What Your Childs Therapist Can Offer

Parenting Children With Asperger's And High-functioning Autism

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Group Social Skills Training

Your family may have adapted to your AS-HFA child's social deficits, and therefore you might not consider the problem an enormous one at home in your daily activities. But social difficulties tend to be more pronounced in groups and with peers. So social problems may in fact be fairly significant for your child at school, at the local playground, or in a scout troop. We know that people with AS-HFA have trouble generalizing from one situation to another, so it's important to teach social skills in settings that are similar to those in which the children experience difficulty. When teaching social behavior to a child with high-functioning autism or Asperger syndrome, the therapist or teacher may be impressed by how fast the child learns new skills, only to be surprised later at how poorly these skills are used with peers. Thus, teaching in a group context is essential.

Formal instruction, with specific skills taught sequentially, is also important. Most parents are not equipped to deliver this type of instruction, so you will probably have to look for a group at an outpatient clinic or school, where the therapy will be delivered by a therapist or teacher. This does not mean, however, that you're not part of the process. As managers of your child's care, you should think of yourselves as consumers of the social skills training that teachers and therapists can offer your child. If the group training offered to your child diverges substantially from what we describe here, in ways that seem uncon-structive or counterproductive, you may want to look elsewhere for a different program or concentrate on other ways to teach social skills, outlined later in this chapter.

Unfortunately, there are currently very few published curricula to teach social skills to high-functioning children and adolescents with AS-HFA. Several social skills manuals for children with more general behavior or learning disorders do exist and can be helpful starting places for teachers or therapists wishing to design a curriculum for AS-HFA children (see the resource list in the Appendix), but often significant modifications are required to make the curriculum "autism-friendly."

As with interventions in the schools summarized in the last chapter, there are some basic principles for teaching social skills that capitalize on your child's strengths. We summarize these principles and give you examples of how they might be implemented in a therapy group in the box on page 192. Social skills training for children with AS-HFA should break down the complex social behaviors that most children learn automatically into concrete steps and rules that can be memorized and practiced in a variety of settings. Abstract concepts, like friendships, thoughts, and feelings, should be introduced through visual, tangible, "hands-on" activities as much as possible. For example, the therapist might hold a cardboard arrow at the side of your child's face, pointed at the person to whom he is speaking, to help him learn and practice eye contact. Written schedules use your child's natural reading abilities to help him or her transition from one task to another while minimizing anxiety. A predictable routine will capitalize on your child's memory and rule-following strengths to help him or her anticipate the different group activities. There should be a behavioral plan that specifies individual goals for group members and a specific system for delivering rewards. Social skills training will be difficult for your child and, as with all people, he or she may need to be enticed to participate in this less-than-favored and possibly very challenging activity.

A final important ingredient is collaboration with parents to promote generalization. Weekly therapy in a clinic will do little to change basic deficits of AS-HFA unless there is daily practice and reinforcement of the skills being learned in situations outside the therapy room. Thus, it is very important that you be aware of what your child is learning and that you be taught how to practice the skills or implement specific techniques at home, in the neighborhood, or at school. This may be accomplished partially through homework. It is also important that the therapists or teachers provide explicit opportunities to address the skills outside the group, in more natural settings for the child (for example, in the classroom, park, video arcade, bowling alley, or restaurant), perhaps through community outings. It is important that the teacher or therapist working with your child tell you how and where to

Make the abstract concrete.

Help with transitions.

Motivate.

Generalize.

Provide rules, such as "make eye contact for 5 seconds when you begin a conversation."

Break complex behaviors into steps, such as "a conversation consists of a beginning, a middle, and an end," and teach each step.

Use visual cues, such as a double-tipped arrow to depict the turn taking and back-and-forth of a conversation. Use hands-on activities to practice, such as role-playing a conversation.

Provide a written schedule that outlines the group activities in order. Use a predictable routine every session, such as an opening discussion, a group activity, a role play, a snack, jokes, and good-bye.

Set realistic goals for each child. Provide rewards for attaining goals.

Establish communication and collaboration between parents and therapists.

Give assignments to be completed outside the clinic, such as calling another group member and having a phone conversation. Take outings into the community to practice skills, such as having conversations at a restaurant.

help your child practice away from the clinic or school. If this is not happening, request a private session with the therapist or group leader. Say that you want to be more involved in your child's therapy and request specific assignments or procedures for following up on skills at home.

A variety of topics should be covered in any social skills group for children and adolescents with Asperger syndrome and high-functioning autism. Perhaps most basic is teaching the nonverbal behaviors that are important to social interaction, such as appropriate eye contact, social distance, voice volume, and facial expression. We call this social body language. A typical program might also include the following topics:

• Friendship skills: greeting others, joining a group, taking turns, sharing, negotiating and compromising, following group rules, understanding the qualities of a good friend.

• Conversational skills: starting, maintaining, and ending a conversation; taking turns talking; commenting; asking others questions; expressing interest in others; choosing appropriate topics.

• Understanding thoughts and feelings: showing empathy, taking others' perspectives, handling difficult emotions.

• Social problem solving and conflict management: coping with being told "no," being teased, being left out.

• Self-awareness: learning about autism spectrum disorders, personal strengths, unique differences, and self-acceptance.

