What is the effectiveness and plausibility of social skills interventions that take place in the school setting in improving social outcomes of children with autism spectrum disorder?
Rapid Review
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By
Kathryn Gabel
Abstract
Purpose: Children with autism spectrum disorder (ASD) often struggle with social aspects of communication and, because of this, are at-risk for being isolated from their peers in the general education classroom. This rapid review aims to synthesize relevant information available on the effectiveness and plausibility of social skill interventions for children with ASD that take place in schools. School personnel including general education teachers, special education teachers, speech-language pathologists, and administration members would benefit from reading this rapid review.
Search strategies: Five peer-reviewed articles from PubMed, PsycINFO, and Google Scholar were included. All articles were published within the last eleven years, examined school-age children with ASD, and discussed a social skills intervention that took place in an inclusive setting within a school.
Primary results: Results indicated that school-based social interventions significantly improved social outcomes of children with ASD.
Bottom line: When possible, social skills in children with ASD should be targeted within the general education classroom, with inclusion of typically developing peers into therapy and school support for implementation of intervention.
Introduction
Children who have autism spectrum disorder (ASD) are estimated to have a prevalence of one in fifty-nine school-age children in the United States (Johns Hopkins University Bloomberg School of Public Health, 2018). When a typical elementary school classroom has, on average, thirty students, it can be expected that there is at least one child with ASD in half of the classrooms in the United States. With a push within school systems for inclusion of neurodiverse students, many children with ASD are served within general education classrooms alongside their typically developing peers. Inclusion of children with ASD within the general education classroom allows more opportunities for rich social interactions, reduced stigma, increased peer models of language and behavior, and access to a more rigorous academic curriculum (Camargo et al., 2014).
It is well established that the hallmark feature of ASD is difficulties with pragmatic use of communication. These deficits in social communication can involve difficulty using appropriate eye contact and body language, initiating interactions with others, maintaining a topic while conversing, participating in appropriate turn taking, taking the perspectives of others, and understanding emotional cues (Camargo et al., 2014). Due to these challenges with pragmatics, the social outcomes of children with ASD are likely to be poorer than their typically developing peers (Locke et al., 2018). Camargo et al. 2018 noted that deficits in social communication could increase the risk for rejection from peers, social anxiety, difficulty forming meaningful relationships, social isolation and decreased academic performance. Though inclusive education environments provide many opportunities for children with ASD to flourish, poor social abilities pose a threat to their cognitive, social, and behavioral success in the general education classroom (Camargo et al., 2014).
Traditional social interventions for children who have ASD have shown varying levels of success. Studies have noted that this population has difficulties generalizing skills learned in treatment to real-life scenarios, likely because most traditional social interventions are conducted in an isolated therapy room (Bellini et al., 2007; Camargo et al. 2014). A pragmatic intervention that takes place in an inclusive school setting (e.g. a setting in which typically developing peers are present) would allow children with ASD to practice using targeted skills in a familiar environment with typically developing peers, potentially alleviating difficulties with maintaining and generalizing goals.
Legislation such as the No Child Left Behind Act (NCLB, 2002) and Individuals with Disabilities Education Act (IDEA, 2004) requires evidence-based practices in both academic and behavioral programs to be used within school systems in the United States (Locke et al., 2017). Though theory suggests that social intervention within the general education setting would be beneficial to children with ASD, it is unclear whether this type of intervention holds the scientific backing to be considered evidence-based practice. This rapid review will attempt to synthesize available information on the effectiveness of pragmatic interventions for children with ASD that take place in the school setting.
Though school systems are required to incorporate evidence-based practice into their programs, many schools are tightly limited in their resources. Limitations in time, staffing, and monetary resources play a key role in a school's ability to carry out evidence-based interventions (Locke et al. 2017; Locke et al. 2018). A secondary aim of this rapid review is to quantify the feasibility of social skills interventions for children with ASD that take place in the schools.
METHODS
As discussed by Khangura et al. (2012), rapid reviews have become a popular method of streamlining multiple sources of evidence in order to obtain information on clinically-relevant questions in a timely matter. While systematic reviews and meta-analyses are much more thorough, and therefore time consuming, analyses of research, a rapid review is intended to serve as an overview of evidence available on a subject matter in a way that is easily accessible to readers (Khangura et al. 2012). As such, this report is not intended to serve as a comprehensive analysis of all available research on the subject of school-based social interventions for children with ASD, but a synthesis of the most relevant evidence that is pertinent to this topic.
