Running head: GROUP THERAPY VS ONE ON ONE THERAPY
Effects of Group Therapy vs One on One Therapy in Improving Social Skills of Autistics
Chidera N. Oyeka
San Jose State University
1
Introduction
Autism spectrum disorder (ASD) is a neurodevelopmental disorder typically
characterized by deficits in social skills, communication, and the presence of repetitive behaviors
(Wolstencroft et al., 2018). While all persons with autism are different, depending on the severity
of the deficits, autistics can be sub categorized into three levels: requiring support, requiring
substantial support, and requiring very substantial support (Wolstencroft et al., 2018).
Individual’s at the requiring support level are informally labeled as high functioning autistics.
The DSM V does not acknowledge the term high functioning autism (HFA) as an actual
diagnosis of autism spectrum disorder. Researchers developed the term in order to distinguish the
developmental level of an autistic. Indicators used to label HFA are typically an IQ of 80 or
higher, and appropriate speaking, reading, and writing ability (Wolstencroft et al., 2018). People
with HFA still exhibit some difficulties with typical ASD deficits (need for routine, hyper focus
on certain subjects, repetitive behaviors). However, intervention in HFA emphasizes treatment
related to social cognition (initiating interactions with others, making friends, conversation
skills), understanding social cues, and nonverbal communicative behaviors (body language, eye
gaze, facial expression) (Laugeson, Frankel, Gantman, Dillon, & Mogil, 2012).
Due to the increase of complexity in social communication that follows maturity, the
social deficits of HFA become much more prominent during adolescence. As children grow, they
become more aware of the effects of their social deficits and their inability to easily 'fit in' with
peers. Lack of social skills can also impair adolescents’ ability to initiate romantic and friendly
relationships. Consequently, adolescence for teens with HFA often consists of peer rejection,
bullying and a lack of social support (Laugeson et al., 2012). This results in high self reports of
feelings of loneliness, depression, and isolation (White, Ollendick, Scahill, Oswald, & Albano,
2009). Therefore, it is necessary to combat these shortcomings through interventions.
Providing an adolescent with the ability to understand the ground rules of social etiquette
can severely impact their ability to establish supportive relationships with peers. While many
aspects of intervention for ASD focus on improving the child’s behavioral deficits and functional
communication, it is necessary to also concentrate on developing effective treatments for social
skills deficits. Accordingly, much of the research in autism intervention is dedicated to early
childhood intervention studies for more severely impaired autistics. Thus the literature focusing
on treatment for adolescents with higher cognitive function is lacking in comparison. Within the
established literature, for social skills intervention among HFA adolescents, treatment is often
administered in either a group or individual therapy context (Roope, 2009). However, there are
no established consistencies in the “mode of delivery, teaching strategy, content or intensity of
therapy” (Wolstencroft et al., 2018). Although many of these interventions have proven effective,
due to their variabilities in design, there is no comprehensive understanding of which aspects of a
intervention determine the successfulness of a social skill therapy. In order to determine and
develop an effective intervention to improve social skills this literature review seeks to answer
the question : Do adolescents with high functioning autism show improved social skills as
measured by improved social performance and increased social knowledge parent, after group
therapy, as opposed to one on one therapy? This literature review also attempts to determine
what key features across both methods influence the effectiveness of treatment. Finally, this
review will discuss the generalizability of the intervention after treatment was completed.
Review of Literature
Within the context of this review it is necessary to understand the distinction between
social performance and social knowledge. Social knowledge deficits refers to one’s lack of
knowledge of regarding the performance of social behaviors. Social performance deficits are
exhibited when a child has knowledge of appropriate social behaviors, but fails to exhibit them in
real life situations (McMahon, Lerner & Britton, 2013). While most social skills interventions
include training in both areas, the distinction allows for better understanding of the effectiveness
of both knowledge based and social performance based intervention techniques. Finally, specific
social behaviors targeted within these interventions include non verbal communication (eye
contact, facial expression, posture, gesture), verbal communication (tone of voice, humor and
jokes, non literal language), social interaction (initiating conversation, joining and maintain
social conversations, maintain friendships), and social problem solving (conflict in relationships,
negative emotions, bullying) (McMahon, Lerner & Britton, 2013).
