Evidence-Based Social Skills Interventions for Children ...qcpages.qc.cuny.edu/rcautism/publications/Wang social skills.pdf · Evidence-Based Social Skills Interventions for Children

Evidence-Based Social Skills Interventions for Children withAutism: A Meta-analysis

Peishi WangQueens College, City University of New York

Anne SpillaneNational University

Abstract: The purpose of this study was to provide a synthesis of research studies published in the last ten yearson interventions to increase social skills for children and adolescents with ASD, examine the outcomes of thesestudies and evaluate whether a given intervention meets the criteria for evidence-based practice. Thirty-eightstudies were included in this review, of which 36 were single subject research studies and 2 group experimentalstudies. Results varied widely both between intervention types, and with the different studies within eachintervention type. While Social Stories, Peer-Mediated, and Video-Modeling all met the criteria for evidence-based, a closer look at percentage of nonoverlapping data points (PND) shows that only Video-Modeling meetscriteria for being evidence-based as well as demonstrating high effectiveness as an intervention strategy.

Interacting with one’s peers can have a signif-icant positive impact on the lives of individualswith disabilities, allowing them to build andparticipate more fully in their communities.Numerous interventions to teach social skillshave been developed over the years (Carter &Hughes, 2005, Vaughn, et al., 2003, White,Keonig, & Scahill, 2007). However, many ofthese methods do not meet the requirementsfor evidence-based practice. New regulationsin the reauthorization of IDEA in 2004 re-quire that evidence-based practices be used toensure individuals with disabilities receive thehighest quality instruction.

Autism is a developmental disorder whoseprevalence rate has been increasing dramati-cally over the past decade. One in 150 chil-dren in America today have an autism spec-trum disorder (Centers for Disease Controland Prevention, 2007). The Autism Society ofAmerica (ASA) estimates that 1.5 millionAmericans and their families are now affected.

In fact, autism is growing at a startling rate of10-17 percent per year, and has become anational health crisis, costing the U.S. at least$35 billion annually (Autism Society of Amer-ica, 2007).

Deficits in social skills are one of the corefeatures of autism spectrum disorders (ASD),and are a major source of impairment regard-less of the intellectual or language ability ofpersons with ASD (Carter, Davis, Klin, & Volk-mar, 2005). Individuals having better socialskills are more likely to be accepted in inte-grated settings, live more independently, andwork in integrated settings (Scheuermann &Webber, 2002). However, treating the socialdeficits of individuals with ASD remains achallenge (Weiss & Harris, 2001).

There have been many interventions usedto teach social skills to individuals with ASD.These include social stories (e.g. Delano &Snell, 2006), peer-mediated strategies, (e.g.Laushey & Heflin, 2000), video modeling(e.g. Paterson & Arco, 2007), cognitive behav-ioral training (e.g. Bock, 2007), pivotal re-sponse training (e.g. Jones & Freely, 2007),Theory of Mind (e.g. Chin, Bernard-Opitz,2000), among others. Additionally, a numberof meta-analyses have looked at social skillstraining for individuals with ASD (Bellini &Akullian, 2007; Carter & Hughes, 2005; Cook,

Correspondence concerning this article shouldbe addressed to Peishi Wang, Graduate Programs inSpecial Education, Department of Educational andCommunity Programs, Powdermaker Hall 032J,Queens College, City University of New York, 65-30Kissena Blvd, Flushing, NY 11367. Email: [email protected]

Education and Training in Developmental Disabilities, 2009, 44(3), 318–342© Division on Developmental Disabilities

318 / Education and Training in Developmental Disabilities-September 2009

Gresham, Kern, Barreras, Thornton, & Crews,2008; Hwang & Hughes, 2000; Vaughn et al.,2003; White et al., 2007). None of this re-search has discussed whether the studies metcriteria for being evidence-based practice.

Defining Evidence-Based Practices

National policies, such as No Child LeftBehind (NCLB) require that teachers useevidence-based practices in their classrooms.Also, new regulations in the reauthorizationof IDEA in 2004 require that evidence-basedpractices be used to ensure individuals withdisabilities receive the highest quality instruc-tion. However, there has never been a cleardefinition of what evidence-based practice is.Therefore, in January 2003, the Council forExceptional Children (CEC) Division for Re-search established a task force to address theissue of evidence-based practices. A specialissue of Exceptional Children (2005) was ded-icated to establishing criteria for evidence-based practice in special education.

First, let’s clarify what a practice is. Accord-ing to Horner, Carr, Halle, McGee, and Wol-ery (2005), a “practice refers to a curriculum,behavioral intervention, systems change, oreducational approach designed for use byfamilies, educators, or students with the ex-press expectation that implementation will re-sult in measurable, educational, social, behav-ioral, or physical benefit.” (p. 175)

In the 2005 special issue of ExceptionalChildren, Odom et al. set the context for thedevelopment of research quality indicatorsand guidelines for evidence of effective prac-tices provided by different methodologies inspecial education, including group experi-mental or quasi-experimental research, singlesubject research, correlational research andqualitative research. For the purpose of thisarticle, we will focus on two types of researchmethodologies: group experimental or quasi-experimental and single subject research.These two methodologies are largely used toidentify cause-effect relationships between in-terventions and target behaviors, therefore,they are more appropriate for identifyingevidence-based practices.