The PubMed database was used to begin the search for evidence. The terms "(social OR pragmatic) AND (treatment OR intervention) AND (autism OR ASD)" were used to yield initial results from peer-reviewed journals. Results were then filtered with the options "titles with your search terms" and "most recent", which yielded a list of twenty items. From these twenty, eight studies were downloaded for review. Any study that did not include an intervention aimed at improving social skills in school-age children with ASD that did not take place in an inclusive setting was excluded. After review, two articles met the listed criteria: Locke et al. (2017) and Locke et al. (2018).
PsycINFO was then searched with similar criteria. Search terms again included "(social OR pragmatic) AND (treatment OR intervention) AND (autism OR ASD)". Results were filtered to include only peer-reviewed journals. Index terms "Autism Spectrum Disorders", "Intervention", "Social Interaction", "Social Skills", and "Social Skills Training" were applied to further filter results. Three results with the selected criteria were yielded, of which one was downloaded and included in the present rapid review: Camargo et al. (2014).
The last database used was Google Scholar. Search terms "school-based social intervention for children with autism" yielded nearly 32,000 results. The most relevant studies were selected based on article titles. Of these results, six articles were downloaded. After applying the exclusion criteria specified above, two peer-reviewed articles were included: Bellini et al. (2007) and Kasari et al. (2012).
In total, five articles were included in this rapid review (Bellini et al., 2007; Camargo et al.; 2014, Kasari et al., 2012; Locke et al., 2017; Locke et al., 2018). Each article was peer-reviewed, published within roughly the last ten years, examined school-age children with ASD, included an intervention aimed at improving social outcomes, and took place in inclusive school settings. In order to examine both the effectiveness and feasibility of interventions, roughly half of the studies aimed to evaluate the effects of a specific intervention (Bellini et al., 2007; Camargo et al., 2014; Kasari et al., 2012) and half examined the factors that led to successful implementation of an intervention in the school setting (Locke et al., 2017; Locke et al., 2018).
SYNTHESIS
Effectiveness of Intervention
Bellini et al. (2007), Camargo et al. (2014), and Kasari et al. (2012) all investigated the effectiveness of school-based social interventions for children with ASD. Bellini et al. (2007) conducted a meta-analysis that included 55 intervention studies with single-subject designs; some of the included studies used pullout methods for therapy while others took place in the student's usual classroom. The authors independently coded each study on a variety of factors including participant characteristics, intervention characteristics, research design, and intervention effectiveness. The dependent variables in the study were separated into two categories: collateral skills (e.g. play development, eye contact, sharing) and social interaction skills (e.g. initiating interactions, commenting, topic maintenance). Results of the study demonstrated questionable effects of interventions, with moderate maintenance effects and low generalization effects. Studies that took place in the child's general education classroom produced significantly higher effects across all three categories. Though Bellini et al. (2007) suggests minimal effectiveness of social skill interventions for children with ASD, the authors propose that therapy that takes place in inclusive settings has a higher rate of success. Multiple factors signal that the results of this study should be interpreted with caution, including lack of blinding, a questionable choice of statistics, and potential publication bias (Bellini et al., 2007).
Camargo et al. (2014) and Kasari et al. (2012) each suggested more promising outcomes for social skills interventions in the school setting for children with ASD. Camargo et al. (2014) reviewed thirty studies with single-subject research designs that utilized social skills interventions for children with ASD in inclusive settings. Each study was independently rated on multiple characteristics in order to determine quality of research evidence. Overall, nineteen of the studies met minimal standards for research quality, indicating that social skills intervention for children with ASD that takes place in inclusive school settings can be considered evidence-based practice. Of these studies that met quality research standards, fourteen reported positive effects after intervention, with four reporting mixed results and one reporting no effect after intervention. Maintenance and generalization of targeted social skills was also reported by the majority of studies. Though this study seems to be thorough and well-designed, it did not report any statistical numbers to justify their interpretations of "positive" effects (Camargo et al., 2014).
Kasari et al. (2012), a randomized controlled trial, used a 2 x 2 factorial design to compare two social interventions for children with high-functioning ASD that took place in the school setting. Groups included intervention with a peer-mediated approach (e.g. typically developing peers were trained in how to interact with children who have social difficulties), intervention with a child-assisted approach (e.g. children with ASD were taught social strategies for interacting with others), no intervention, and both interventions. The peer-mediated intervention group showed significantly increased social network salience, playground engagement, and teachers' perceptions of social abilities when compared to the child-mediated intervention group. Somewhat unsurprisingly, those children who partook in both the peer-mediated and child-assisted interventions showed the greatest improvements in social outcomes. Treatment effects for the child-assisted and both intervention groups were maintained after a three month period, even when many of the children with ASD were in new classrooms or schools, suggesting generalization of skills as well. This study suggests that the most important component of social interventions for children with ASD is including a component that educates typically developing peers on how to interact with their neurodiverse classmates (Kasari et al., 2012).
