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Social Skills Success for Students with Autism/Asperger’s

Helping Adolescents on the Spectrum to Fit In

Fred Frankel

Jeffrey J.Wood

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About the Authors

Fred Frankel, Ph.D., is professor of medical psychology in the Department of Psychiatry and Biobehavioral Sciences at the UCLA Semel Institute for Neuroscience and Human Behavior. He is the founder and director of the UCLA Parenting and Children's Friendship Program. Frankel has been principal investigator on two studies of social skills training funded by the National Institute of Mental Health (NIMH)—one grant for students with attention deficit hyperactivity disorder (ADHD) and the second for children with autism spectrum disorders. He has also been co–principal investigator on a grant funded by the Centers for Disease Control investigating social skills training for children with fetal alcohol spectrum disorders (FASD) and an NIMH-funded interdisciplinary training grant for research in childhood psychosis. He is currently a co-investigator in the Center for Autism Intervention Research Network, funded by the National Institutes of Health, and a pediatric overweight prevention grant funded by the Drown Foundation. He has published over fifty-three peer-reviewed studies on autism, ADHD, developmental disabilities, FASD, and childhood obesity. Frankel has authored three books: Children's Friendship Training (with Bob Myatt), Social Skills for Teenagers with Developmental and Autism Spectrum Disorders: The PEERS Treatment Manual (with Elizabeth Laugeson), and Friends Forever: How Parents Can Help Their Kids Make and Keep Good Friends (Jossey-Bass, 2010).

Jeffrey J. Wood, Ph.D., is associate professor of education and psychiatry and biobehavioral sciences at UCLA. He developed and directs the UCLA Behavioral Interventions for Anxiety in Children with Autism (BIACA) research and treatment program. He has been principal investigator on three NIH-funded studies of cognitive behavioral therapy: one for typical students with anxiety disorders and the other two for children and adolescents with autism spectrum disorders, and principal investigator on three studies funded by Cure Autism Now, Autism Speaks, and the Organization for Autism Research investigating cognitive behavioral therapy for children and adolescents with autism spectrum disorders in school and clinic settings. He has sponsored four NIMH-funded training grants for research on child and adolescent developmental disabilities and mental health, including a school-based study of cognitive behavioral therapy for anxiety problems. He is currently principal investigator of the NICHD-funded multisite study of cognitive behavioral therapy for anxiety in adolescents with autism. He has published over thirty peer-reviewed studies on anxiety, autism, depression, and disruptive behavior disorders. Wood has authored one other book: Child Anxiety Disorders (with Bryce McLeod).

Acknowledgments

Fred Frankel: I thank Bruce Kravetz of Palms Middle School, Los Angeles, and Cynthia Whitham, L.C.S.W., for their help in the early drafts of this book. I also acknowledge the invaluable assistance of Thomas Dase, assistant superintendent of education services of the Culver City Unified School District, for his help and support in implementing my social skills program in his school district, and Muriel Ifekwunigwe and staff at the El Rincon School Family Center.

I thank the following staff of Jossey-Bass for helping to make this book a reality: Marjorie McAneny, senior editor; Tracy Gallagher, senior editorial assistant; Robin Lloyd, production editor; Beverly Miller, copyeditor; and Dimi Berkner, senior marketing manager.

Jeffrey J. Wood: I thank my long-time collaborator, Bryce McLeod at Virginia Commonwealth University, for his extraordinary insights on anxiety issues and our ever-fascinating scholarly dialogue during the writing of this book. I am also grateful to Jeffrey Jacobs and Muriel Ifekwunigwe at the UCLA University Lab School and Angela Chiu in the UCLA Department of Psychology, with whom I collaborated on a clinical trial of cognitive behavioral therapy for youth with anxiety in a school setting.

Jossey-Bass Teacher

Jossey-Bass Teacher provides educators with practical knowledge and tools to create a positive and lifelong impact on student learning. We offer classroom-tested and research-based teaching resources for a variety of grade levels and subject areas. Whether you are an aspiring, new, or veteran teacher, we want to help you make every teaching day your best.

From ready-to-use classroom activities to the latest teaching framework, our value-packed books provide insightful, practical, and comprehensive materials on the topics that matter most to K–12 teachers. We hope to become your trusted source for the best ideas from the most experienced and respected experts in the field.

To my wife, Susan, for her daily self-sacrifice to our family and support for my writing this book.

F.F.

To my first and lifelong best friend, my sister, Ann, who taught by example about what it means to be a true friend, and to my son, Jonah, for whom I wish a lifetime of friendship and happiness.