Specifically, for group experimental andquasi-experimental research articles and re-ports, Gersten et al. (2005) presented the fol-

lowing quality indicators: (1) participants in agiven study are sufficiently discussed and theirdisability conditions are confirmed; (2) ran-dom assignment to study conditions are at-tempted and when randomization is not fea-sible, other alternatives are used to ensureparticipants are comparable across condi-tions; (3) sufficient information is providedregarding the interventionists and proceduresimplemented to ensure they are comparableacross conditions; (4) intervention strategiesare implemented with fidelity, (5) multipleoutcome measures are used to capture theintervention’s effect, (6) data analysis includeeffect size calculations in addition to inferen-tial statistics (p. 152).

Furthermore, the panel suggested that apractice is considered evidence-based “whenthere are at least four acceptable quality stud-ies or two high quality studies that support thepractice and the weighted effect size is signif-icantly greater than zero.” (Gersten et. al.,2005, p. 162)

When evaluating research studies usingthe single subject methodology, Horner et al.(2005) stated that “single-subject researchdocuments a practice as evidence based when(a) the practice is operationally defined,(b) the context in which the practice is to beused is defined; (c) the practice is imple-mented with fidelity; (d) results from singlesubject research document the practice to befunctionally related to change in dependentmeasures, and (e) the experimental effectsare replicated across a sufficient number ofstudies, researchers, and participants to allowconfidence in the findings” (p. 175-176).

Additionally, documentation of an evidence-based practice typically requires multiple sin-gle subject studies. “A practice may be consid-ered evidence-based when (a) minimum offive single subject studies that meet minimallyacceptable methodological criteria and docu-ment experimental control have been pub-lished in peer-reviewed journals, (b) the stud-ies are conducted by at least three differentresearchers across at least three different geo-graphical locations, and (c) the five or morestudies include a total of at least 20 partici-pants” (Horner et al., 2005, p.176).

Although there have been a few review ar-ticles published on this topic in recent years(e.g. Matson, Matson, & Rivet, 2007; McCon-

Evidence-Based Social Skills Interventions / 319

nell, 2002; Rogers, 2000; Weiss & Harris,2001), they tend to be more descriptive of thevarious interventions and lack quantitativeevaluations of treatment effectiveness, that is,the researchers relied on the conclusionsdrawn by the studies’ authors. In addition,these qualitative reviews do not compare treat-ment effectiveness across different interven-tion strategies. Furthermore, they fail to ad-dress the critical issue of evidence-basedpractices. The purpose of this study was toprovide a synthesis of research studies pub-lished in the last ten years on interventions toincrease social skills for children and adoles-cents with ASD, examine the outcomes ofthese studies and evaluate whether a givenintervention meets the criteria for evidence-based practice.

Method

A comprehensive review of the literature wasconducted using the following procedures.First, an electronic search was conducted forstudies published between 1997 and 2008August using the Educational Resources Infor-mation Center (ERIC) and PsycINFO data-bases. Searches were carried out using a com-bination of the following descriptors: autism,autism spectrum disorder, ASD, social skills, socialbehavior, social development, conversational skills,play skills, social initiations, requesting, social re-sponses, social interactions, social relationships,joint attention, eye contact, video modeling, peer-mediated interventions, videotape modeling, pivotalresponse training, theory of mind, cognitive behav-ioral training, incidental teaching, social stories,perspective taking, and naturalistic teaching. Sec-ond, a manual search was conducted with thefollowing peer-reviewed journals: Research andPractice for Persons with Severe Disabilities, Journalof Applied Behavior Analysis, Exceptional Children,Education and Training in Developmental Disabil-ities, American Journal on Mental Retardation,and Focus on Autism and Other DevelopmentalDisabilities. In all, 104 studies were located inthis initial search of journal articles.

Studies were selected for review based onthe following criteria. First, participants musthave been identified as having ASD between theage of birth and 21. Second, study participantswere students receiving special education ser-vices either at home or in school settings. Stud-

ies conducted exclusively in community-basedsettings, employment settings and other settingsthat were not clearly described were excludedfrom this synthesis. Third, the study must haveused outcome measures that targeted socialskills. Studies that measured functional skillssuch as daily living skills, reduction of problembehaviors, or non-social communication skillswere not included. Fourth, the study must haveassessed the effectiveness of social skill inter-ventions. Studies that used pharmacologicalinterventions were excluded from this anal-ysis. Fifth, the review comprised an empirical,intervention-based investigation and was pub-lished in a peer-reviewed journal between 1997and 2008. Dissertation studies were not includedin this synthesis. Sixth, the study must meet thecriteria for evaluating evidence-based inter-vention strategies outlined by the Council forExceptional Children Division for Research(2005). For the purpose of this review, onlythose studies that utilized group experimentalor quasi-experimental and single subject re-search were evaluated and analyzed. For groupdesigns, presentation of effect sizes alongwith inferential statistics is recommended. How-ever, some studies included in this meta-analysisdid not report the effect size of the interventionin the original study, they were included onlywhen such calculation could be inferred basedon available statistics reported. Effect sizes areexpressed positively when change occurred inthe predicted direction and negatively whenchanges were opposite to those predicted. Aneffect size of .20 is small, .50 moderate, and .80large. The usually accepted minimum clinicallyacceptable effect size for educational interven-tions is 0.33 (McCartney & Rosenthal, 2000).