While Bellini et al. (2007) suggested that social interventions for children with ASD were minimally effective, they made note that those interventions that took place in inclusive settings made significantly higher gains. Camargo et al. (2014) and Kasari et al. (2012) both yielded positive effects of school-based treatment on social skills of children with ASD, demonstrating effects of maintenance and generalization. As traditional, clinically-based interventions for children with ASD have proven unsuccessful in improving, maintaining, and generalizing pragmatic abilities after treatment, the results of the above studies hold importance that will be further discussed later in this rapid review.
Plausibility of Implementation
However promising an intervention may seem, it will not yield results without the resources to carry it out with fidelity. Locke et al. (2017) and Locke et al. (2018) both examined that factors that are necessary for school personnel to successfully implement school-based social intervention for children with ASD. Locke et al. (2017) interviewed members of school personnel who had previously participated in a social skill intervention program (Remaking Recess) to identify facilitators and barriers to successful implementation of the program. Facilitators of intervention implementation included having support from other staff members, specific team roles, and open communication with colleagues. Barriers included limited time to dedicate towards planning and implementing activities and limited budgets for program materials or for extra staffing required to carry out the intervention (Locke et al., 2017).
Locke et al. (2018) was a randomized controlled trial that compared two groups or participating schools who also carried out Remaking Recess. One group was given training in the intervention and the other was given training in addition to implementation support that was customized to each school's individual needs (e.g. staff scheduling, building teams, providing support, creating a culture of Remaking Recess). While the school personnel's self ratings and researchers' ratings of treatment fidelity did not statistically differ between groups, children with ASD in the treatment group with implementation support showed a significant increase in social network inclusion post-treatment (Locke et al., 2018).
Both Locke et al. (2017) and Locke et al. (2018) emphasized the importance of support when providing social skills intervention to children with ASD within the school system. In both studies, school personnel indicated that staffing, limited time, and lack of support from other staff members could pose as barriers for successful implementation of intervention. Though Locke et al. (2018) demonstrated that social intervention carried out by school staff can have positive social outcomes for children with ASD, support of implementation is vital to this success.
Conclusion
Though studies each demonstrated varying levels of internal validity, overall validity of the included papers was suggestive. Limitations of some articles included lack of blinding, questionable or lack of statistics, potential publication bias, and variability with social goals targeted and social outcome measures. Though these limitations are present, the majority of studies reported positive intervention effects immediately post-treatment, after maintenance periods, and with generalization to different contexts (Camargo et al.; 2014, Kasari et al., 2012; Locke et al., 2018). These findings are immensely important to aiding children with ASD thrive in the general education classroom.
More specifically, main findings suggest that social interventions for children with ASD that take place in the general education setting are most effective when neurotypical peers are incorporated into therapy (Kasari et al., 2012). Additionally, those who wish for interventions to be successfully implemented need to be aware of the potential roadblocks that make this process difficult. Efforts to minimize the amount of time needed to dedicate towards preparing activities, staffing required, and materials needed for intervention should be made. Additionally, one should provide support, clear team roles, and opportunities for open communication to school staff who are carrying out social interventions for children with ASD. Taking these steps to minimize barriers and maximize facilitators of intervention implementation will lead to increased social outcomes in the general education classroom for children with ASD (Locke et al., 2017; Locke et al., 2018).
This rapid review has limitations of its own, the biggest of which is the lack of a comprehensive search for all research that would be relevant to the current topic. Though care was taken in choosing studies that best represented school-based social interventions for children with ASD, there were likely many more studies that were overlooked by this synthesis. An updated meta-analysis on the topic would prove to be useful in gaining more trustworthy evidence-based practice with statistical underpinnings.
Overall, the included studies provided compelling support for school-based social interventions for children with ASD. Though speech-language pathologists have traditionally targeted pragmatic abilities of children with ASD in clinical settings, these children may benefit from implementation of social intervention in their general education classroom, when possible. Doing so could lead to more fulfilling interactions with peers, stronger emotional health, and an increased likelihood for academic success.