"Andy" was diagnosed with an autism spectrum disorder (ASD) at 4 years of age. Throughout elementary school, his parents expressed concern that Andy was constantly being teased by his peers and rejected on the playground. To address these concerns, they requested the school speech-language pathologist provide intervention in group situations whenever possible, and they enrolled Andy in private speech and language treatment for social skills intervention. Andy did well with school and private social supports in grade school, but after his transition to middle school, things became more difficult because Andy had a hard time generalizing his skills to establish new relationships in this more complex social environment. Within social interactions, Andy had difficulty initiating teenage-appropriate topics, engaging in topics that interested his peers, refraining from repeating favorite movie lines out loud (which he would do when nervous), and understanding teasing and humor. His frustration and inappropriate social behaviors escalated to the point that his parents removed him from the public school system.
The scenario above describes what can happen as students with ASD approach adolescence, especially if they are not provided with sufficient social supports along the way. In a longitudinal study following children with ASD from ages 12–13 years to 19–20 years, McGovern and Sigman (2005) found that greater social engagement with peers in elementary school predicted improvements in adaptive behaviors and social skills in later adolescence. The widening social gap between students with ASD and their typically developing peers that begins in elementary school (Prizant et al., 1997) will likely continue as they transition to middle school. Also, some individuals with ASD become more aware of their social interaction deficits as they get older (Tantam, 2003). The transition to middle school involves a host of changes, such as moving between different classes, having different teachers and students in those classes, using a locker, and eating in a large and noisy cafeteria. Due to the more complex social demands of this new environment, and the likelihood these changes will exacerbate children's social deficits, clinicians need to add additional social supports and strategies before and following this school transition. Peer networking interventions may help by creating a network of social supports designed to benefit students with and without ASD (Haring & Breen, 1992; Kamps et al., 1997).
Plotting a Course
Recent reviews on peer-mediated interventions (PMIs) and peer training packages target the core social communication and interaction deficits characteristic of ASD in children, adolescents, and young adults (see Chan et al., 2009 for a review; National Standards Project, 2009). In this type of intervention, students with and without ASD are taught specific social communication skills (e.g., to gain attention by greeting or saying a name, to initiate and maintain topics, answer questions, use social niceties, comment on a joint activity, and use self-monitoring skills) and have opportunities to use these skills during structured and naturally occurring school social contexts. Peers without disabilities are taught these skills to become more responsive communication partners to help students with ASD engage in successful social interactions.
The author and colleagues spent the last decade examining peer-mediated social intervention approaches for elementary school-age students (Thiemann & Goldstein, 2001, 2004; Thiemann & Kamps, 2007; Kamps et al., 1997). We have successfully taught elementary students with and without ASD how to (a) be more responsive conversational partners, (b) prompt and reinforce communication attempts, (c) use written text scripts as social cues, and (d) use these social skills across inclusive school activities (Goldstein et al., 2007; Thiemann & Goldstein, 2001, 2004). These outcomes support other reports on the effectiveness of direct teaching of social skills in small groups (Kroeger et al., 2007), and add to the literature on the positive effects of involving peers as conversational and play partners.
In a recent yet unpublished study, the author integrated these teaching strategies with peer networking strategies, and developed a program for middle-school students. Social intervention research is sorely lacking on peer-mediated programs in middle school settings. A description of peer-mediated and social skill teaching approaches for students in the elementary grades is provided below, followed by preliminary outcomes of the peer networking program implemented in middle school for two students with severe ASD. Once specific techniques are refined and it is determined what enhances students' social supports and relationships, the challenge will be to examine these interventions in larger, randomized controlled trials.
Text Cues and Network Programming
Group contexts provide naturally occurring social opportunities and interactions, and speech-language pathologists need to focus on strategies and skills that allow students to become more engaged and socially active in small and large groups. When provided with written text scripts (i.e., phrases that tell a child what to say) and picture cues (e.g., photos of children interacting), students with ASD and their peers without disabilities can learn to initiate and respond to one another using bids for attention, comments, questions, and compliments, and thereby engage in longer interactions (Spohn et al., 1999; Thiemann & Goldstein, 2004).
