Elsevier

Clinical Psychology Review

Volume 52, March 2017, Pages 164-181
Clinical Psychology Review

Review
Efficacy of group social skills interventions for youth with autism spectrum disorder: A systematic review and meta-analysis

https://doi.org/10.1016/j.cpr.2017.01.006Get rights and content

Highlights

  • Meta-analysis of Group social skills interventions (GSSIs) for youth with ASD.

  • GSSIs have a medium overall effect size, but there is potential publication bias.

  • Parents and observers reported small effects, teachers reported null effects.

  • Self-report effects were attributable to improved social knowledge, not behavior.

Abstract

Group-based social skills interventions (GSSIs) are widely used for treating social competence among youth with autism spectrum disorder (ASD), but their efficacy is unclear. Previous meta-analysis of the literature on well-designed trials of GSSIs is limited in size and scope, collapsing across highly heterogeneous sources (parents; youths; teachers; observers; behavioral tasks). The current meta-analysis of randomized control trials (RCTs) was conducted to ascertain overall effectiveness of GSSIs and differences by reporting sources. Nineteen RCTs met inclusion criteria. Results show that overall positive aggregate effects were medium (g = 0.51, p < 0.001). Effects were large for self-report (g = 0.92, p < 0.001), medium for task-based measures (g = 0.58, p < 0.001), small for parent- and observer-report (g = 0.47 and 0.40, respectively, p < 0.001), and nonsignificant for teacher-report (p = 0.11). Moderation analyses of self-report revealed the effect was wholly attributable to youth reporting that they learned about skilled social behaviors (social knowledge; g = 1.15, p < 0.01), but not that they enacted them (social performance; g = 0.28, p = 0.31). Social skills interventions presently appear modestly effective for youth with ASD, but may not generalize to school settings or self-reported social behavior.

Introduction

Impairment in social functioning is the defining feature of autism spectrum disorder (ASD). Youth with ASD are at increased risk for social isolation and peer victimization (Hobson, 2014, Mendelson et al., 2016). Moreover, social impairments in youth with ASD do not tend to improve merely with development, but rather may become more pronounced during adolescence when the social demands exceed the social skills (Picci & Scherf, 2015), underscoring the need for appropriate interventions to promote social competence in this population.

Group-based social skills interventions (henceforth referred to as GSSIs) are the most widely used approach to address social impairment and foster social skills development in school-age and teenage youth with ASD (McMahon, Lerner & Britton, 2013). As such, it is vital to know the degree to which, and according to what metrics, GSSIs yield benefits. However, despite their widespread use, very little rigorous, well-designed research has been conducted to examine their efficacy (Kasari, Shire, Factor, & McCracken, 2014). Indeed, while there have been more than a dozen systematic reviews of GSSIs conducted in recent years (e.g., Barry et al., 2003, Blacher et al., 2003, Elder et al., 2006, Flynn and Healy, 2012, Kaat and Lecavalier, 2014, Kasari and Patterson, 2012, Koenig et al., 2009, McMahon et al., 2013, Miller et al., 2014, Otero et al., 2015, Rao et al., 2008, Reichow and Volkmar, 2010, Schreiber, 2011, Spence, 2003, White et al., 2007), there has only been one meta-analysis to evaluate efficacy of GSSIs (Reichow, Steiner, & Volkmar, 2012). This sole meta-analysis – which focused on well-designed randomized controlled trials (RCTs) with a wait-list control, of which only five were evident at the time – provided initial support for the efficacy of GSSIs for improving social competence for ASD youth. Due to the very small number of included trials, though, little beyond a headline effect size (g = 0.47) could be determined. However, in the years since, the number of published RCTs of GSSIs has tripled, making evaluation of overall efficacy of GSSIs timely and vital, and facilitating the possibility of a more robust, comprehensive, and precise estimation of their efficacy. Additionally, as evidence of efficacy accumulates, and sufficient studies are available, it is important to identify moderating factors that may influence the strength of intervention effects. Further, extensive literature demonstrates that complex skills expressed in youth are rarely unitary in nature, and so meaningful information can be obtained by disaggregating these constructs into constituent assessments obtained via multiple informants and other sources (De Los Reyes et al., 2015). This information may reveal informative circumstantial variations in expression of skills, especially for highly contextually-dependent domains such as social skills in youth with ASD (De Los Reyes, 2011, Lerner et al., 2012, Murray et al., 2009). Hence, the current meta-analysis sought to ascertain overall efficacy of GSSIs and whether the intervention effects differ by reporting sources.