If a study uses single subject research de-sign, the study must demonstrate experimen-tal control through the use of multiple base-line, reversal or alternating treatment designsas outlined by the Council for ExceptionalChildren Division for Research (2005). Addi-tionally, the study must present data in graph-ical displays that depicted individual datapoints as these graphical displays were criticalfor the calculation of PND (percentage ofnon-overlapping data points), the metric anal-ysis employed in this meta-analysis. Scruggs,Mastropieri, and Castro (1987) suggested that“PND is the only major evaluative criterionthat can consistently be applied in the largest


number of cases of single subject studies”(p. 27). PND is usually computed by dividingthe number of treatment data points that ex-ceeds the highest baseline data point in anexpected direction by the total number ofdata points in the treatment phase. A PNDbetween 91 and 100 is considered a highlyeffective intervention, between 71 and 90moderately effective, between 51 and 70mildly effective, and between 0 and 50, non-effective (Scruggs & Mastropieri, 1998).

Using these methods and criteria, we iden-tified 38 studies for inclusion in this review, ofwhich 36 were single subject research studiesand 2 group experimental studies.

Classification

For the 36 single subject research studies,we used a coding system established by Mas-tropieri and Scruggs (1985-1986) and mademodifications based on the criteria outlinedby Horner et al. (2005). Each study was ana-lyzed across the following categories: (1) par-ticipant characteristics, including the numberof participants, diagnosis, settings, age andfunctional levels; (2) description of target be-haviors and skills; (3) description of interven-tion; (4) research design; (5) intervention re-sults including intervention, maintenance andfollow-up, and generalization effects as mea-sured by PND; and (6) confirmation ofwhether the study measured treatment integ-rity and social validity.

Interrater Agreement

To establish interrater reliability for the cod-ing procedure and the PND analysis, the firstauthor coded all the single subject studies andcalculated the PND while the second authorrandomly selected 30% (12) of single subjectstudies, independently coded and calculatedthe PND for those studies. Interrater agree-ment was obtained by dividing the total num-ber of agreements by the total number ofagreements plus disagreements and multiply-ing by 100. The mean interrater agreementbetween the two authors was 97% (range 78%-100%).

Results

A summary of the participants, target behav-iors, intervention strategies, and research de-

sign was constructed and presented in Table1. Table 2 provides descriptive information onintervention results, study effect size or PND,maintenance, follow-up and generalization re-sults, treatment integrity and social validitymeasures.

Overall Findings

Single subject designs were used to evaluateintervention effects in 36 studies and groupdesigns were used in 2 studies. Five categoriesof different interventions emerged from these38 studies, including Social Stories (n � 6),Peer Mediated (n � 9), Video Modeling (n �11), Cognitive Behavior Training (n � 3), andOthers (n � 9).

A total of 147 participants were included.Thirty-one studies used a variation of a multi-ple baseline or probe design, five studies useda reversal design, and two studies used pretestand posttest with a control group design.Treatment integrity was reported in 14 stud-ies, of which 11 reported agreement percent-age, ranging from 77% to 100%. Social valid-ity was measured in 16 studies.

Participants and Settings

Of the 147 participants with ASD, among thestudies that reported on gender, 73 partici-pants were boys, and 6 were girls. Additionally,seven studies reported participation of a totalof 68 typical peers. Participants with ASDranged in age from 2 to 17 years old. The vastmajority of participants were between the agesof 6-12 (82 participants), with thirty partici-pants being five years or younger, and threeparticipants being over 12 years of age. Not allstudies reported ages of participants.

The studies primarily took place in inte-grated settings at public schools. Some studieswere conducted across more than one setting.Ten studies reported being conducted in in-tegrated public school settings not otherwisespecified, 9 in specialized class settings at apublic school. Six studies reported lunch, hall-way, or other integrated school settings, threestudies took place in general education class-room settings. Four studies took place inhome or community settings, three studiestook place in private segregated settings, andone study took place in a private integratedsetting.


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wer

eco

llect

edtw

ow

eeks

afte

rth

etr

eatm

ent

FPN

D�

50%

Mai

nte

nan

cere

sult

sn

otre

port

ed

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opa

rtic

ipan

tsda

taw

ere

repo

rted

,88

%&

92%

3rdch

ild’s

fam

ilyfa

iled

topr

ovid

en

eede

din

fo

Yes

Del

ano

&Sn

ell

(200

6)Im

prov

edpe

rfor

man

ceon

all

targ

etbe

havi

ors

acro

ssal

lth

ree

part

icip

ants

(3/3

)PN

D�

90%

Inte

rven

tion

was

grad

ually

fade

d(2

phas

es)

2pa

rtic

ipan

tsde

mon

stra

ted

gain

sin

thei

rge

ner

aled

clas

sroo

mse

ttin

gsM

PND

�81

.57%

Mea

n�

93%

(78%

-100

%)

Yes

Th

iem

ann

&G

olds

tein

(200

1)3/

4ta

rget

beha

vior

sw

ere

obta

ined

by3

boys

;2/4

targ

etbe

havi

ors

wer

eob

tain

edby

2bo

ysPN

D�

47%

2bo

ysge

ner

aliz

edto

untr

ain

edso

cial

beh

avio

rs;

1ge

ner

aliz

edw

ith

incl

assr

oom

MPN

D�

37.9

7%

Not

repo

rted

Yes.