Teaching social communication using written text and picture cues within the context of peer groups may be successful for a number of reasons. First, it is widely believed that some children with ASD have a strong ability to recall or process visual information but limitations in recalling sequences of verbal information (Grandin, 1995; Hodgdon, 1995). Using written words and picture cues as visual stimuli may allow children constant access to appropriate social language "scripts" to use with peers, for example. Also, students with and without ASD have continual access to the written and picture cues for repeated practice and repeated peer models of the skills. Furthermore, trained peers provide natural social reinforcers and feedback on the appropriateness of the focus child's utterances. Finally, communication attempts are better understood given that everyone in the group knows the target cues and communication skill. All students in the groups are taught to use the written-text cues to interact socially at opportune times such as during group games, art and science activities, and less structured times (e.g., recess and lunch). In these less-structured settings, written-text cues need to be portable and can be attached to lanyards around the neck, wrist bands, or a key ring.
Benefits of a Peer Program
Peer networking social programs are based on the premise that a supportive network of peers may motivate attitudinal change toward individuals with disabilities among students not directly involved in the program, as well as allow students with ASD more opportunities to learn appropriate social responses. Haring and Breen (1992) implemented a peer network program for two junior high students with disabilities (one with ASD, one with cognitive impairments). They recruited up to five students with normal development to meet weekly to assess and discuss interactions, seek solutions to any social problems, advocate for changes, develop and role play social skill strategies, and collect data on social gains. Peer schedules were matched with the two students during multiple school transitions (e.g., hallway, locker areas, and cafeteria) and lunch periods. In addition, the students with disabilities worked 1:1 with an adult twice a week for 15-minute periods to learn their peers' names and match names to their photos. The networks led to more interactions across the school day, greater peer acceptance, involvement with peers in non-treatment school settings, and invitations to community events.
Given the critical need for intervention studies investigating the efficacy of programs designed to improve social communication for older students with ASD, the author recently implemented a peer network program for students entering middle school. The program combined evidence-based strategies from the peer mediated intervention (PMI) literature, based on the pioneering work of Haring and Breen (1992), and both picture cues and written text scripts within a peer network approach. The primary objective was to determine if written text scripts and picture cues embedded within peer networks would be associated with improved social communication skills among middle-school students with ASD. The intervention was implemented in the first semester of seventh grade with two students with severe ASD. Both students were verbal, had some reading ability, and attended special and general education classes with some adult support.
Treatment Steps in Elementary School
The following treatment steps were used successfully with elementary-age peer groups, and later were modified for middle-school students:
- Students read aloud a social story written about a social communication skill.
- Adult models and students rehearse two different text cues of target skill (e.g., request action or object cues might be "Can I have it?" and "Pick one.").
- Adult prompts students with ASD and other peers to practice with each other.
- Adult teaches peer to prompt child to read/say the text cue of target skill.
- Students play a game or do an activity and peer prompts focus children to use the text cues as appropriate.
- Teacher assists as necessary to ensure frequent opportunities to practice target skill (Thiemann & Goldstein, 2001, 2004).
In eight to 12 weeks of intervention, elementary students with ASD in our studies learned how to:
- Initiate age-appropriate topics, comments, questions, and compliments.
- Independently use written text scripts and picture cues without adult or peer prompts.
- Greet peers by name.
- Be responsive to peers in conversations and following rules in play.
- Use functional social communication across the school day (e.g., gym class, recess, lunch, and centers).
For students without ASD in elementary school, we have observed similar improvements in:
- Frequent and spontaneous repetitions of target communication skills.
- Assisting students with ASD by pointing to text and picture cues to prompt utterances.
- Positive reinforcement (e.g., pats on back, high fives, verbal praise) for engaging in group activities and using target communication skills.
In addition to gains in rates of targeted communication skills and use of the text cues, we have observed positive social outcomes: more time engaged with peers, longer conversations, more playground interactions, and higher peer acceptance and friendship ratings.
