It has been a mixed blessing for children with Asperger’s Disorder or High Functioning Autism (ASD) to be placed in regular education classrooms (Burack et al. 1997
). On the one hand, such placement has been associated with increases in the complexity of their play and decreases in nonsocial activity when compared to how they behave in special education settings (Sigman and Ruskin 1999
). On the other hand, perhaps because these children are aware of their social limitations, they report feeling lonelier and having poorer quality friendships (Capps et al. 1996
), than their typically developing classmates (Bauminger and Kasari 2000
). They initiate and reciprocate peer interactions much less frequently than language-matched children with developmental disabilities (Hauck et al. 1995
; Sigman and Ruskin 1999
). In the absence of additional treatment, placement together with typically developing children has not been shown to increase social interaction (McConnell (2002
Learning to make and keep friends may be especially difficult for the child with ASD, since the natural development and transmission of necessary peer etiquette requires generally positive and sustained interaction with peers and learning from best friends. Continued isolation makes deficits in the knowledge of peer etiquette more obvious as the child with ASD gets older. Not surprisingly, as adults, many individuals with ASD consequently lack community connections and friendships that are taken for granted by typically developing persons (Baxter 1997
). Thus, teaching the skills necessary to make and keep friends has a significant life long impact for persons with ASD.
Best friendships among typically developing children become stable by about the fourth grade (Frankel 2010
; McGuire and Weisz 1982
). Having one or two best friends is of great importance to later adjustment, can buffer the impact of stressful events (Miller and Ingham 1976
), correlates positively with self-esteem and negatively with anxious and depressive symptoms (Buhrmester 1990
). In typically developing children, best friends may promote the development of social competence: while conflicts with acquaintances can decrease subsequent social interaction, conflicts among best friends and their resolution are associated with subsequent increases on measures of social problem solving (Nelson and Aboud 1985
Sigman and Ruskin noted that only 27% of children with ASD had a best friend while this applied to 41% of children with other developmental disabilities. There is considerable interest among clinicians in how best to help these often highly motivated children with their social difficulties and best friendships.
Recently, Bauminger et al. (2008
) have explored the best friendships of children with ASD. Although the sample was composed only of children who had at least one best friend and thus may not be representative of children with ASD, the results suggest that children with ASD may show greater social benefit from best friendships with typically developing children than with other children with disabilities. These “mixed” friendships were “…found to be more durable and stable and to exhibit higher levels of goal oriented social behaviors and positive affect. Friends in mixed dyads were more responsive to one another; showed higher levels of positive social orientation and cohesion, and demonstrated a more complex level of coordinated play than those in non-mixed dyads” (p.1224).
Much of the literature concerning difficulties of children with ASD specific to making friends has been based upon clinical observations and inferences from core deficits. Shaked and Yirmiya (2003
) noted that children with ASD tend to have an egocentric conversational style characterized by difficulties in conversational reciprocity. Bauminger (2007
) reviewed studies suggesting that initiating and sharing conversations are friendship skills deficient in children with ASD. Attwood (2000
) noted that children with ASD have difficulties sharing interests or enjoyment with others as well as specific deficiencies in how they attempt to join a group of children already at play (cf., also Bauminger 2007
). Prior et al. (1998
) noted that some children with ASD try to make friends but in a clumsy manner that is generally unsuccessful. Attwood (2000
) suggested that children with ASD lack what would be considered good host behavior on play dates, such as their inability to accept suggestions from their playmate, reciprocity and sharing with the play mate and conflict resolution skills.
The preponderance of research on social skills training for children with ASD has employed single case designs. Three recent reviews of this research have yielded different conclusions. Hwang and Hughes (2000
) reviewed 16 studies which treated children across a wide range of functioning, including children with ASD who were nonverbal and\or echolalic. Programs were typically embedded in every day activities in more naturalistic situations including peer-mediated interventions, as opposed to teacher-directed discrete trial settings. Generalization was reported in many studies and follow-up also tended to report maintenance of treatment effects. But measures of outcome were generally limited to circumscribed target behaviors rather than to friendship skills.
) developed a taxonomy of social skills interventions, dividing them into five categories: environmental modifications (physical and social environment), child-specific (training the child in specific skills), collateral skills (training play behaviors and language skills rather than direct training of specific skills), peer mediated (training non-disabled peers), and comprehensive interventions (combining two or more of these interventions). He used it to classify 55 studies of children with ASD, which included 157 participants younger than 9 years old. McConnell relied on the conclusions of investigators, and did not find differences in effectiveness between the different categories of interventions.
Bellini et al. (2007
), focused upon school-based approaches, for children with ASD using a standard metric to measure outcome. Bellini et al. concluded that there was minimal evidence for effectiveness of social skills interventions for children with ASD.
Much of the literature on social skills training for children with ASD has focused on interventions with younger children in the lower ranges of social functioning (Wolfberg and Schuler 1993
). Few social skills interventions have been devoted to investigating the efficacy of social skills training for children that are less socially impaired (Marriage et al. 1995
). Among the social skills intervention studies conducted with this population, most have not been formally tested in terms of improving social competence or the development of close friendships. A notable exception was Ozonoff and Miller (1995
), who taught five high functioning adolescents with ASD basic interaction and conversation skills and how to infer the mental states of others (Theory of Mind) over 14 sessions. Comparison with four non-treatment controls demonstrated significant improvement in false belief tasks in the treatment group only, but parent and teacher ratings of social competence did not improve. Moreover, the authors reported negative correlations between Theory of Mind scores and parent and teacher ratings of social skill.
Parent-assisted Children’s Friendship Training (CFT, Frankel and Myatt 2003
) contains modules that teach social etiquette and specific rules of behavior which are used by the peer group. This is a simple way for children with ASD to understand their social context. Targeted skills include conversational skills, peer entry, expanding and developing friendship networks, handling teasing, practicing good sportsmanship and good host behavior during play dates with friends.
Parents may have significant effects upon their child’s friendships, both in terms of direct instruction and supervision, as well as supporting their child’s development of an appropriate peer network (Frankel and Myatt 2003
). Parents are integrated into CFT within separate concurrent sessions. CFT addresses both a child’s reputation in the peer group as well as the development of a best friend through parent-structured and supervised play dates with children not in the treatment group which emphasize selecting typically developing peers as potential playmates.
The effectiveness of CFT has been demonstrated for children with ADHD (Frankel et al. 1995
; Frankel et al. 1997a
) and Fetal Alcohol Spectrum Disorders (O’Connor et al. 2006
). Results of these studies suggest that skills generalize outside the treatment situation and are maintained at least three months after treatment ends. The present study was intended to test the following hypotheses:
- Children who participate in CFT will show greater mean gains in indices of social skills, than a Delayed Treatment Control (DTC) group at post-test.
- Child measures of popularity and loneliness will show significantly greater mean improvement for the CFT than for the DTC group from baseline to post testing.
- Parent measures of play date quality and social skills will show significantly greater mean improvement for the CFT than for the DTC group from baseline to post testing.
- Teacher measures of peer relationships will show significantly greater mean improvement for the CFT than for the DTC group from baseline to post testing.
- The CFT group will maintain improvement in indices of social skills after a 3 month follow-up period.
- Child measures of popularity and loneliness will maintain improvement for the CFT group after 3 months follow-up.
- Parent measures of play date quality and social skills will maintain improvement for the CFT group after 3 months follow-up.
- Teacher measures of peer relationships will maintain improvement for the CFT group after 3 months follow-up.