Martin is a 14-year-old boy who has recently starting expressing increased levels of anxiety, particularly about his impending transition into high school starting this fall. Martin was diagnosed with ASD as a younger child and finding a place among his peers has always been an obstacle. Although he has one friend he occasionally spends time with—mainly by playing video games and exchanging ideas about shared interests—he often complains that he does not have many friends at school and that he is not very much liked by his peers. Kids at school have previously called him “weird” and have not readily invited him into their groups or cliques. Distressed that he will continue to feel this way in high school, Martin is beginning to shut down and avoid many of the daily school social interactions. His parents are concerned that his ostracization will persist and, as a result, he will feel increasingly down and insecure about his relationships and identity.
A misconception exists whereby, because individuals with Autism Spectrum Disorder (ASD) are challenged in the area of social development and skills, they do not need socialization and friendships (Sicile-Kira & Sicile-Kira, 2012). People with ASD are indeed more socially isolated, but it is often not out of their own personal doing or desire. They will frequently express wanting to befriend others, and can experience intense disappointment when they are having difficulty doing so. This appears to especially be the case for those individuals with higher functioning and cognitive abilities who often have a better understanding of their inabilities (Grynszpan et al., 2011; Tse, Strulovitch, Tagalakis, Meng & Fombonne, 2007).
The capacity to establish lasting friendships emerges as critical in the middle and high school years when young people increasingly rely on their peers, rather than their families, for social support, validation, and feedback concerning their burgeoning identities (Mitchell, Regehr, Reaume & Feldman, 2010). Typically developing children usually learn via natural exposure and observation, as well as from specific feedback from their parents, teachers and peers about what constitutes appropriate social skills and good friendship behavior. Since children with ASD have difficulty naturally picking on these skills from their daily environment and interactions, they appear to require much more direct, structured and frequent feedback regarding their social behavior (Laugeson, Frankel, Mogil & Dillon, 2009). Thus, making and sustaining friendships often continue to evolve as common areas of struggle for young people with ASD (Laugeson, Frankel, Gantman, Dillon & Mogil, 2012).
Specific social deficits in persons with ASD often involve “poor social communication, impaired social cognition and a lack of understanding of social cues” (Laugeson et al., 2012, p. 1025). That is, these young people will have: trouble engaging in reciprocal conversation, including taking turns and flexibly changing topics (Klin & Volkmar, 2003); problems with understanding and expressing emotions and empathizing with others’ feelings (Krasney, Williams, Provencal & Ozonoff, 2003); and a strained understanding and ability to pick up on nonverbal and subtler forms of communication—for example, changes in voice inflections and gesturing (Weiss & Harris, 2001).
As children enter adolescence and the complexity of social communication expands with the pressure to fit in and be accepted, deficits in the aforementioned areas tend to become even more pronounced in these young individuals with ASD and to those in contact with them (Tse et al., 2007). Unsurprisingly, perhaps, this commonly results in peer rejection and subsequent feelings of loneliness, depression, anxiety, and isolation (Bauminger & Kasari, 2000). As adolescents progress into adulthood, these social complications can permeate other important social areas of life, including the ability to navigate college, dating and seeking and maintaining employment (Mitchell et al., 2010). Given that social difficulties continue on into adulthood and across the lifespan and may, in fact, represent a more chronic feature of ASD (Orsmond, Krauss & Seltzer, 2004), it is key that intervention aims to improve social functioning during these formative years prior to adulthood.
Commencing this fall, NYU Child Study Center intends to address these issues by offering the Program for the Education and Enrichment of Relational Skills (PEERS; Laugeson et al., 2009; Laugeson & Frankel, 2010). UCLA developed PEERS over the last few years as an evidence-based social skills group intervention for adolescents presenting with higher functioning ASD. An adaptation of Frankel and Myatt’s (2003) elementary school-aged evidence-based Children’s Friendship Training Program (CFT), UCLA’s program has produced promising treatment results and longer-term gains post treatment. The program is unique, not only in light of its strong evidence base and maintenance of gains over time (Mandelberg et al., 2014), but mostly, perhaps, because it incorporates structured parent involvement concurrently alongside the participation of adolescents. As research shows, parents significantly impact their child’s relationships, yet few programs have actively included them in the child’s process (Schohl et al., 2014). Research, including PEERS, indicates that parents’ engaged and consistent involvement in treatment assists adolescents in making longer lasting and meaningful gains. By equipping parents with greater knowledge concerning the trials their child faces, they can learn to socially coach their child by helping him/her locate appropriate friendship networks and employ the skills he/she develops in groups in the outside world; parents can also model and supervise appropriate social behavior long after the program has ended (Frankel & Myatt, 2003; Schohl et al., 2014). Research has also revealed that PEERS participants demonstrated significant improvements in their knowledge of social skills, including, for example, an overall growth in their frequency of hosting get-togethers with friends (Laugeson et al., 2009). A recent replication study of PEERS has shown that PEERS further improves co-morbid conditions, such as social anxiety (Schohl et al., 2014).