7ge

ned

teac

her

san

d6

SLP

grad

uate

stud

ents

wh

oar

ebl

ind

toth

est

udy

rate

dpa

rtic

ipan

ts’

perf

orm

ance

pre-

and

post

-trea

tmen

tvi

a2-

min

vide

ovi

gnet

tes.

Bar

ry&

Bur

lew

(200

4)B

oth

part

icip

ants

mad

ega

ins

inm

akin

gin

depe

nden

tch

oice

san

dpl

ayap

prop

riat

ely

duri

ngfr

eepl

aytim

ein

the

self-

cont

aine

dse

ttin

gPN

D�

100%

Gen

eral

izat

ion

effe

cts

wer

ere

port

edvi

aan

ecdo

tal

evid

ence

—th

egi

rltr

ansi

tion

edto

age

ner

aled

clas

sroo

mdu

eto

the

sign

ifica

nt

gain

sin

her

soci

alsk

ills

Not

repo

rted

Not

repo

rted

Scat

ton

e,T

ings

trom

,&

Wilc

zyn

ski

(200

6)In

crea

sein

appr

opri

ate

soci

alin

tera

ctio

nsfo

r2/

3pa

rtic

ipan

tsPN

D�

46.7

%

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e10

0%fo

r2

stud

ents

,86

%fo

r1

stud

ent

IRP-

15sc

ores

all

inth

eac

cept

able

ran

ge

Dod

d,H

upp,

Jew

ell,

&K

roh

n(2

008)

Incr

ease

dta

rget

beha

vior

sfo

rbo

thbo

ysPN

D�

60%

(zer

oba

selin

e)

Rep

orte

dfo

ron

ly1

subj

ect

MPN

D�

100%

Part

icip

ant

1�10

0%;

Part

icip

ant

2�97

.1%

Yes

(con

tinue

d)


TA

BL

E2

Con

tinu

ed

Stud

yR

esul

tsM

aint

enan

ce/F

ollo

wup

/G

ener

aliz

atio

nT

reat

men

tIn

tegr

itySo

cial

Valid

ityM

easu

res

Peer

Med

iate

d(n

�9)

Lau

shey

&H

eflin

(200

0)Si

gnifi

can

tim

prov

emen

tin

soci

alsk

ills

for

both

child

ren

PND

�10

0%

On

ly1

part

icip

ant

repo

rted

follo

wup

data

inge

ner

aled

clas

sroo

man

dh

em

ain

tain

edth

ega

ins

FPN

D�

100%

(1ch

ildon

ly)

Yes

Focu

sgr

oup

was

used

tova

lidat

eth

eD

V&

IV

Pier

ce&

Sch

reib

man

(199

7)B

oth

part

icip

ants

mad

esi

gnifi

can

tga

ins

inth

eir

soci

alsk

ills

PND

�71

.01%

Bot

hpa

rtic

ipan

tsge

ner

aliz

edth

eir

gain

sin

toot

her

sett

ings

wit

hn

ovel

peop

leas

wel

lM

PND

�66

.67%

FPN

D�

71.0

5%

Not

repo

rted

Not

repo

rted

Hw

ang

&H

ugh

es(2

000)

3/3

part

icip

ants

incr

ease

dta

rget

beh

avio

r;PN

D�

72.2

2%

Gen

eral

izat

ion

ofey

eco

nta

ctan

dm

otor

imit

atio

nw

ere

foun

dac

ross

new

sett

ing

and

diff

eren

tpa

rtn

er;

join

tat

ten

tion

rare

lyge

ner

aliz

ed

Yes

Yes

Petu

rsdo

ttir

,M

cCom

as,

McM

aste

r,&

Hor

ner

(200

7)

No

effe

cts

ofpe

ertu

tori

ng

alon

eon

soci

alin

tera

ctio

ns.

Add

ing

play

-rel

ated

com

mon

stim

uli

toth

epe

er-tu

tori

ng

acti

vity

incr

ease

dso

cial

inte

ract

ion

sdu

rin

gfr

eepl

ay.

