Unless you are a hermit,
you’ll need social-pragmatic skills.
But what happens when someone visits you?
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Schools and Institutions
Frustrated? We can help your school meet the unique needs of this population.
Adult Issues
We can help adults and/or couples having employment and social difficulties.
School Age Issues
We can help increase social-pragmatic communication skills so they can make and keep friends and increase academic success
Rationale
We can help you understand the intent behind the Individual’s with Disabilities Education Act – the driving force for Special Education in the schools as well as how our techniques used in treatment meet Evidence Based Learning standards.
We know you have lots of questions and invite you to contact us. All therapy is virtual using a varity of platforms.
“The most perfect technique is that which is not noticed at all.”
Pablo Casals was speaking about music but the same can be said about social-pragmatic communication.
Most people do not think about social-pragmatic communication skills... until something goes wrong. Few of us actually need instruction in this area. However, for some individuals, inappropriate social pragmatic communication skills impact their ability to make and keep interpersonal relationships. Structured assistance on developing the fine art of social skills is a necessity.
We simply don’t pay attention to good social skills
Think about it, you don’t really pay attention to good social skills. You only pay attention to bad social skills. You don’t notice everyone in the mall. You only notice the guy with blue spiked hair or the extremely loud group of teens enjoying themselves. A person has to do something that draws our attention because it wasn’t what we expected.
When was the last time you said to someone “I really enjoyed our conversation. You remained on topic and used good eye contact?" We don’t say things like that because it is expected that you will. But if you make a social blunder in a presumed social-pragmatic communication rule, then those around you will immediately have negative thoughts about you … and if this blunder was their first impression of you, studies show it will require 8-12 consecutive good interactions with you before that impression is erased. How likely is the individual with social-pragmatic communication deficits able to remain with socially expected boundaries for 8-12 consecutive interactions? Do you see why appropriate help is needed?
It’s best to know the rules before you get in the game
It’s not what you say but how you say it!
Body language, facial expression, vocal tone, recognizing and expressing emotions, using appropriate conversation and communication skills all directly impact interpersonal relationships. Therapy for social-pragmatic communication skills is designed to target these areas in a meaningful manner.
Therapy addresses three areas of social deficiency:
• Social Interaction
• Social Communication
• Social Emotional Regulation
Social Interaction
Social Interaction concentrates on developing interpersonal relationships – how to join in a group, being left out, the difference between requests and demands, how to agree/disagree, apologizing, fitting in, and caring/sharing are just some of the areas addressed.
Social Communication
Social Communication addresses initiating, maintaining, and ending a conversation; the different responsibilities between speakers and listeners, what to do when things go wrong (aka Repair Strategies), body language, and facial expressions
Social-Emotional Regulation
Social-Emotional Regulation focuses on recognizing emotional states in both yourself and in others, expressing these emotional states using socially appropriate means, and maintaining self-control.
Theories Impacting Therapeutic Intervention
How many times have we heard the question "Why do they act that way?" While we may never truly know why, four major theories relative to social interaction may hold a clue. By looking at the individual's behavior using these four conceptual models, we may have a better starting place for intervention.
In John Elder Robison's wonderful book, Look Me In The Eye: My Life With Asperger's, he describes an incident where he was on a playground and observed another child playing with a toy truck - but the child wasn't playing with the truck in the correct manner. So John decided to show the child how to correctly play with the truck and snatched it away from the other child without ever explaining what his intentions were. This caused the child to cry and John wanted to console the child. He remembered that his dog likes to be petted when upset, so he decided to pet the child. However, due to his difficulty with depth perception and motor planning, his "petting" was more like slapping which caused the child to cry even more. Remembering that he too, doesn't like to be touched by others (a sensory processing concern), he decided to use the nearby stick to pet the child. The teacher saw what was happening and punished John. In her eyes, John's behavior was viewed as abusive and punishment was swift in coming. However, in John's eyes, his behavior was an attempt at both instructing and consoling another child. Punishment would not "fix" the problem and it is likely that it would happen again.
If the teacher had attempted to view what John was doing using these theories as an attempt to understand his perspective, then more appropriate intervention could have been provided. Try to view the individual’s behavior in light of the following four theories as they may provide a different perspective on the reason behind the behavior. In almost all cases, what the individual is doing makes perfect sense to him/her and is an attempt to be social. However, what we see is often perceived by us as something entirely different – and in most cases described as inappropriate. By asking “What were you trying to do?” you may discover the individual’s true intent and avoid all the arguing.