For middle-school students with ASD, the primary social supports included teaching "scripted" communicative interactions (e.g., text cues of what to say and how to respond) within age-appropriate activities; peer models, prompts, and reinforcement of appropriate communication; and teaching the skills in structured contexts followed by opportunities to practice skills in natural environments (e.g., physical education, chorus, hallway transitions). One important feature was that the middle-school students with ASD had multiple opportunities to interact with trained peers in their network over the school day and throughout the week. Additionally, picture cues were modified for older students to be age-appropriate, and included black-and-white line drawings as well as photos of the students pasted onto cartoon frames, with cartoon bubbles inserted above their heads for the written text cues.
The primary difference from elementary school social programs was having the peers "drive" the intervention, by asking them to identify communication skills as appropriate targets, teaching them to collect social data, and seeking their feedback and suggestions on a weekly basis.
In a sample schedule, a student with ASD met with two peers every Monday and Tuesday for a 20-minute social lesson and activity; partnered with one peer during physical education; chatted before chorus started every day with another peer; and talked with a third peer after school on the way to lockers. Having the peers "drive" the intervention was unique; they chose schedules, selected skills and strategies, collected data, and reviewed program success in weekly meetings with an adult facilitator. Components of this intervention are listed in the sidebar "Creating a Peer Network Program with Embedded Text and Picture Cues." At the all-group meeting, all students shared their opinions of social issues and came up with strategies to address those issues (see Table 1 [PDF]).
After 16 to 19 peer network sessions over a 12-week period, the two students with ASD had increased their initiations and responses to peers in their network. Improvement was greater for responses than for initiations, with both students doubling their average rate of responses per minute from approximately two to four. Greater peer responsiveness also was noticed—response rates per minute tripled that observed in baseline for one student (from one to four per minute). At the end of the 12 weeks, response rates increased more in the generalization settings such as hallways, transitions, and lunch than in the structured group games for both of the participants.
For example, prior to chorus, one of the students with ASD started greeting one of her peers with a smile, and then began to respond consistently when asked questions about her day. During lunch, the other student with ASD started getting up from his table, walking to his peer's table, greeting the peer, and then staying to talk for a few minutes. For both students, these improvements in social exchanges increased after about one month of the peer network intervention; it seemed as if they began to anticipate the "before-chorus routine" or "lunch routine" and it became part of their daily school experience. Social responding may have been higher within these settings as they typically involved a one-to-one conversation with a peer, who had been coached to ask the student questions about topics of interest; nonetheless, this approach seemed to facilitate longer and more frequent social exchanges.
A primary advantage of peer network programming is that students with ASD can begin to assume responsibility for initiating social interactions in a supported context. This approach appeared to help the students with ASD to begin taking the lead in creating social situations independent of adult involvement.
In this study, up to six peers were trained to complete the data sheets with reliable information that rated the quality of interactions (e.g., had fun, enjoyed hanging out) and quantity of targeted conversational skills (e.g., used friendly words, kept talking, flexible topics). Peers collected data after their weekly social lesson and game, and following independent interactions across the school week. In comparing ratings of social behaviors on a scale of 1 (not very often) to 4 (a lot of the time), agreement between research staff and peer ratings ranged from 87% to 93%. These findings are similar to those reported by Haring and Breen (1992), who successfully taught middle-school students to collect data on rates of social interactions with 86% agreement with an adult coder. Thus, peers can be a valuable resource during middle school years, when students with ASD are less likely to be involved in daily social activities than in elementary school.
Staying on Course
An essential part of living successfully in the community is a young adult's social and interpersonal network. Recent interviews of adolescents and adults with ASD found they have the desire to interact socially and be involved in relationships; however, they report feeling lonely and have difficulty defining exactly what it means to have a friend (Bauminger et al., 2003; Carrington et al., 2003). The opportunity to assist this population of students with ASD should not be missed. Clinicians may be able help students with ASD stay on course throughout middle school by recruiting a network of trained peers to guide appropriate social interactions across the school day. Combining direct skill instruction using concrete visual (text and picture) cues and peer networking strategies may be critical components of a program designed to help students establish and maintain social relationships.
The success of social programs involving peers without disabilities depends in large part on the commitment of school administrators; it is important, therefore, that clinicians be able to impart a clear understanding of how fostering positive relationships among students with ASD and their typically developing peers is essential to their success as young adults.