J.J.W.

Introduction

noteYes, the rule thing is pretty frustrating. I am always trying to learn THE RULE, and non-Aspie types do not seem to notice these unspoken ‘rules’ at all, yet they instinctively know how to behave. But I feel like there MUST be a decoding trick somewhere because I am OBVIOUSLY missing something!note

—From the blog Life with Asperger's

All of the chapters in this book begin with a quotation from or about an adolescent with autism. Some of these come from students we have personally worked with and others from cases we've read about. We intend for these quotations to give a more human face to the issues and interventions you will read about in the following chapters.

We are hearing more about autism and Asperger's disorder these days. In 1943, using primitive diagnostic techniques, Leo Kanner first identified a group of children with a strikingly unusual pattern of behavioral disturbances that began before they were thirty months of age. He was struck by the aloofness and repetitive stereotyped behaviors that were common among these children and labeled them as having “early infantile autism.” Since then, diagnostic and research tools have become substantially more sophisticated, so that we can detect autism and Asperger's disorder in children and teens who have much milder symptoms. We are also getting better at treating these children and teens. One of the early lessons was that educational approaches are essential in this treatment and can substantially improve children's functioning. Clinicians and researchers have since determined that autism is not a unique and separate condition as once thought, but a spectrum or range of disorders, with the most severe being classic autism. Most individuals on the autism spectrum have much milder symptoms. The U.S. Centers for Disease Control estimates that the prevalence of autism spectrum disorders may be as high as 1 in 152 individuals. About 80 percent of those individuals are considered high functioning, with minimal impairments and at least average intelligence. Seven times as many males as females are affected.

Often kids with autism spectrum disorders find themselves in regular education classes. Teachers are frequently surprised by their behavior in class, yet these behavioral symptoms are often just the tip of the iceberg in terms of the difficulties with which these kids are trying to cope. They are clearly different from most other students. Teens on the autism spectrum (often referred to simply as “on the spectrum”) who are included in regular education are generally able to function adequately most times. Perhaps most puzzling is the occasional meltdown, when they completely and strikingly lose control of their behavior, which is common among these kids. Regular education teachers often find these meltdowns and many other behaviors to be challenging to deal with. Special education teachers and education specialists, who are generally more aware than most regular education teachers of the problems of students with disabilities, are typically not aware of effective techniques to teach these kids how to function better.

The central deficits of autism spectrum disorders are impairments in social relations and communication (both nonverbal and verbal), together with restrictions in flexible and creative, context-sensitive thinking. Teens and tweens on the spectrum vary widely in their mental abilities and limitations, as well as in their personality and sociability. Most have average or above-average intelligence. Although individuals vary on the symptoms they have, in most cases they continue to experience significant impairment in social and vocational functioning after graduation from high school. Students on the spectrum have profound difficulties in relating to their peers, regardless of their level of cognitive ability, and these difficulties place them at significant risk for developing other behavioral and emotional difficulties such as anxiety.

Kids on the spectrum will not learn how to have more meaningful social relationships simply by watching other people or participating in various social situations. They don't seem to have guiding principles as to how to acquire the social knowledge they need. Nevertheless, they are very motivated to learn, and the interventions we have conducted in our research and outpatient clinic programs have shown us that students on the spectrum can indeed learn social interaction and self-regulation skills. These kids are enjoyable to work with: they are usually eager to learn skills that help them fit in and have few defenses to get in the way of learning. They don't hide their emotions or lie about their feelings.

Our Approach to Social Skills Training

Our approach to social skills training has been to identify key common social situations and teach the social etiquette as a series of simple rules to follow. This is an easy way for tweens and teens to understand how to fit in based on social context. Structuring social behavior in terms of critical situations and accompanying rules of etiquette for each requires minimal consideration of the viewpoints of others and abstract thinking on the part of the tweens and teens on the spectrum.

Consider the etiquette that has evolved around ATM machines. Such machines are relatively new. When faced with this novel situation some years ago, considerate people began to apply the golden rule (do unto others as you would have them do unto you). They wanted to make others as comfortable as possible about personal space and also make it clear that they were not looking at the ATM screen when others were entering passwords to withdraw money. So they lined up as in other situations, but kept a distance of four or five feet between the person using the machine and the next in line. This is close enough to signal they are in line but far enough away to maintain the privacy of the person using the machine. Soon everyone began to do this in front of ATM machines.

The Knowledge Base Behind This Book

This book is based on techniques we've developed in the fields of social skills instruction and emotion regulation. These techniques have been found to be successful in helping students on the spectrum.