It is also important to identify the measures used to assess the effectiveness of
intervention. Typically the Social Responsiveness Scale (SRS) and the Social Skills Rating
System (SSRS) were used to measure outcomes of the interventions discussed in this review. The
SRS is a parent and teacher completed questionnaire used to assess the extent or presence of a
child’s social impairment. The SSRS is parent, teacher, and child completed questionnaire that
measures the child’s social skills, problem behaviors, and academic competence across different
settings.
Group Social Skills Interventions. In their study, Laugeson et al. (2012) evaluated the
efficacy and generalization of a social skills training, Program for the Education and Enrichment
of Relational Skills (PEERS), for adolescents with HFA. PEERS is a social skills intervention
that also features a parent training component. The goal of the intervention was to increase
adolescents’ knowledge of social skills, social skill performance, and improve the adolescents
scores on the SSRS. PEERS consisted of a 14 week manualized program that utilized role
playing and behavioral rehearsal exercises as its primary teaching strategies. Each week focused
on a different social skill lesson (ie conversational skills, appropriate use of humor,
sportsmanship etc.). The parent training component reviewed the adolescents’ weekly goal, and
introduced parent’s to their role as the child’s coach. Parents were instructed to help scaffold and
reward their child’s performance of appropriate social skills at home in order to help generalize
the skill to a natural setting. Following the intervention, an improvement in observed social skills
was reported by parents and teachers on the SSRS. Lastly, the findings infer that successful
maintenance and generalization of social skills in the participants can be attributed to the parent
intervention component of the study.
In his study Bolte (2016) attempted to investigate the behavioral effects of a social skills
group training, KONTAKT, for HFA children and adolescents within a clinical setting. Bolte
utilized a randomized control trial (RCT) in which HFA adolescents were either assigned to a
waiting list control group or the social skills treatment group. KONTAKT, a manualized group
training, was delivered in twelve 60 minute interventions and twenty-four 90 minute training
sessions. Trainings focused on discussion of social cognition and interaction. Exercises and
strategies were also implemented to improve verbal and nonverbal communication, coping
strategies, and self confidence. The study utilized the SRS as its assessment measurement.
Results noted an improvement in social cognition of the treatment group when compared with
the control. However, improvements only proved significant for the adolescent aged participants
not child aged. KONTAKT also was able to decrease maladaptive behaviors in participants.
Finally, after completion of the intervention, a decrease in personal stress levels was also
reported by parents.
White, Koenig, and Scahill's (2010) study evaluated the feasibility and efficacy of a trial
group social skills program for adolescents with ASD. The intervention was modified from a
manual based program created for elementary age children with ASD. The program utilized
small groups that consisted of 4 ASD adolescents and one neurotypical developing peer. The
teaching strategy of the program, similar to other studies, was didactic. Group sessions consisted
of skill teaching, practice, and time to socialize with peers. Neurotypical peers were tasked with
modeling target skills as well as engaging other adolescents in social interactions. The
intervention was also modified from the original in order to incorporate age appropriate social
topics and age appropriate activities. Results of the study were mixed. After completion of the
intervention teacher reported SRS scores showed no significant change of participants social
skills in the classroom. However, parent reported SRS scores reflected an improvement of
expressive social skills and motivation for social interaction. The study concludes that the social
skill training proved beneficial to some participants. However, follow up assessments suggested
a poor maintenance of gained skills, as well as lack of generalization across other settings.
Crooke, Hendrix, and Rachman (2008) conducted a study to determine the effectiveness
of using a social cognitive approach to teach social skills to high functioning autistics. Unlike,
other related studies, Crooke et al. attempted to improve deficits in social cognition through
lessons in social thinking, as opposed to only focusing on the practice and reinforcement of
appropriate social behaviors. The social thinking approach intended to educate students about the
reasoning behind acceptable social behaviors. This study utilized two locations. The first site,
which was set up for more leisure activities, was used for establishing baseline and
generalization. The second site, which was more structured with a classroom design, was used
for treatment. Participants engaged in 60 minute sessions that consisted of teaching social
cognitive strategies and social thinking lessons, followed by open discussion. Video and
transcriptions of these discussion from pre treatment and post treatment where coded by
researchers to determine frequency of ‘expected’ (appropriate) verbal and non verbal behaviors
vs ‘unexpected’ (inappropriate) verbal and nonverbal behaviors. ‘Expected’ behaviors where
defined as conversation initiation and attending to conversation with eyes. Results of the study
found a significant improvement in ‘expected’ behaviors from baseline to post treatment.
