A report from KATIE L COLE, community support worker and CAMHS specialist from Gwent Healthcare NHS Trust.
Addressing social communication difficulties in children with autism
The National Autistic Society (NAS) reports that in the UK there are over half a million people with an autistic spectrum disorder (ASD), equating to around one in every hundred individuals. It’s likely a much higher number remain undiagnosed.
Aspergers Syndrome (AS) is found at the higher-functioning end of the autistic spectrum and is diagnosed using criteria stated by the Diagnostic and Statistical Manual for Mental Health (DSM-IV) and in similar terms by ICD-10 classification.
Criteria indicate that individuals experience impairment in social interaction and display restricted patterns of behaviour and interests, leading to manifestations of failures in developing peer relations, lack of social and emotional reciprocity, stereotyped, repetitive behaviours and preoccupation with objects.
Clearly this deficit is significant, particularly for school-aged children who find it difficult to make and maintain friendships, understand non-verbal cues and interpret emotions.
The truth hurts
They tend to enjoy unusual interests not shared by their peers, in some cases causing the child to become socially isolated and unable to integrate fully with school life.
Indeed, children with AS are unaware of the rules of social conduct and so may say things which are too truthful or potentially embarrassing, turning them into prime targets for school bullies. The NAS confirms this and early adolescence, when peer groups alter during transition from primary to secondary school, is of particular concern.
Although studies have investigated the use of social skills training in schools, limited research has measured the efficacy of outpatient social communication groups. Spence (2003) highlights a need for social skills training with all young people to enhance communication skills and interpersonal relationships.
For those with AS this task becomes increasingly complex. However, Tantam and Prestwood (1999) report it is possible for them, assisted and supported by family and professionals, to achieve adequate social competence enabling effective functioning and interaction within a social environment.
Current group work
A social communication skills group was established after the Torfaen and Newport West CAMHS team received a number of referrals of children, already diagnosed with AS and co-morbid psychiatric difficulties, in need of further assistance in improving social communication.
It was decided that group work could best meet the needs of these children, based on findings such as Attwood’s (1998) which reports on the success of previous social skills groups with AS youngsters as each child is provided with opportunities to learn interaction skills through practice.
The social skills programme here involved three girls and five boys, aged 12 to 16. The group was kept small to allow minimal distractions and encourage participation. Group sessions lasted for three-and-a-half hours every Wednesday morning, starting at 9.30am, for eight weeks in September and November 2007.
The aim was to give them an opportunity to learn and practice social communication skills, adaptive behaviours and interpersonal skills within a group setting. There were three facilitators – an occupational therapist, community psychiatric nurse and community support worker – based at a child and adolescent unit in South Wales.
Selection criteria for group members was either a diagnosis of AS or being currently under assessment for diagnosis. Also each child was assessed by staff as likely to benefit from social communication skills intervention.
Setting up
Before the group work started, families were visited at home and provided with an information pack and consent form. This enabled the facilitators to explain the objectives of group work fully and answer any parental queries or concerns.
They also explained the range of topic areas and covered appropriate body language such as eye contact, recognising and expressing emotion, starting and ending conversations, asking questions and appropriate speech as well as general friendship building skills.
Spence suggests that the demonstration of target behaviours and responses is crucial for skill acquisition and improvement. Therefore, facilitators used reinforcement, modelling, group activities and role play to enable participants to have an opportunity to learn communication skills necessary for effective social interaction with peers.
Importantly, checklists and insight sheets were used to identify participants’ needs and activities were timetabled at the beginning of each session to minimise anxiety.
Results and recommendations
The group facilitators were aware of previous research indicating that parental reports show skills taught in group are not generalised outside of the clinic setting. In fact, Solomon et al (2004) suggest the need for further research to determine if skills taught in group are able to be generalised.
The current group ensured the use of common social situations and specific conversation, namely role playing classroom and shop scenarios, therefore addressing this concern in part.
However, further work outside the clinic could be incorporated, first using a clinic environment to teach skills, followed by real-life practice at a supermarket or cinema to enable skills practice with and then without the safety net of a facilitator being present.
Generalisation may also be aided by increased parental involvement and education. A half-way parent session to review progress and provide psycho-education may be appropriate.
Increased confidence
Success was measured using facilitator observation as well as parental feedback from “expectation” and “evaluation” questionnaires distributed prior to and after the group programme.
There was evidence of skill acquisition and application, and importantly, all parents reported their child had enjoyed the experience and developed friendships with fellow group members.
Families indicated that since the programme ended, participants experienced a feeling of being “lost” as the group had provided a sense of normality and now, in the real world, this security was lacking. This indicated that community support groups for children are needed to enable constant peer support, plus opportunities for friendship and continuous skill development.
Group work did have its drawbacks
Using just three facilitators meant the remaining two were left to manage a higher child-to-facilitator ratio if one was ill or on leave. In future, an extra facilitator or a rotation of staff may be used, depending on the number of children attending and their needs.
The social communication work carried out here provides a firm basis from which new group work can be developed. Recommendations for the future include increased practical work taking place within real social situations to aid skill acquisition and development; and increased parent involvement and psycho-education would aid generalisation and continued skill application following group conclusion.
In future it may be necessary to split the two categories for selection and run separate groups as it became clear the AS diagnosis for some group members could be queried. Consequently some individuals became increasingly disruptive to the group. It is apparent, however, that those with AS are on a spectrum and will therefore differ widely in presentation and behaviour.
Consideration of these issues must be taken into account. Alternatively, standardised pre-group selection procedures could be incorporated, with reports from school and family being used to design the group to ensure needs are adequately met.
Social communication central to treatment
It may be appropriate, where funding is available, to consider introducing structured social communication group work programmes as part of AS assessment and/or treatment packages, due to this trait being particularly problematic to a child with AS.
Furthermore, parental feedback indicates a deficit in local support groups for children with AS. The facilitators feel that this need could be met by a specialist CAMHS team dedicated to providing education and support to schools, facilitating continuous group work and promoting a need for early identification of AS to allow for intervention with infant and primary school-aged children.
Acknowledgements: Bryn Millichip, Community Psychiatric Nurse, and Caroline Davies, Occupational Therapist.
References on request.