Children's Friendship Training/PEERS

Fred Frankel has published two treatment manuals that have been tested in studies and found to help. Children's Friendship Training, coauthored with Bob Myatt, describes in detail twelve sessions devoted to training conversational skills, other skills to allow children and early teens (up to sixth graders) to meet new friends, and how parents and children can collaborate to have a parent-supervised play date. The PEERS Treatment Manual, written with Elizabeth Laugeson, extends this program to teens in middle and high school. Both interventions are designed to take place in an outpatient setting using concurrent student and parent weekly one-hour sessions over three months.

Both programs are compatible with school-based interventions, such as those described in this book. Results of clinical trials at the University of California, Los Angeles, on both interventions showed that students on the spectrum increased their numbers of monthly get-togethers from a baseline level of typically none to two to three per month at the end of treatment. Our three-year follow-up study of thirty-three teens and sixty-eight children (with the expected amount of sample attrition over the three years) revealed that students continued to have get-togethers at the frequency we noted immediately after treatment stopped. The most gratifying finding was that three years after the end of treatment, these get-togethers were reciprocated by their friends with equal frequency.

Frankel has successfully implemented children's friendship training as an after-school program in the Culver City, California, schools. He has also helped professionals in a private clinic to implement PEERS in the Seattle, Washington, public schools.

The unique features of children's friendship training are as follows:

  • Parent participation is an integral part of the intervention.
  • Homework assignments are part of every treatment session.
  • Skills that have been shown to contribute to social competence in typically developing (that is, neurotypical) peers (those off the autism spectrum) are taught to group members.
  • Parents and children work together to host get-togethers. Having enjoyable play dates promotes best friendships.
  • Teaching tactful methods in handling being teased in order to gain sympathy from bystanders.

The PEERS intervention contains all of these features. In addition, modules have been designed to address social issues specific to teens with autism spectrum disorders:

  • Identification of appropriate crowds for the teen (members of these crowds may call themselves the jocks, the band crowd, or computer geeks). The teen is then coached on how to join in conversations that peers in these crowds are having, for example, in the school lunchroom.
  • Teaching teens how to gracefully exit a conversation after choosing the wrong peers.
  • Distinguishing between teasing and embarrassing feedback (for instance, about poor grooming and hygiene).
  • Teaching teens how to organize a get-together.
  • Teaching rules for electronic communication, including phone etiquette, and rules of text messaging, instant messaging, and e-mailing, in which the teens may unknowingly “harass” others.

Although this book is focused on helping kids on the spectrum fit into middle and high school life, the PEERS manual helps them primarily with the social skills they need after school in order to develop best friendships. We refer in this book to the relevant modules of the PEERS manual that will enhance the school experience of teens on the spectrum.

Cognitive-Behavioral Strategies for Emotional Self-Regulation

Jeffrey Wood has developed techniques to help students on the spectrum with emotional self-regulation. Students who lack skills to manage their anxiety are prone to outbursts and meltdowns in school, which jeopardizes their ability to make and maintain positive peer relationships and interferes with their academic achievement. Wood has developed three treatment manuals to address anxiety and related emotional problems: one for neurotypical children and two for children and teens on the autism spectrum. Multiple research studies have shown that these interventions are effective in increasing emotional self-control, decreasing behavioral symptoms, and improving the social adjustment of youth on and off the spectrum. About 70 percent of participants in these treatments no longer have an anxiety disorder diagnosis after completing the treatment. Wood's follow-up studies show that these improvements are maintained at least one year after the end of the intervention. The interventions, designed for and tested in both school and outpatient clinic settings, typically have involved about twelve to sixteen weekly ninety-minute sessions. Parent involvement and homework assignments are an integral aspect of each version of the anxiety program.

The unique features of the anxiety management program are as follows:

  • Emotion recognition skills are taught using multimodal teaching: incorporating class discussions, visual supports, role-playing, and writing. Examples are used that are interesting and motivating to teens on the spectrum in order to enhance their understanding of the material and their level of participation.
  • Teens learn basic psychological principles of thought recognition and thought modification as a means of coping with anxiety and distress. These are core skills for individuals who are able to manage their emotions effectively.
  • The universal principle of facing fear to fight fear is taught and practiced in multiple ways that encourage continuous success, engagement, and mastery of challenging situations over the course of the intervention.
  • Parents and teachers are given tools to promote student participation in the anxiety program and use of the skills in the classroom and at home.

This training program, adapted for use in schools, is presented in Chapters Nine and Ten of this book.