The following four theories offer a description as to how they impact individuals with Social-Pragmatic Disorders:
Theory of Mind
For individuals with Theory of Mind (ToM) deficits, the ability to take on another person’s perspective is extremely difficult. They may not recognize that not everyone thinks like they do. Many often have an inability to realize their actions (or lack of actions) impact another person’s desire to want to be their friend (or why they do not want to be their friend).
In the above story by John Elder Robison, the student was unable to fully understand the teacher’s peception of what was happening. He never took on her perspective. Had he done so, he likely would have explained what he was doing and why, which likely would have drastically altered the outcome.
Central Coherence
For individuals with Central Coherence deficits, the ability to integrate details into a bigger picture is difficult. They may have an inability to integrate information into the “Big Picture” and get consumed with details.
Phrases like “You always/never…” seem to constantly create difficulty. For example when a wife says “You always leave the toilet seat up,” the husband knows she does not mean 100% of the time. It is understood that she means he often does it (or at least enough to draw her attention to it)!
But for many individuals with Central Coherence difficulty they may reply “No, I don’t…” (knowing that June 18, 2018 I did remember to put it down!) Unfortunately, this may be met with “Stop arguing with me!” to which he may reply “I’m not,” (but the unspoken finish to his statement could be, “I’m just helping you get the details straight!”
Because all words are equally important these individuals often have difficulty summarizing. They may provide a prologue to help one understand the context of their statement, get distracted and start side stories due to the use of too many details, finally remember they are off track, return to the original story, perhaps recognize their conversation is taking too long (but often they do not), try to wrap it up and get to the point, and then apologize and feel bad about themselves for their conversational inefficiency.
Executive Function
Executive Functions are concerned with organization – how one processes, plans, and utilizes a procedure to complete a task. It may be seen in:
• Flexibility of Thought: can’t shift thoughts, change ideas, hyper-focus on specific topic
• Identification of Relevance: hyper-focus on details, can’t see the “Big Picture”
• Experiential Learning: inability to identify what works and what doesn’t, applying a skill to a new situation, seeing the similarity in one task in a new task
• Goal Focus: not realizing how long a task will really take to complete, not realizing how long one has been at a particular task at the expense of other tasks (was planning on getting to homework but played on computer too long)
Emotional Intelligence
Emotional Intelligence is the ability to perceive, identify, and manage emotions on a personal and social level. Manifestation in Personal Competence may be seen in 3 areas:
1. Reduced Self-Awareness:
• Inability to recognize one’s own emotions and their effects
• Inability to know one’s own strengths and limits
• Inability to be sure about one’s capabilities
2. Reduced Self-Regulation:
• Inability to manage disruptive emotions and impulses
• Inability to be honest
• Inability to be responsible for one’s own actions
• Inability to be flexible and open to new ideas
3. Reduced Self-Motivation:
• Inability to meet or exceed a standard of excellence
• Inability to embrace the goals of the group
• Inability to act on opportunities
• Inability to continue a goal despite setbacks
Manifestation in Social Competence may be seen in two areas:
1. Reduced Social-Awareness:
• Inability to recognize others’ feelings and perspectives
• Inability to anticipate, recognize, and meet the needs of others
• Inability to recognize what others need to enhance their abilities
• Inability to embrace multiculturalism to develop positive opportunities
• Inability to recognize a group’s emotional currents and power relationships.
2. Reduced Social-Skills:
• Inability to be an effective persuader
• Inability to express oneself clearly and effectively
• Inability to inspire and guide individuals and groups
• Inability to initiate changes in a positive manner
• Inability to negotiate and resolve differences
• Inability to nurture appropriate relations • Inability to collaborate and cooperate effectively
Retaliation
Ever wonder why someone with social-pragmatic communication deficits (especially if they are secondary to hfASD) seems to continually want to get the last say in an argument or why he would say things to family members that he would never say to his teacher? In my practice I frequently encounter these situations. Parents are frustrated because it seems to them that their child has a complete disrespect for them and not others. How then does this happen?
First one has to realize that this is a neurodevelopmental disorder. In short, the individual’s brain is wired differently than others. This difference causes him to look at the world in a different manner. His perception of a situation may be extremely different than someone else’s. Hence, others may see his reaction to a situation as completely inappropriate.