PND

�36

.17%

Not

repo

rted

81%

(ran

ge56

%-9

2%)

for

the

K-P

AL

S;91

%(r

ange

86-9

6%)

for

com

mon

stim

uli

acti

viti

es

Yes

Lon

cola

&C

raig

-U

nke

fer

(200

5)A

llde

pen

den

tva

riab

les

impr

oved

acro

ssal

lsu

bjec

tsPN

D�

56.7

2%

Not

repo

rted

98%

(80%

-100

%)

Not

repo

rted

(con

tinue

d)


TA

BL

E2

Con

tinu

ed

Stud

yR

esul

tsM

aint

enan

ce/F

ollo

wup

/G

ener

aliz

atio

nT

reat

men

tIn

tegr

itySo

cial

Valid

ityM

easu

res

Gar

riso

n-H

arre

ll,K

amps

&K

ravi

ts(1

997)

Incr

ease

ddu

rati

onof

peer

inte

ract

ion

sac

ross

sett

ings

,in

crea

sed

use

ofau

gmen

tati

veco

mm

unic

atio

nsy

stem

,so

me

incr

ease

inve

rbal

izat

ion

s,in

crea

sein

peer

acce

ptan

ceFr

eque

ncy

ofin

tera

ctio

ns

PND

�48

%D

urat

ion

ofin

tera

ctio

ns

PND

�95

%

Non

eN

otre

port

edN

otre

port

ed

Car

ter,

Cus

hin

g,C

lark

,&

Ken

ned

y(2

005)

Hig

her

leve

lof

soci

alin

tera

ctio

ns,

and

con

tact

wit

hth

ege

ner

alcu

rric

ulum

wh

ensu

ppor

ted

by2

peer

sPN

D�

35.0

9%

Non

eN

otre

port

edN

otre

port

ed

Koe

gel,

Wer

ner

,V

ism

ara,

&K

oege

l(2

005)

Sign

ifica

nt

incr

ease

sin

unpr

ompt

edsy

nch

ron

ous

reci

proc

alin

tera

ctio

ns

PND

�10

0%

Non

eN

otre

port

edFr

eque

ncy

ofre

cipr

ocal

invi

tati

ons—

mor

ein

vita

tion

sex

ten

ded

bype

ers

afte

rtr

eatm

ent

Har

per,

Sym

on,

&Fr

ea(2

008)

Bot

hpa

rtic

ipan

tsim

prov

edth

eir

soci

alpe

erin

tera

ctio

ns

duri

ng

rece

ssPN

D�

75%

(zer

oba

selin

e)

Yes

GPN

D�

100%

Yes

Dat

aw

ere

repo

rted

ina

tabl

e,ra

ngi

ng

from

78%

-100

%

Yes

but

thro

ugh

anec

dota

lre

port

s

(con

tinue

d)


TA

BL

E2

Con

tinu

ed

Stud

yR

esul

tsM

aint

enan

ce/F

ollo

wup

/G

ener

aliz

atio

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reat

men

tIn

tegr

itySo

cial

Valid

ityM

easu

res

Vid

eoM

odel

ing

(n�

11)

Pate

rson

&A

rco

(200

7)B

oth

part

icip

ants

incr

ease

dth

eir

appr

opri

ate

verb

alan

dm

otor

play

beh

avio

rac

ross

toys

;th

eir

repe

titi

veve

rbal

and

mot

orpl

aybe

hav

ior

decr

ease

d;PN

D�

100%

1bo

yge

ner

aliz

edm

otor

play

wit

hth

ree

rela

ted

toys

;fo

llow

upda

taw

ere

reco

rded

1w

eek

afte

rtr

eatm

ent

was

wit

hdr

awn

for

both

boys

FPN

D�

100%

Not

repo

rted

Not

repo

rted

Nik

opou

los

&K

een

an(2

007)

Exp

erim

ent

I:m

ixed

resu

lts

acro

sssu

bjec

tsan

dbe

hav

iors

PND

�90

.57%

Gen

eral

izat

ion

toa

nov

elpe

erw

asm

easu

red

for

all

thre

epa

rtic

ipan

ts;

Follo

wup

data

wer

eta

ken

at1-

and

2-m

onth

s.FP

ND

�10

0%

Not

repo

rted

Th

eso

cial

valid

atio

nof

the

trea

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tou

tcom

esw

asas

sess

edby

ten

mot

her

sof

sch

ool-a

ged

child

ren

.

Nik

opou

los

&K

een

an(2

004)

All

part

icip

ants

incr

ease

dth

edu

rati

onof

reci

proc

alpl

ay;

soci

alin

itia

tion

impr

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ent

resu

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wer

em

ixed

PND

�72

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w-u

pte

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con

duct

edat

1an

d3

mon

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afte

rth

est

udy

FPN

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100%

Not

repo

rted

Not

repo

rted

Gen

a,C

oulo

ura,

&K

ymis

sis

(200

5)A

ll3

part

icip

ants

incr

ease

dth

eir

affe

ctiv

eca

tego

ries

Invi

vom

odel

ing

PND

�88

%V

ideo

mod

elin

gPN

D�

79%

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w-u

pat

1-an

d3-

mon

ths

GPN

D�

100%

FPN

D�

100%

Not

repo

rted

Not

repo

rted

Hin

e&

Wol

ery

(200

6)B

oth

part

icip

ants

show

edim

prov

emen

tin

both

pret

end

play

beh

avio

rsPN

D�

70.4

5%

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eral

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acro

ssm

ater

ials

and

acro

ssse

ttin

gsw

ere

mea

sure

dM

PND

�10

0%

M�

95%

(83.