The Purpose of This Book

This book is directed to teachers and special educators working with high-functioning adolescents on the spectrum who are in special education settings or partially or fully included in regular education classes. Parents of tweens and teens on the spectrum often have to take on the advocacy role in the absence of services. Thus, parents may be interested in this book as a resource for their child's teachers.

This book helps teachers recognize the social problems of these adolescents, educates teachers as to what they need to know about autism spectrum disorders, discusses the advantages and disadvantages of different school options for these students, and gives them brief classroom interventions they can use to remedy social problems without further stigmatizing the teens. The book has three main purposes:

  1. 1. To provide teachers with a better understanding of students on the spectrum
  2. 2. To provide teachers with the tools to help these youngsters fit in better with peers, so that they are better able to be integrated into the academic life of students in middle and high school
  3. 3. To give school personnel an understanding of and tools to use with teens on the spectrum who have anxiety and meltdowns

Our approach is to teach the kids how to handle their anxiety so that they avoid meltdowns and provide them with skills to be better integrated into their school environment. In the long run, this is a more beneficial approach than adjusting their environment to accommodate their symptoms.

There are different levels of peer acceptance. At the lowest level, it involves a willingness to tolerate and associate with the student on the spectrum for purposes of school assignments. A higher level is characterized by respect for the tween and teen as an individual. Neither of these levels involves what we might consider friendships. The next higher level is that of accepting a kid into a crowd. The highest level is maintaining a mutual best friendship. Since this book is aimed at informing teachers how best to help students on the spectrum participate more fully in school life, we focus primarily on the first two levels of acceptance and touch on the highest levels insofar as teachers can help in these areas.

The lack of peer acceptance can have indirect effects on academic achievement. When kids face peer rejection, neglect, or sometimes even abuse and bullying, they may develop anxiety and depression that, among other things, undermines their motivation to focus on school work. When peers avoid and isolate the student on the spectrum from classroom participation, these young people are at a distinct disadvantage in completing assignments. Students on the spectrum who know how to fit in with peers can gain increased help in academic and social areas of life.

How to Use This Book

As a convenience for purposes of this book, we refer to students with any of the autism spectrum disorders as either “on the spectrum” or “students with autism spectrum disorder.” This includes those having classic autism who are high functioning, those with Asperger's syndrome, those with pervasive developmental disorders, and those who are frequently referred to in the popular literature as having nonverbal learning disorders. In case examples and elsewhere, we refer to students as “he” for simplicity of presentation, but recognizing that we are also including girls on the spectrum. We are focusing on students in grades 6 to 12—tweens and teens alike. However, for simplicity, we use the term teen.

This book is divided into three major parts. The emphasis in Part One is on providing a deeper level of understanding of the challenges to adolescents on the spectrum. We provide a review of developmental issues facing all teens that are important for a better understanding of kids on the spectrum. Chapter One describes how teachers are likely to encounter the symptoms of autism spectrum disorders in their students and offers helpful advice for how to address some of the minor symptoms. Chapter Two reviews different options for educational placement for teens on the spectrum. We provide a lesson plan to help the school community, including possible peer mentors, better understand and help students with autism spectrum disorders. Chapter Three reviews tips for classroom management for kids who are in segregated, partially, and fully included classroom situations, as well as how to have teachers start formal social skill training programs.

Part Two describes brief interventions that will help teens on the spectrum better integrate into the social fabric of middle and high school. The interventions offered in this part are short and focused. Chapter Four helps kids expand their interests and after-school activities so that they are more likely to fit in with their peer group. Chapter Five improves comprehension of nonliteral language (idioms and sarcasm). Chapter Six addresses increasing adolescents' skills for understanding conversations. Chapter Seven improves social conversation by teaching teens on the spectrum to use small talk as a way of cautiously approaching peers for friendship overtures and by helping teens on the spectrum identify and use the parts of a conversation. Chapter Eight provides teachers guidelines for helping students on the spectrum select appropriate peers to eventually be closer friends.

Part Three presents more extensive interventions that have a broader impact. Chapter Nine focuses on understanding and assessing the sources of anxiety that concern kids on the spectrum. Chapter Ten describes an effective intervention for anxiety-related responses that may stigmatize teens. Chapter Eleven presents individual and whole-school approaches to prevent and deal with victimization. Chapter Twelve offers an approach for peer mentoring and coaching that has proven effective in helping kids fit in.

We hope that readers will find that students on the spectrum and their neurotypical peers will have a more rewarding school experience as a result of trying the lessons we present in this book.

Part One
Basic Information about Teens with Autism Spectrum Disorder