The sole small previous meta-analysis of GSSIs for youth with ASD found a medium effect, primarily according to parent report (Reichow et al., 2012). This effect was comparable to the mean ES found for behavioral interventions impacting social skills for individuals with ADHD (g = 0.47; Daley et al., 2014) and social skills treatment for individuals with schizophrenia (g = 0.52; Kurtz & Mueser, 2008), but somewhat larger than that found in social skills treatment for youth with learning disabilities (g = 0.21; Forness & Kavale, 1996). Despite these promising results, the study contained only four studies, reflecting the limited state of the literature at the time. As a result, it was unable to consider any potential predictors of variation in effects or test for publication bias, and failed to consider variation in the reports of social competence change across different informants.

Although individual studies have yielded some support for the efficacy of GSSIs (e.g., Koning et al., 2013, Lopata et al., 2010), results have not been consistent. One evident source of this variation is the outcome of interest – that is, the source of information on social functioning (e.g., Koning et al., 2013, Laugeson et al., 2009). Such a finding is not uncommon. Indeed, extensive literature has consistently shown that ratings of child symptomatology vary between various reporting sources (De Los Reyes et al., 2015). These differences reflect the complex nature of “social skills” and may reveal important and meaningful information about contextual variations in the expression of skills and in the perceived impact of the intervention (Koenig et al., 2009, Lerner et al., 2012). Understanding the shape and nature of changes in GSSIs according to different informants not only offers practical information about what outcomes can be affected, but also provides deeper insight into the nature of the intervention itself and its mechanisms of action (Lerner, White & McPartland, 2012).

Hence, it is important to consider differences in assessment measures used to evaluate the efficacy of a GSSI, as the efficacy is dependent on the quality of assessments (McMahon, Lerner et al., 2013). In fact, GSSIs commonly utilize various sources to assess efficacy. Parent-report questionnaires, in which parents rate broad metrics of frequency or quality of social behavior across windows of time ranging from several days to several months (e.g., Constantino and Gruber, 2007, Gresham and Elliott, 1990, Reynolds and Kamphaus, 2004), are one of the most regularly utilized assessment methods, owing in part to easy and quick administration. Teacher-report questionnaires, in which teachers rate broad metrics of frequency or quality of social behavior as they appear in the classroom (e.g., Gresham and Elliott, 1990, Pekarik et al., 1976), are frequently used to gather information about child's functioning in school settings. Participants themselves also frequently rate their social competence, via questionnaires, where participants rate broad metrics of frequency or quality of their own social behaviors as they perceive them to be occurring (e.g., Gresham and Elliott, 1990, Reynolds and Kamphaus, 2004) and indicate their own social knowledge, whereby participants indicate what they believe is the right thing to do (regardless of whether they believe they themselves do it) in various social situations (e.g., Laugeson and Frankel, 2006, Lopata et al., 2008). Participants also complete task-based assessments that are often aimed at measuring specific skills related to social competence, such as social cognition, emotion recognition, and social response planning (e.g., Nowicki, 2004, Sofronoff et al., 2011). Observer-report measures in which (typically blinded) independent, trained observers evaluate and rate the frequency or quality of social behaviors of the participants in either naturalistic (such as playgrounds) or structured (such as lab-based interactions) settings (e.g., Koning et al., 2013, Lerner and Mikami, 2012), are also used, though not as commonly as parent or teacher ratings (McMahon, Vismara & Solomon, 2013). Some observer-report measures are uniquely designed by the intervention staff to assess participant's behavior (Kamps et al., 2015, Rodgers et al., 2015), whereas others are standardized across settings (e.g., Bauminger, 2002). Therefore, examining change in ratings of social competence as a result of these interventions by different sources is useful to gain a clear understanding of GSSI outcomes.

The mixed results of individual studies may also be due to differences in participant or intervention-related characteristics – that is, plausible moderators (Kazdin, 2007, Lerner and White, 2015, Lerner et al., 2012). Indeed, GSSIs vary widely according to a broad range of characteristics, from participant age to length of treatment to the cognitive profile of the participants (McMahon, Lerner et al., 2013). This heterogeneity invites the likelihood that such factors may contribute to differences in intervention efficacy. Therefore, we consider factors that may moderate the effects of GSSIs, which can help to better identify efficacious methods of GSSI as well as for whom, and under what conditions, these interventions are best suited (Kazdin & Nock, 2003).

The target age range of GSSIs can vary widely (e.g., Ichikawa et al., 2013, Laugeson et al., 2015). Several studies have shown different effects of GSSI by age, though these findings are inconsistent. For example, some have indicated relatively greater improvements in older participants (e.g., Herbrecht et al., 2009, Mathur et al., 1998), while others suggest greater benefits for younger children in some approaches (McMahon et al., 2013, Wang et al., 2011). Considering the inconsistent findings of the effects of GSSIs for each age group, it is currently unclear whether effects should be larger or smaller among older youth, but is vital for guiding service recommendations.