Additionally, a significant decrease in unexpected behaviors from baseline to post treatment was
also noted. The study concluded that social cognitive approaches to social skills intervention, for
children with HFA, can effectively increase appropriate social behaviors and decrease
inappropriate social behavior.
Individual Treatment. Roope (2009) conducted a study in which clients received both
individual and group therapy. The aim of the study was to determine which setting improved
social language skills for children with HFA. The study utilized a withdrawl design in which
clients received 6 sessions of individual therapy, as well as 6 sessions of group therapy. Group
therapy consisted of the participant, clinician and two neurotypical peers. Individual therapy
consisted of only the participant and the clinician. Before each treatment setting, baseline of the
child’s social skills was taken. Following each treatment stage was a treatment withdrawl period.
The intervention utilized discrete trial training as a method of teaching. Participants initially
received a stimulus item, a turn card, to indicate when it was the child’s turn to speak. The
clinician would then give the participant a speaking prompt. The speaking prompt either directed
the participant to discuss with a peer, or to initiate conversation with just the clinician depending
on the therapy setting. After the client responded, the clinician would provide immediate
feedback about the appropriateness of the response. The turn taking card was then removed to
signify the end of the participants speaking turn, as well as the trial. During these trials the
clinician was assessing three characteristics of the participants turn taking: appropriate eye
contact with listener, body positioning of participant towards listener, and relevance of the
participants utterance towards the prompted topic. As sessions continued the stimuli was faded
out of trials. Additionally, clinicians also began providing feedback in the forms of cue cards and
simple gestures. During withdrawl phases, clinicians observed participants during recess in order
to collect data on child’s social performance in a natural setting. Effects of the study were
determined by data collected from observation of play and observation of participant in the
communication lab were treatment took place. The results of the study determined that the
participants exhibited improvement of the target social behaviors during the treatment phases,
regardless of the therapy setting. Also consistent with both participants was the inability to
maintain and generalize turn taking skills during play in any phase of the study. The study
concludes that the participants inability to generalize the learned behavior is consistent in similar
studies.
A pilot study was conducted by Gutman and Raphael-Greenfield (2012) to determine
whether motor based role play, using a canine assistant, could improve the use of social skills in
adolescents with HFA. The researchers created a manual treatment plan with specific role play
activities intended to aid participants in recognizing and understanding non verbal
communication (body language, gestures, facial expression, and voice intonation). Participants in
the study each received 4 weeks of hour long intervention. Sessions consisted of warm up and
role play activities. Role play activities typically consisted of scenarios that evoked a specific
emotion, but also incorporated the canine aid. During the scenario the clinician and participant
would both assume a role. The participant would then practice social performance of non verbal
communication elements. Following the role play, the client and participant would discuss the
scenario and practice motor based gestures associated with the emotion exhibited during the role
play. During the discussion the participant would receive feedback on how to further identify and
practice the motor based actions of the emotion. Results of the study indicated improvement in
social skills based on scores in the Evaluation of Social Interaction (ESI) assessment. However,
only one of the two participants was able to maintain improved social skills after a 3 month
follow up. Finally, researchers concluded that inclusion of canine support may have increased the
adolescent’s level of comfort with social interaction, as well as their motivation to participate in
the intervention.
White, Ollendick, Scahill, Oswald, and Albano (2009) discovered that there was limited
research in respect to the correlation between anxiety and social competence amongst
adolescents with ASD. The purpose of this study was to determine how effective cognitive
behavioral intervention programs would be for anxious adolescents with ASD in congruence
with addressing their social competency (White et. al, 2009). In order to test their hypothesis four
adolescents with (HFA) were selected to partake in cognitive behavioral therapy (CBT) sessions
and group social therapy. Findings showed that the majority of participants displayed significant
improvement in relation to their anxiety disorder(s). Participants displayed improved social
skills, especially with social communication and social motivation. The purpose of this study
was to test the preliminary efficacy of CBT programs amongst anxious adolescent with ASD,
therefore this study successfully proved that upon initial treatment CBT can likely by effective.
The study concluded studies should utilize a larger sample group to examine how CBT programs
improve anxiety and social competency on a long-term basis.