3%to

100%

)Ye

s

(con

tinue

d)


TA

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Con

tinu

ed

Stud

yR

esul

tsM

aint

enan

ce/F

ollo

wup

/G

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aliz

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reat

men

tIn

tegr

itySo

cial

Valid

ityM

easu

res

Wer

t&

Nei

swor

th(2

003)

All

4pa

rtic

ipan

tssh

owed

sign

ifica

nt

impr

ovem

ent

PND

�97

%

Yes

MPN

D�

100%

Not

repo

rted

Not

repo

rted

Sim

pson

,L

ango

ne,

&A

yres

(200

4)A

ll4

part

icip

ants

show

edsi

gnifi

can

tim

prov

emen

tPN

D�

97.3

0%

Not

repo

rted

Not

repo

rted

Not

repo

rted

Ch

arlo

p-C

hri

sty,

Le,

&Fr

eem

an(2

000)

Ove

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vide

om

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ing

led

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g.In

vivo

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72.8

8%V

ideo

mod

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76.9

2%

Gen

eral

izat

ion

prob

esac

ross

diff

eren

tst

imul

i,pe

rson

s,an

dse

ttin

gw

ere

con

duct

eddu

rin

gba

selin

ean

dal

so3

to5

days

afte

rcr

iter

ion

perf

orm

ance

was

dem

onst

rate

din

trea

tmen

t.In

vivo

GPN

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58.8

2%V

ideo

GPN

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84.6

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Yes.

For

the

invi

voco

ndi

tion

,th

em

odel

ing

sess

ion

sw

ere

vide

otap

edan

dra

ted

at99

%.

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repo

rted

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le,

Bill

ings

ley,

&Sc

hw

artz

(200

5)D

urin

gvi

deo

mod

elin

g,bo

thpa

rtic

ipan

tsw

ere

able

toac

quir

eth

esk

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ofco

mpl

imen

t-giv

ing

resp

onse

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xper

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tII

:Se

lf-m

anag

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tin

crea

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subj

ects

’in

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orin

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own

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ior

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Res

pon

dto

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PND

�10

0%In

itia

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0%

Exp

erim

ent

IIn

itia

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FPN

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0%

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tinue

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TA

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tinu

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yR

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enan

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cial

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ityM

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�R

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orce

men

tIn

itiat

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PND

�10

0%R

espo

nse

PND

�10

0%R

einf

orce

men

tIn

itiat

ion

PND

�10

0%R

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�10

0%(Z

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base

line)

Exp

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gR

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Self

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100%

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pons

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Gai

nsm

ade

infr

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ncy

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cial

initi

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to4.

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d.1

7to

4.25

initi

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ay)

PND

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ron

epa

rtic

ipan

t)

Res

ults

mai

nta

ined

MPN

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FPN

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100%

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repo

rted

Not

repo

rted

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arlo

p-C

hri

sty

&D

anes

hva

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003)

Var

ious

gain

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ade

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erra

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ofge

ner

aliz

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wer

ere

port

edG

PND

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repo

rted

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(con

tinue

d)


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tinu

ed

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yR

esul

tsM

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men

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ityM

easu

res

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tal

Res

pon

seT

rain

ing

(n�

1)Jo

nes

&Fe

ely,

(200

7)A

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child

ren

achi

eved

mas

tery

(90%

inde

pend

ent

corr

ect

resp

ondi

ng,a

cros

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cons

ecut

ive

sess

ions

and

days

)PN

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66.1

1%

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orm

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con

tin

ued

duri

ng

6-30

mai

nte

nan

cese

ssio

ns,

and

duri

ng

gen

eral

izat

ion

prob

esG

PND

�10

0%

Vid

eo-ta

ped

reco

rdin

gs:

86-9

7%pr

esen

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on80

-100

%pr

ompt

ing

77-9

6%co

nse

quen

ces

Not

repo

rted

Th

eory

ofM

ind

(n�

1)C

hin

,B

ern

ard-

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000)

Incr

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dtim

esp

ent

insh

ared

inte

rest

inco

nver

satio

nsIn

crea

sed

perc

enta

geof

resp

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sap

prop

riat

eto

cont

ext

ofco

nver

satio

nSc

ore

of0

for

alls

tude

nts

onfir

stor

seco

ndor

der

Fals

eB

elie

fta

sks.

PND

�80

.77%

1ch

ildin

crea

sed

shar

edin

tere

stti

me,

perc

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geof

con

text

ually

appr

opri

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resp

onse

sw

ith

typi

cally

deve

lopi

ng

peer

GPN

D�

100%

Not

repo

rted

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ease

dey

eco

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nta

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and

taki

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turn

sac

cord

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toso

cial

valid

ity

asse

ssm

ent

ques

tion

nai

re

Cog

nit

ive

Beh

avio

ral

Tra

inin

g(n

�3)

Lop

ata,

Th

omee

r,V

olke

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006)

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ifica

ntm

ain

effe

cts

wer

efo

und

from

pare

ntra

tings

for

gene

rali

mpr

ovem

ent

for

soci

alsk

ills,

adap

tabi

lity,

and

atyp

ical

ity.S

taff

ratin

gsha

dsi

gnifi

cant

impr

ovem

ents

for

soci

alsk

ill,b

utno

nsig

nific

ant

ratin

gsfo

rad

apta

bilit

y,an

dsi

gnifi

cant

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Target Behaviors

A number of social behaviors were targetedacross the studies; many studies targeted morethan one behavior. Maintaining conversationand/or appropriate social behavior was tar-geted in 28 studies, 17 studies targeted initiat-ing conversations or social behavior (includ-ing greetings and requests), 5 studies targetedinitiating play. Eight studies targeted appro-priate play skills (including turn-taking), twostudies targeted eye contact, and two studiestargeted perspective-taking.