PEERS lasts 14 weeks with weekly sessions that run 90 minutes each. The PEERS curriculum is taught in a small group format using a variety of evidence-based methods, including didactic instruction, modeling of appropriate social skills, coaching and feedback regarding the use of newly learned social skills and weekly homework assignments completed by participations with the support and guidance of their parents (Laugeson & Frankel, 2010). A variety of pertinent topics are reviewed as part of the program, such as teaching adolescents how they can choose appropriate friends and discover common interests by exchanging information and using appropriate conversation skills, and how they can more effectively manage conflict with friends as well as experiences of rejection, teasing and bullying (Laugeson & Frankel, 2010). Later modifications to the program include training in: the appropriate use of social media and online safety, and engaging others through suitable humor and learning-strategies for handling rumors and gossip (Laugeson, Frankel, Gantman, Dillion & Mogil, 2011). PEERS has also been expanded to provide social skills intervention to young adults and teachers have directly incorporated it in their classrooms (Laugeson, Ellingsen, Sanderson, Tucci & Bates, 2014).
Karina G. Campos, PsyD, is Clinical Psychologist and Assistant Professor of Child and Adolescent Psychiatry at the NYU Langone Medical Center and NYU Child Study Center.
If you are interested in learning more about Autism Spectrum Disorder Clinical and Research Program, including PEERS, and other our programs, please contact our Intake Department at (646) 754-5000 or by email at: csc.intake@nyumc.org. You can also contact Dr. Karina G. Campos, directly at (646) 754-4876 or at karina.campos@nyumc.org.
References
Bauminger, N. & Kasari, C. (2000). Loneliness and friendship in high-functioning children with autism. Child Development, 71(2), 447-456.
Frankel, F. & Myatt, R. (2003). Children’s friendship training. New York: Brunner-Routledge.
Grynszpan, O., Nadel, J., Constant, J., Le Barillier, F., Carbonell, N., Simonin, J., et al., (2011). A new virtual environment paradigm for high-functioning autism intended to help attentional disengagement in a social context. Journal of Physical Therapy Education, 25(1), 42-47.
Klin, A. & Volkmar, F. R. (2003). Asperger syndrome. New York, NY: Guilford Press.
Krasney, L. Williams, B. J., Provencal, S. & Ozonoff, S. (2003). Social skills interventions for the autism spectrum: Essential ingredients and a model curriculum. Child and Adolescent Psychiatric Clinics of North America, 12(1), 107-122.
Laugeson, E. A., Ellingsen, R., Sanderson, J., Tucci, L., & Bates, S. (2014). The ABC’s of teaching social skills to adolescents with autism spectrum disorder in the classroom: The UCLA PEERS program. Journal of Autism and Developmental Disorders.
Laugeson, E. A., Frankel, F., Gantman, A., Dillon, A. R. & Mogil, C. (2012). Evidence-based social skills training for adolescents with autism spectrum disorders: The UCLA PEERS Program. Journal of Autism and Developmental Disorders, 42(6), 1025-1036.
Laugeson, E. A. & Frankel, F. (2010). Social skills for teenagers with developmental and autism spectrum disorders: The PEERS treatment manual. New York, NY: Routledge.
Laugeson, E. A., Frankel, F., Mogil, C. & Dillion, A. R. (2009). Parent-assisted social skills training to improve friendships in adolescents with autism spectrum disorders. Journal of Autism and Developmental Disorders, 39(4), 596-606.
Mandelberg, J., Laugeson, E. A., Cunningham, T. D., Ellingsen, R., Bates, S. & Frankel, F. (2014). Long-term treatment outcomes for parent-assisted social skills training for adolescents with autism spectrum disorders: The UCLA PEERS program. Journal of Mental Health Research in Intellectual Disabilities, 7, 45-73.
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Schohl, K. A., Van Hecke, A. V., Carson, A. M., Dolan, B., Karst, J. & Stevens, S. (2014). A replication and extension of the PEERS intervention: Examining the effects on social skills and social anxiety in adolescents with autism spectrum disorders. Journal of Autism and Developmental Disorders, 44(3), 532-545.
Sicile-Kira, C. & Sicile-Kira, J. (2012). A full life of autism: From learning to forming relationships to achieving independence. New York, NY: St. Martin’s Press.
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