Cognitive-Behavioral Therapy

Another clinic-based therapeutic model that may be useful to teach social skills to adolescents and young adults with AS-HFA (those who are able to tolerate a bit more abstraction) is called cognitive-behavioral therapy. It was originally developed to help people with depression, who are often highly critical of themselves, pessimistic, and likely to interpret neutral events in a negative light (the "glass-is-half-empty" kind of person). At the crux of this therapy is showing people how their thoughts influence their feelings and how negative "self-talk" is related to (even causes) feelings of sadness and depression. The antidote, in a cognitive-behavioral therapy model, is to learn more positive self-talk, changing negative thoughts into positive ones and learning new ways of thinking about the self and the world. Cognitive-behavioral therapy turned out to be remarkably effective and is still a widely used treatment for depression and other psychological disorders.

Cognitive-behavioral therapy helps people focus on the causes and consequences of their behavior, as well as on the emotions and thoughts that accompany their behavior. Its relevance to people with AS-HFA should be readily apparent. Often, those with high-functioning autism or Asperger syndrome have trouble reading the social cues in the environment accurately, resulting in odd or unexpected behavior. They often report difficulty understanding their feelings and trouble differentiating among similar emotions. For example, some people with high-functioning autism or Asperger syndrome say that they can tell when they feel "bad" but are not sure if they are sad or angry and, most confusingly, aren't sure why. And they often have poor understanding of the consequences of their behavior. So cognitive-behavioral approaches may be of some use for the autism spectrum disorders.

Josh, a 15-year-old with Asperger syndrome, came to group one day and announced that he had had a bad week because he got expelled from school. When queried about the circumstances, he replied simply that he had pushed another boy's head into a water fountain. No other explanation was forthcoming, and Josh seemed almost puzzled by what had happened. The cognitive-behavioral model was used to help Josh and the other group members understand the links among situations, responses, and consequences. The group leader stressed the importance of four aspects of Josh's situation: who, did what, when, and where. Josh began with a simple description: "This kid made me mad at school." With the structural aid of a written list, he was eventually able to describe many specifics of the situation: details about the boy involved, what he had done (he called Josh "fatso"), time of day, and exactly where the incident had occurred. The group then explored three aspects of Josh's response: his emotions, his actions, and his thoughts (or self-talk). While he could readily identify his actions (shoving the boy's head into the water fountain), his emotions (shame, embarrassment, and anger) and especially his self-talk were murky to him. Finally, the group discussed both the short- and long-term consequences of Josh's response. Josh had a clear understanding of one consequence (his expulsion from school), but seemed to have very limited awareness of other outcomes of his actions (for example, that the other boy had been injured and that Josh might be more likely to be teased again in the future because of his extreme reaction). Using a cognitive-behavioral model significantly improved Josh's understanding of the situation and his ability to prevent a recurrence in the future. The group also addressed ways to change Josh's response, including substituting more positive self-talk, using relaxation techniques, and alerting a teacher when faced with teasing.

Cognitive-behavioral therapy, delivered in either a group or an individual format, may be helpful for teens and adults with AS-HFA, not only because of the mood problems that are so common in this group, but also because of the explicit links this therapy model makes among situations, responses, and consequences, concepts that are difficult for those with autism spectrum disorders. Cognitive-behavioral treatment is more structured and concrete than other forms of psychotherapy. Relying less on insight and judgment than other treatment models, it focuses instead on practical problem solving, making it an "autism-friendly" form of therapy. However, cognitive-behavioral approaches are probably too complex for most younger children with Asperger syndrome and high-functioning autism, so it is best to wait until adolescence and adulthood, when abstraction ability matures, to try this type of treatment.

Implicit Didacticism

At the University of Washington, some therapists are developing an approach called implicit didacticism that uses the therapeutic relationship as a forum for modeling and teaching social skills. This strategy aims to help people with AS-HFA learn appropriate social skills through the therapist's demonstration of appropriate social behaviors in realistic social settings, such as a cafeteria or a store. Through this combination of social modeling, personal accounts of social dilemmas and their resolution, and feedback about observed social behavior, the therapist teaches individuals with AS-HFA appropriate social behaviors and the art of picking up on social norms through observation.

Perry, an 18-year-old boy with Asperger syndrome, sees his therapist weekly for a traditional "talk therapy" session. Each week they review his highlights of the week, as well as any difficult experiences. His therapist reinforces the successful strategies he has used and suggests alternative strategies that may be helpful for similar scenarios in the future. The therapy also provides a context for the therapist to observe and provide input about his style of social interaction. When he is looking off into space or fiddling with a pencil, the therapist's comment "Gee, I must be boring, you're not even looking at me" can elicit more appropriate social behaviors that can be practiced and reinforced immediately. When Perry began college, his therapy sessions occasionally took place on campus, in social settings that he had to learn to navigate. For example, a therapy session took place in one of the university's cafeterias, where the therapist modeled for Perry how to order food, how to treat the cafeteria staff politely and congenially, how to pay, and how to bus his tray when he was done eating. Perry's family has noticed that the skills addressed in this psychotherapeutic format have carried over into both family interactions and Perry's dealings with peers.

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