Now stop and think of the countless times he attempted to interact with another individual and was unsuccessful. In most instances, the rejection was intense and humiliating. Add to this situation, the fact that he likely was not trying to be irritating or rude but in his opinion, was wrongly accused of doing so. It doesn’t come as a surprise that he may begin to think the world is out to get him.
This distortion in cognition creates dysfunctional thinking in which his assumptions about others are often incorrect. His ability to perceive a situation as an accident or a deliberate attack becomes difficult to differentiate. The outcome typically is to assume any comment, interaction, look, etc. is being done with malice toward him. His reaction often leads to retaliation in which he attempts to inflict an equal amount of pain on his “offender” who perceives the situation as something “out of the blue.”
Due to faulty central coherence, his definition of words is very specific and he cannot perceive the broader aspect of how the word takes on a different meaning based on context. Neurotypicals (those people who do not have ASD) use a much more relaxed, “loosey-goosey” interpretation of definitions and immediately know the phrase “You always…” really means “You usually…” But for these individuals, the definition is very specific. This leads to what parents define as an argument to which he will get upset and often respond that he’s not arguing which only increases the “argument.” I am forever interjecting into these interactions between the parent and child with the phrases “So how do you define that word?” Doing so often reduces the social friction. Not doing so allows the perception of the interaction to change from a “discussion” about the definition into an accusation of oppositional behavior and insubordination with likely references to previous similar situations.
What then should we do to help him see that his perception of the situation is very different than another person’s perception? Try these strategies:
1. Get him to see the “Big Picture” and not focus on the minutia. How many times do we explain using a similar example and his reaction is “But I don’t do that!” Correct, you may not do THAT but how does this example compare to the concept of what is being discussed. “Correct, you didn’t hit your brother with the branch from the oak tree. It was a branch from a maple tree!” Most people can immediately see the intent behind the comment – the “Big Picture.” He seems to focus only on the difference and can’t get past that. Try to help him develop flexible thinking.
2. Use visuals to help him process the concept. These may be flow charts, diagrams, and Comic Strip Conversations.
3. Do not fall into the trap of the “argument.” Quickly defuse the potential for escalation by asking him to define his interpretation of the “offending word.” This in turn, allows for a conversational repair in which the parent can redefine or explain their intention and hopefully allow the child to understand the true intent and not get hung up on the details.
4. Teach relaxation techniques to help him be calmer. He is likely to be on edge just waiting for the inevitable. This paranoid-like thinking increases his social anxiety and ultimately makes his interaction with others more difficult.
5. Get him to incorporate physical exercise into his daily activities to increase blood flow to the brain. Aerobic activity will have a positive effect on reducing stress that will lead to an easier time trying to correctly perceive situations.
Diagnosis
Social difficulties can result from a wide variety of diagnostic factors. Certain medical conditions, such as Autism Spectrum Disorder and Schizophrenia, will consistently present with social deficits, as they are an integral component in the diagnostic profile. However, other medical conditions such as Attention Deficit Disorder, Bipolar Mood Disorder, and Anxiety Disorder, may also present with impaired social skills. Bear in mind that a social-pragmatic communication deficit can be present without a medical diagnosis. The American Psychiatric Association, in their recent revision to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) has now included the diagnostic label Social (Pragmatic) Communication Disorder to represent individuals who have difficulties in social relationships that result in functional limitations in effective communication, social participation, academic achievement, or occupational performance, alone or in any combination. Be aware that there is a difference between a medical diagnosis and a public school evaluation. Only appropriately licensed professionals can make a medical diagnosis of Autism Spectrum Disorder, etc. The public school assessment is designed to determine if a child meets eligibility standards to receive special education services, it does not provide for a diagnosis. Also note that the term “Autism” is found in both the educational and medical models but does not mean the same thing. Check your State Department of Education’s definition for autism as each state uses different definitions as to what features must be present for the use of this label.
Are Social Skills Groups the Answer?
That, in a nutshell, is the $1,000,000 question. Many commercially available programs for social skill groups are often inefficient when working with these individuals because they do not address the underlying causal factor. Most of us are quick to realize what someone really means when they say “Quit being a jerk.” Unfortunately for many individuals with social-pragmatic communication deficits they do not rapidly realize how to repair this social breakdown because they think they are doing the right thing at that time.