Participants in GSSIs are generally thought to exhibit average to above-average cognitive ability (McMahon, Lerner et al., 2013), however, participants above this level still display a wide range of overall cognitive and verbal ability (Lerner & White, 2015). Research has shown that more cognitively-able participants with a higher IQ and better verbal ability have demonstrated greater improvements in emotion recognition (e.g., Solomon, Goodlin-Jones, & Anders, 2004) and benefit most from participating in a GSSI (Herbrecht et al., 2009). Therefore, participants with higher cognitive and verbal ability may show greater improvements after participating in the GSSI.

In addition, males and females with ASD may have unique social challenges that could potentially moderate treatment outcomes (Dean et al., 2014). However, while many interventions do include at least a few female participants, there has rarely been sufficient sample size in an individual study to empirically examine effects of gender on treatment outcomes. Intriguingly, the one study that examined gender effects of a GSSI showed relatively greater improvements in girls (McMahon, Vismara et al., 2013). Owing to the dearth of evidence of gender on the outcomes of GSSI, it is unclear whether effects are indeed larger in females than males, but current clinical practice urges examination of potential differences.

Individuals with ASD commonly experience other comorbid psychiatric conditions (Simonoff et al., 2008) that may affect treatment outcomes. There is strong reason to believe this may be the case for GSSIs. For example, one study found that those with ADHD comorbidity showed less improvement in social skills, while those with anxiety comorbidity showed greater improvements (Antshel et al., 2011). A more recent study found attenuated effects associated with comorbid anxiety (Pellecchia et al., 2015). Therefore, there is evidence to suggest that participants with (versus without) psychiatric comorbidities (that is, the preponderance of ASD youth seeking GSSIs) should show less improvement in social competence following GSSIs.

Relatedly, psychopharmacological medication is often prescribed to youth with ASD due to frequent psychiatric comorbidities (Malone, Maislin, Choudhury, Gifford, & Delaney, 2002). The literature investigating the effects of medication on interventions has been inconclusive, with some showing greater improvements in a medicated group (Herbrecht et al., 2009) and others showing greater improvements in an un-medicated group (Frankel, Myatt, & Feinberg, 2007). Given the current evidence, it is unclear whether effects should be larger or smaller among participants who are on psychopharmacological medication, but the high rate of medication use necessitates their investigation.

GSSIs for youth with ASD show a wide range of variation in their content, type, structure, and therapeutic targets. For example, the length of interventions often varies dramatically, ranging from a few weeks to spanning two academic years (e.g., Kamps et al., 2015, Lopata et al., 2010). Moreover, while the majority of GSSIs are conducted for 1- to 2-h weekly sessions, there are more intensive interventions, often during the summer, that meet for 5–6 h/weekday for several weeks (McMahon, Lerner et al., 2013). There has been a recent effort to evaluate how duration/intensity of an intervention may be associated with intervention efficacy (i.e., “dose-response relationship”; Turner-Brown, Perry, Dichter, Bodfish, & Penn, 2008), however results of this investigation are mixed. While in one study intervention length was not correlated with social improvement (Tyminski & Moore, 2008), another study found greater increase in peer interactions among those who attended more intervention sessions (McMahon, Vismara et al., 2013). Considering the inconsistent findings, it is currently unclear whether effects should be larger in longer or more intense interventions, but guidance is needed for service providers to optimize dosage (and minimize costs) to individuals and families.

In some cases, non-ASD youths of similar age participate in GSSIs as peer tutors or peer models (Kamps et al., 2015, Wang et al., 2011). This strategy involves the use of socially competent students to model, interact, and occasionally use intervention strategies to promote social skill development in individuals with ASD (DiSalvo and Oswald, 2002, Rogers, 2000). Although a meta-analysis of single-subject research studies showed evidence that peer-mediated intervention may be an effective strategy for social skill deficits (Wang et al., 2011), the impact of such peers as an adjuvant in the context of a group intervention has not explicitly evaluated, and it is unclear whether it is an effective treatment component (Kaat & Lecavalier, 2014).