Research Designs

The vast majority of studies (31) utilized amultiple baseline design. Twenty-four studieswere conducted across participants, six studieswere conducted across behaviors, three stud-ies were conducted across settings, three stud-ies were conducted across other individuals,and two studies were conducted across tasks.Some of the studies were conducted acrossmultiple categories within the study.

Of the other seven studies, five utilized theABAB or reversal design, and two studies uti-lized the group experimental design. Both ofthe experimental studies followed a pre-post-test format with a control group.

Outcome Measures across Interventions

Social Stories. Six studies used Social Storiesto teach social skills. The PND scores rangedfrom 46.7% to 100% with a mean of 67.21%,which represents questionable effectiveness asan intervention according to Scruggs and Mas-tropieri (1998). Although Social Stories metthe criteria for evidence-based practice ac-cording to Horner et al. (2005), the effective-ness of Social Stories as an intervention forimproving social skills is questionable due tothe low PND scores.

Peer Mediated. A total of nine studies in thisreview used peer mediated strategies. ThePND scores ranged from 35.09% to 100% witha mean of 60.69%, which represents low toquestionable effectiveness. Twenty-four partic-ipants were included in these studies. Thestudies were conducted by 25 researchersacross nine geographic areas. However, theeffectiveness of peer mediated strategies to

improve social skills in children with autismremains to be questionable due to the lowPND scores.

Video Modeling. There were eleven studiesused video modeling to teach social skills. ThePND scores ranged from 50% to 100% with amean of 84.25%, which represents effectiveintervention. Video Modeling met the criteriafor evidence-based intervention and its PNDscores shows that it is an effective interven-tion for teaching social skills to children withautism.

Cognitive Behavioral Training. Three stud-ies were included in this category to examinethe effects of cognitive behavior training onsocial skills, two of which were group experi-mental designs. We used available data re-ported in the original studies to obtain theeffect size due to the absence of such results inthe original studies. The effect size for Lopataet al (2006) ranged from .59-.24 indicatingmoderate to mild effects, while the effect sizefor Baumringer (2002) ranged from 1.24-.47indicating high to moderate effects. The thirdstudy used a multiple baseline across settingsdesign. The PND for intervention was calcu-lated at 100%, which is very promising. How-ever, more studies are needed to confirm theefficacy of cognitive behavioral training.

Others. In this category, most of the inter-ventions were represented by only one study,i.e. pivotal response training (n � 1), Theoryof Mind (ToM, n � 1), scripts and cue cards(n � 2), Keys to Play (n � 1), incidentalteaching (n � 1), PECS training (n � 1),tactile prompting device (n � 1) and socialskills training with scripts and reinforcement(n � 1). Even though some of the studiesreported fairly promising PND scores, (e.g.ToM PND � 80.77%, indicating an effectiveintervention), more studies are needed withmore participants and by different research-ers to further evaluate their effectiveness asevidence-based and effective interventions.

Intervention Maintenance and GeneralizationEffects

Twelve out of 36 studies reported the mainte-nance effects of the intervention. The PNDscores ranged from 38% to 100%, with a meanof 78.5%. Nine studies reported the generali-zation effects of the intervention. The PND


scores ranged from 40% to 100% with a meanof 80.95%. In addition, nine studies reportedthe follow-up data of the intervention. ThePND scores ranged from 60% to 100%, with amean of 92.15%. However, these averageswere obtained across five categories of inter-ventions, making it impossible to concludewhether the impact of individual interven-tions was effectively maintained and general-ized due to limited number of studies in eachcategory reporting such results.

Treatment Integrity

Fourteen studies assessed the extent to whichintervention conditions were implemented asintended; eleven studies actually reportednumerical data on treatment integrity. Re-searchers in 3 studies discussed that treatmentintegrity was monitored but provided no nu-merical data. In studies in which treatmentintegrity was reported, interventions were im-plemented with a high degree of fidelity. Be-cause most studies did not include assessmentof treatment integrity, we find it difficult todraw definite conclusions that the changes inthe target behaviors are the results of the in-terventions. Also because most studies re-viewed in this article were implemented byresearchers, additional research is needed todetermine whether interventions can be im-plemented with high fidelity by teachers, par-ents, or others. Otherwise, the generality ofthese interventions for use in the real schoolsettings remains to be unclear.

Social Validity

Measures of social validity were reported in 16studies. Most studies provided evidence forthe social importance of intervention out-comes. Assessment of social validity was ob-tained either through interviews or question-naires. It is important that parents andclassroom teachers believe that the selectedintervention strategies are effective and ap-propriate. If the intervention lacks social va-lidity, parents and teachers are less likely toexert the necessary effort to implement theintervention, thus diminishing the interven-tion fidelity.

