Most people do not think about social skills... until something goes wrong. Few of us actually need instruction in this area. However, for some individuals, inappropriate social skills impact their interpersonal relations. Structured lessons on developing the fine art of social skills are a necessity.
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 AttentionDeficit 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 Asperger syndrome, Autism Spectrum Disorder, etc. The public school evaluation is designed to determine if a child meets eligibility standards to receive special education services. Also note that the term “Autism” is found in both delivery models but does not mean the same thing. Check your State Department of Education’s definition for autism as each state uses different definitions.
That, in a nutshell, is the $1,000,000 question. Many commercially available programs for social skill groups are inefficient when working with individuals having Asperger syndrome because they do not address the underlying causal factor. Many people with Asperger syndrome do what they do because they think they are doing the right thing at that time. Sadly, those of us who do not have Asperger syndrome (known as “neuro-typicals” or NTs) are quick to realize these social blunders. Even more troubling are the findings of a recent 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. The group leader must be aware of the inherent difficulties in generalization or functional gains will 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.
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 - especially 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, "...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).
"School systems are being held accountable to deliver instruction and intervention that have demonstrated 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 the use of The Zone (Kowalski, 2011) meet EBP? The American Speech-Language-Hearing Association (ASHA) uses four steps 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 Asperger Syndrome 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) 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 ASD (Tanner, Hand, et al., 2015).
Step 3 requires one to Assess the Evidence. Is it consistent with question being asked? The range of Autism Spectrum Disorder (ASD) is extremely vast. As such, 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.
Timothy P. Kowalski, M.A.,C.C.C.
1401 Edgewater Dr., Suite A • Orlando, FL 32804 • 407-245-1026