Hopkins et al. (2011) tested the effectiveness of a new computer software called FaceSay
in improving the social skills of children with low functioning autism (LFA) and high
functioning autism. Previous studies have tested social skills with differing computer software,
however FaceSay is a program that utilizes animated avatars geared towards administering an
interactive approach. The purpose of this study was to observe how FaceSay impacts participants
emotional development and facial recognition capabilities. The authors discovered that both LFA
and HFA participants demonstrated overall improvement, with both groups showing
improvement in the domains of emotional recognition and social interaction. However, only HFA
participants exhibited improvement with facial recognition as well. In conclusion, this study
proved that computer simulated programs designed to train individuals in social skills are
effective in improving social interaction and emotional recognition amongst children with ASD.
The life-like avatar assistants in FaceSay promote a safe start for those with ASD to simulate real
life interactions.
Efficacy of Individual and Group Therapy. Despite the variabilities in design, strategy,
and assessment, significant effects of treatment were reported in both group and individual
therapy settings as evidenced by a measurable improvement in social performance and/or social
knowledge. However, no one specific approach to social skills training yielded consistently
better results than any other method. One key that has been associated with increased effects of
intervention is parent involvement. Additionally, aside from an improvement in displayed social
skills, reports from the SRS noted a significant decrease in restricted interests and repetitive
behavior in participants after treatment. This indicates that social skill training can also lessen the
severity of non social skill symptoms of ASD.
Generalizability of Individual and Group Therapy. Despite the reported effectiveness
of interventions, reports of generalization during treatment were only moderate. When studies
implemented follow ups, reports of generalization were considered poor. However treatments
that utilized multiple settings during treatment did report higher generalization, than studies that
provided treatment in one setting. Further research has proposed the idea that poor generalization
of learned skills for high functioning autistics is due to a specific deficit of ASD. Plaisted (2015)
theorized that individuals with ASD lack the ability to identify similar stimuli in different
settings. Because of this deficit, these individuals have difficulty appropriately applying learned
behaviors outside of training environments. Stokes and Bear (1977) infer that generalization of a
behavior must be “actively programmed” during intervention. Future social skill intervention
may benefit from employing explicit generalization techniques, from established literature that
have resulted in successful generalization of skills.
Limitations. Literature regarding the true effectiveness of group and individuals social
skills training is limited. This is mainly due to deficits in the study methodology. Specifically,
results of treatment were typically measured through questionnaires, feedback reports, and
observation. These measures only employed feedback from either a parent, teacher, or in few
cases the participant themselves. The majority of observations made during treatment were by
the study’s staff and researchers. These means of data collection are subject to bias and can
heavily influence the perception of treatment effectiveness. Future observer reports should
incorporate a blind rating by the study staff. Staff would then be blind to which participants
where included in which treatment group and phase of study. This would help to eliminate
potential rating biases. Lastly, many of the studies in this review employed training mainly
through learned behavior of social performance. Studies would benefit more from self report of
participants in order to gauge true developments in the participants social knowledge.
Future Implications of Research. Future research in social skills intervention could
benefit from improved methodology. Currently, the established research has not been grouped in
such a way that identifies the key characteristics of social skills intervention that improve the
efficacy of a program. While including a parent component in interventions has been recognized
as an effective method of generalizing learned social behaviors in the home environment, other
measures should be taken to ensure generalization across multiple settings. The development of
more reactive and multi dimensional assessments is necessary in order to truly gain an
understanding of specific aspects of treatment that influence social skill acquisition in HFA.
Ideally future research and intervention of the effects of social training in group and
individual settings would utilize a randomized control trial design. HFA adolescents would
receive an extensive intervention in phases that focused on a dual understanding of social
knowledge and social performance. The independent variable of the study would be the setting of
training (group or individual training). The dependent variable would be the effects on social
skills. The control groups for the study would consist of individuals who received delayed
treatment of intervention. In order to combat the shortcomings of previous studies, this
intervention would employ a variety of tactics to improve effectiveness as well as generalization.
For instance during intervention, one weekly session a month could take place in a novel
environment (park, school campus, social event). This would allow participants to practice and
generalize social skills in unfamiliar environments with strangers. Similar to the PEERS
program, a concurrent intervention for parents of participants could help educate parents on how
to improve the child’s social knowledge and practice social performance outside of intervention.
Finally, assessment measures would include self report questionnaires for participants. Use of
these self reports could be used to gain a better understanding of which aspects of intervention
the participant perceived as helpful in improving social knowledge and performance.
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