Discussion

Results varied widely both between interven-tion types, and within each intervention type.While Social Stories, Peer-Mediated, andVideo-Modeling interventions all met the cri-teria for evidence-based practices according toHorner et al. (2005), a closer look at PNDscores shows that only Video-Modeling meetscriteria for being evidence-based as well asdemonstrating high effectiveness as an inter-vention strategy. The PND scores of two of thesix Social Stories intervention studies (Barry &Burlew, 2004; Delano & Snell, 2006), andthree of the nine Peer-Mediated interventionstudies (Garrison-Harrell, Kamps, & Kravits,1997; Koegel, Werner, Vismara, & Koegel,2005; Laushey & Heflin, 2000), demonstratedhigh effectiveness. Looking more closely atthose highly effective studies could provideclues to implementing interventions in waysthat will be effective. Cognitive behavioraltraining is another intervention that showsgreat promise; more research is needed inthis area to demonstrate both its status as anevidence-based practice, and its overall effec-tiveness.

Zero Baseline Effects

Seven out of the 36 single subject studies re-ported zero baseline, by which is meant allbaseline data are equal to zero. Such data areproblematic due to the fact that a minor effectcould result in relatively high levels of non-overlapping data. In the case of zero baselines,it is often difficult to believe that “the subjectwas exhibiting no task-relevant behavior at all.It often seems that the observational measurewas not sensitive to relevant levels of behaviorthat were being examined” (Scruggs, et al.,1987, p. 30). Therefore, during final dataanalysis, we need to be more cognizantwhether a specific treatment was effective onlyin the presence of “zero baseline” data. Insuch case, conclusions regarding the effective-ness of a particular treatment should be inter-preted with caution.

Implications for Practice

This review described a variety of interven-tions that have been developed and evaluated


to promote social skills in children with autismspectrum disorders. The results of the presentstudy are consistent with those of previousmeta-analysis indicating that social skills inter-ventions are minimally effective for childrenwith ASD (Bellini et al. 2007; Vaughn et al.,2003). The exception to this is video model-ing; that intervention was shown to meet thecriteria for evidence based practice, as well asbeing highly effective. Practitioners imple-menting video-modeling as a method forteaching social skills can do so with greaterconfidence of its effectiveness. While socialstories and peer-mediated strategies can besaid to be evidence-based practices, practitio-ners should monitor these strategies closelywhen implementing them as they may havelimited effectiveness. Other strategies shouldbe implemented carefully, with the under-standing that they have not met criteria asevidence-based practices, and require contin-uous monitoring for effectiveness.

Most of studies included in this review wereconducted by researchers with a few excep-tions that were implemented by classroomteachers, paraprofessionals or parents. How-ever, social skills training in general is carriedout by teachers and parents in integrated set-tings. If the interventions implemented byprofessional researchers yield mixed results, itwould be a real challenge for classroom teach-ers and parents with limited resources andtime to achieve the same or better outcomes.

Limitations

This synthesis only evaluated social skills inter-ventions for children with ASD published be-tween 1997 and August 2008. Evaluating stud-ies over a longer period of time may haveresulted in more interventions meeting thecriteria for evidence-based practice, or morestudies demonstrating a higher level of effec-tiveness. However, the criteria for evidence-based practices were only recently established;studies done before 1997 would have beeneven more less likely to meet those criteria.We also only looked at studies that were pri-marily implemented in school-based settings;the effectiveness of these interventions on so-cial skills in community settings or for adultswith ASD cannot be determined from thismeta-analysis.

Suggestions for Future Research

Although our initial search of the literaturefound 104 studies that targeted social skills, inthe end only 38 of those met criteria to beevaluated as evidence-based practice, as well asallowing for the calculation of treatment ef-fects. Future research in this area should beplanned and implemented in such a way thatmeets the criteria for evidence-based practice,as well as reports treatment effects.

Most of the studies targeted students be-tween the ages of 5-12; many of the remainingstudies targeted preschool children. Onlythree studies were implemented with individ-uals over 12 years of age. Studies targetingthese older children would be beneficial indetermining if particular interventions aremore effective with this age group.

Generalization of skills is an integral com-ponent of social skills interventions. Futurestudies are needed to examine the generaliza-tion of skills across multiple settings and withmultiple persons. Researchers and teachersshould create an explicit plan for promotinggeneralization when developing a social skillsintervention.

Single subject designs were used to evaluateintervention effects in 36 out of the 38 studiesincluded in this review. Multiple baseline de-signs were utilized in almost all of the studiesto establish the experimental control. Al-though such designs are well-suited to demon-strate analyses, certain limitations do apply—itdoes not allow for comparison of differentinterventions. Future research is needed todetermine which intervention is most effectivefor which students. Compounding this limita-tion is the presence of near or at zero baselineperformance by the participants in many stud-ies. Because most social skills interventions arelikely to boost social interaction above thefloor levels, comparative analysis can assist re-searchers in identifying which interventionachieves this objective most effectively.

References

References marked with an asterisk indicate studiesincluded in the meta-analysis.

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