Even more troubling are the findings of a study (Journal of Remedial and Special Education, June 2007) that outcomes for social skills training are largely ineffective due to minimal generalization into functional daily use. Practice does not make perfect. Bad therapy just increases anxiety and possibly paranoia. The group leader must be aware of the inherent difficulties in generalization or functional gains will continue to remain elusive.
In this office, the concept of social skills using a meta-cognitive approach (always thinking about me and how I relate to my surroundings) is continually stressed. This allows for greater functional generalization of social skills.
Evidence Based Practice
According to the American Speech-Language-Hearing Association (ASHA), Evidence-Based Practice (EBP) is "The integration of (a) clinical expertise, (b) current best evidence, and (c) client values to provide high-quality services reflecting the interests, values, needs, and choices of the individuals served." Unfortunately, many individuals and school systems, confuse a Randomized Controlled Trial (RCT) with Evidence-Based Practice. Randomized Controlled Trials are studies in which people are assigned at random to receive one of several treatment conditions, including the experimental treatment and either a different type of treatment or no treatment. Outcomes of such studies allow for a comparison of the treatment under question with other interventions.
These studies are often viewed as the "gold standard" for clinical research as they are designed to eliminate bias when determining clinical efficacy. Randomized Controlled Trials are not the only means to establish Evidence-Based Practice. Evidence-Based Practice decisions are used when making assessment and intervention decisions on a daily basis. These decisions require an integration of clinical expertise, theoretical knowledge, client preference, and empirical research. As such, it "...should be evident that EBP does not refer to a singular focus on using research to make decisions about children (Justice, L. and Fey, M., 2004). Therapists in all settings are rightfully being held accountable to deliver instruction and intervention that demonstrates efficiency and effectiveness. Unfortunately, in their drive to meet these standards, they may place a singular focus on evidence and research. A good clinician knows that evidence-based practice is supported through a variety of factors.
How then, does one decide if a treatment option is evidence-based? One of the techniques developed by Timothy P. Kowalski is the use of The Zone (Kowalski, 2011). Let’s analyze how the American Speech-Language-Hearing Association’s (ASHA) four steps can be used in the decision process:
Step 1 requires a Framing of the Clinical Question. It addresses four areas: Population, Intervention, Comparison, and Outcome (PICO). The first part of the EBP determination, could be written as, "Are patients with Social-Pragmatic Communication deficits who received treatment using The Zone, more or less likely to achieve functional social pragmatic communication than those who did not?" It addresses each of the PICO concerns.
Step 2 requires Finding the Evidence relevant to the clinical question. This may be through systematic reviews and individual studies. Use of The Zone incorporates a visual support to help achieve social success by increasing joint attention. According to ASHA, "visual supports include objects, photographs, drawings, or written words that act as cues or prompts to help individuals complete a sequence of tasks/activities, attend to tasks, transition from one task to another, or behave appropriately in various settings." A systematic review supports the efficacy when using The Zone in a variety of articles, one of which is Knight and Sartini's (2015) article entitled “A Comprehensive Literature Review of Comprehension Strategies in Core Content Areas for Students with Autism Spectrum Disorder” published in the Journal of Autism and Developmental Disorders which reviewed single case design and group studies. Findings indicated that visual supports can be considered established interventions to teach comprehension skills across content areas. Another study that reviewed research literature showed strong supporting evidence for joint attention strategies to improve social communication in young children with Autism Spectrum Disorder (Tanner, Hand, et al., 2015).
Step 3 requires one to Assess the Evidence. Is it consistent with question being asked? The behavioral range of Autism Spectrum Disorder is extremely vast and constitutes individuals from extremely mild to profound. As such, literature reviews that focused on the more profoundly impaired individual should be excluded when determining EBP for our question. Another concern is to determine who wrote and published the review. This is designed to tease out investigator bias. Looking at the above referenced studies, both supportive studies were meta-research based designs that looked at a number of studies to determine efficacy. Step 4 requires one to Make a Decision. The combined use of clinical expertise, the patient's perspective and the available scientific evidence is used to determine if a specific approach may benefit a particular client. As a result of the EBP decision making process, it becomes apparent that use of The Zone is consistent with external scientific evidence and as such merits Evidence Based Practice.
Professional Communication Services, Inc.
Timothy P. Kowalski, M.A.,CCC-SLP, ASDCS