional Children.

Quill, K. (2000). Do-Watch-Listen-Say: Social Communication Intervention for Children with Autism. Baltimore, Maryland: Paul H. Brookes Publishing Co. Soloman, M., B. Goodlin-Jones, et al (2004). A social adjustment enhancement intervention for high functioning autism, Asperger’s Syndrome, and Pervasive Developmental Disorder NOS. Journal of Autism Developmental Disorders. 34 (6): 649-668.

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