GSSI strategies often vary in terms of the specific content they focus on. That is, some focus (at least in part) on didactically presenting information about correct behaviors in social contexts (i.e., social knowledge training), while others aim more squarely on providing a context in which successful peer interactions may occur and reinforcing them when they happen without prescriptive teaching of rules (i.e., social performance; Gresham, 1997, Lerner and Mikami, 2012, Lerner and White, 2015, White et al., 2007). As such, the specific content targeted in these GSSIs may be assessed using measures that aim to collect information on either gains made in the participants' self-reported social knowledge or social performance (i.e., enacted social behavior), which may conclude different information about the changes in skills of the participant as a result of the intervention. Though there is reason to believe that social knowledge and social performance may be independent constructs (Lerner and Mikami, 2012, Lerner and White, 2015, Lerner et al., 2012), many studies assess social knowledge and social performance together via self-report. Hence, it is important to consider whether there may be a difference between self-reported gains in social knowledge (i.e., knowing what to do in a social situation) and self-reported gains in social performance (i.e., applying the social skills and displaying appropriate social behaviors) when evaluating efficacy of GSSIs.

A crucial question when examining complex, group-based interventions such as GSSIs is whether group effect comparisons are valid and accurate. Most meta-analytic studies of RCTs examine treatment effects by using post-test scores to obtain standardized mean difference (SMD) between experimental and control conditions, based on the assumption that randomization will produce two equivalent groups (Durlak, 2009). However, especially for a complex construct like social competence that is both treated and measured in the context of other people (Koenig et al., 2009), intervention effects may be confounded by many unmeasured constructs (Rosenbaum & Rubin, 1983), which may lead to biased intervention effects. Meta-analyses of such interventions that examine treatment effects by comparing endpoint may be susceptible to such confounding (Preece, 1983). As such, it is especially crucial to not take for granted that the two groups are equivalent and consider whether the pattern of change itself over the course of intervention is different across the two groups.

Examining whether, how much, and according to whom GSSIs may be efficacious is essential for guiding delivery and improvement of this core clinical service for ASD youth. Thus, the present study first sought to meta-analytically examine the efficacy of GSSIs as assessed using well-designed RCTs according to the contemporary literature. Second, we aimed to consider whether these effects differed according to all known sources of information in the literature (parent report, teacher report, self report, observer report, measured behavior on a relevant task), as well as according to intervention characteristics, content, and change measurement.

Section snippets

Identification and selection of studies

The databases of PsycINFO, PubMed and Web of Science were searched using the following Boolean String: (ASD OR autism spectrum disorder OR Asperger OR autism OR pervasive developmental disorder) AND (social skills OR peer interaction OR social competence OR social functioning OR friendship OR social interaction OR social play) AND (treatment OR intervention) NOT (early intervention OR toddler OR early intensive behavior intervention) NOT (pharmacological OR medical).

Study selection and literature search

The systematic literature

Descriptive characteristics

For the 18 studies included in the overall meta-analysis, data were collected from 735 participants (see Appendix B). Sample sizes ranged from 11 to 97 participants, M (SD) = 40.83 (25.56). The age of participants ranged from 5.30 to 20.42 years, M (SD) = 10.54 (4.18). 33.3% of studies had study samples with > 90% male, and all other samples were between 50% and 90% male. The mean overall standardized cognitive ability of participants was 102.27, ranging from 87.55 to 112.45 across studies. The mean

Discussion

This study was the largest meta-analysis conducted to date evaluating the efficacy of GSSIs for youth with ASD. Moreover, this was the first study to examine effect sizes by varying reporting sources of social competence. Results indicated that GSSIs led to moderate overall improvements in social competence, reflected in data from parents, youth, observers, and tasks, but not teachers, supporting variations by reporting sources. Notably, the large self-report effect was wholly attributable to

Role of Funding Sources

JAG received support from the American Academy of Arts & Sciences; EK received support from the Simons Foundation Autism Research Initiative (SFARI# 381283); and MDL received support from NIMH grant R01MH110585, the Simons Foundation Autism Research Initiative (SFARI# 381283), Arts Connection, the Alan Alda Fund for Communication, and the Adelphi University Center for Health Innovation during the course of this project. These funders had no role in the study design, collection, analysis or

Contributors

JAG and MDL designed the study and wrote the protocol. JAG and EK conducted literature searches and provided summaries of previous research studies. JAG, EK, and MDL conducted the statistical analysis. JAG wrote the first draft of the manuscript, and all authors contributed to subsequent drafts, and have approved the final manuscript.

Conflict of Interest

The authors declare no financial or personal conflicts of interest.

Acknowledgements

The authors wish to thank the undergraduate and graduate students in the Social Competence and Treatment Lab, who provided valuable feedback on earlier drafts of the manuscript. They also thank Dr. Anne Moyer for her training and input on conducting the meta-analysis. Portions of these analyses were presented at the Autism & Developmental Disabilities Special Interest Group Preconference of the 2016 Association for Behavioral and Cognitive Therapies Annual Convention.

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