Handbook of Autism and Pervasive Developmental Disorders: Assessment, Interventions, and Policy, Third Edition Edited by Fred R. Volkmar, Rhea Paul, Ami Klin and Donald Cohen Copyright © 2005 John Wiley & Sons, Inc. CHAPTER 38 Addressing Social Communication Skills in Individuals with High-Functioning Autism and Asperger Syndrome: Critical Priorities in Educational Programming WENDY D. MARANS, EMILY RUBIN, AND AMY LAURENT Social communication skills, or the lack thereof, play a major role in our success or inability to form social relationships that enable us to function happily and effectively in the communities and cultures within which we live. Our ability to engage reciprocally, to appreciate the communicative intent of others and to convey our own, to establish and maintain joint attention, and to appreciate another’s perspective or point of view is essential to learning and to forming friendships. The capacity to appreciate nuances of mood, to empathize, and to understand the complexities of pretense, imagination, humor, sarcasm, irony, and other implicit messages contributes to the richness of our lives and of those around us with whom we have relationships. For most of us, the underlying appreciation of social communicative behavior and use of skills permitting such complex interactions were never taught directly. Rather, our innate social interest in others and our ability to appreciate the complex verbal, nonverbal, and environmental cues that convey this social information permit us to form hypotheses, make inferences, adjust our impressions and actions accordingly, and reach a level of social sophistication that should not be underestimated (Nelson, 1985). It is only when we are faced with breakdowns in social behavior or with individuals for whom this social understanding does not come naturally that the complexities of social capacities and the difficulties of teaching them explicitly become apparent. The pronounced social communication disability in individuals with high-functioning autism (HFA) and Asperger syndrome (AS) is often masked by relatively sophisticated linguistic abilities (i.e., the ability to produce novel and creative verbal utterances) and, in some cases, the presence of exceptional cognitive abilities such as a mechanical talent or a specialized knowledge about an academic subject area (Koenig, Rubin, Klin, & Volkmar, 2000). These areas of relative strength, however, stand in stark contrast to the inability to engage in mutually satisfying social interactions. Clearly, there is great heterogeneity among typically developing children, adolescents, and even adults with respect to their level of social competence in any given setting. For individuals with HFA and AS, however, learning style differences and developmental vulnerabilities remain significant challenges across all settings of their life and provide devastating barriers to achieving social communicative competence (Volkmar, Klin, Schultz, Rubin, & Bronen, 2000). It is now well documented that positive longterm outcomes for individuals with HFA and AS are strongly correlated with the achievement of social communicative competence 977 978 Interventions (Garfin & Lord, 1986; Koegel, Koegel, Yoshen, & McNerney, 1999; National Research Council [NRC], 2001; Venter, Lord, & Schopler, 1992). Specific knowledge of the obstacles to achieving this long-term goal is essential, as individuals with these social disabilities will clearly benefit from opportunities to acquire strategies to engage in positive and successful experiences with a range of social partners and across a range of social settings. For example, we know that individuals who display a greater capacity to establish and follow the attentional and conversational focus of their communicative partners are more likely to initiate socially appropriate bids for interaction, follow turns and topics in conversation, use more sophisticated nonverbal gestures and symbolic language, and recognize and repair communicative breakdowns (Carpenter & Tomasello, 2000; Wetherby, Prizant, & Hutchinson, 1998). We also know that, by their very nature, social communication disabilities are transactional, and, thus, direct instruction with the individual does not necessarily ensure success across all social partners. Those who interact with the individual must learn to accommodate and modify their interactive style to facilitate success. As a result, to achieve positive long-term outcomes, effective programs must include learning supports and accommodations not only for the individual with the disability but also for all the social partners and settings within an individual’s community (e.g., family members at home, peers and teachers at school, colleagues at work, and individuals within community settings; NRC, 2001; Prizant, Wetherby, Rubin, Laurent, in press). Last, we know that challenges in social communication are part of a larger picture of developmental strengths and vulnerabilities (Prizant, Wetherby, & Rydell, 2000). In particular, we are concerned with an individual’s ability to use language and information gained through social interactions for the purposes of self-monitoring his or her physiological arousal and emotional state. This capacity, otherwise referred to as emotional regulation, enables an individual to be organized and focused, to problem solve, to communicate, and to maintain social engagement (Bolick, 2001; Prizant, Wetherby, Rubin, & Laurent, 2001). Because individuals with HFA and AS are particularly challenged with interpreting the emotional states of others as well as appreciating and expressing their own, these factors further compromise their social communicative competence and can limit availability for learning and social engagement across contexts. Thus, this chapter provides an outline of: (1) our current understanding of the core challenges facing individuals with HFA and AS that compromise their social communicative competence, (2) the unique learning style differences often associated with HFA and AS, (3) implications for intervention and educational programming, and (4) critical priorities for developing a comprehensive intervention program designed to foster social communicative competence. CORE CHALLENGES IN SOCIAL COMMUNICATION Social communication is broadly defined as those competencies that contribute to an individual’s ability to effectively communicate in social contexts. Although there is great heterogeneity in the social communicative profiles of individuals with HFA and AS, there is also a common pattern of impairments. Contemporary research has, in fact, identified that developmental vulnerabilities tend to fall into two primary areas: the capacity for joint attention and the capacity for symbol use (NRC, 2001; Prizant et al., 2000). The capacity for joint attention is central to the qualitative impairments in reciprocal social interaction, the most profound in its impact over time of the triad of diagnostic features used to define pervasive developmental disorders (PDDs) in the DSM-IV (American Psychiatric Association, 1994). Regardless of an individual’s level of functioning or developmental stage, the capacity for joint attention allows an individual to orient and, likewise, attend to a social partner, to both read and share affective states, and to establish and follow another’s attentional focus when sharing experiences in reciprocal conversation (Carpenter & Tomasello, 2000). An individual not only needs to acquire a range of grammatical forms, syntax, and vocabulary, but he or she also needs to develop a greater awareness of a social partner’s perspective. For example, a child may Communication Skills in Individuals with High-Functioning Autism and Asperger Syndrome have a great deal of language to communicate about a preferred topic, such as the makes and models of race cars, but may have difficulty determining whether the listener is paying attention to the conversation, interested in the topic, and/or has enough information to follow his or her ideas. These joint attention skills are essential for social problem solving and social judgment, which become areas of particular concern, especially during the preteen and adolescent years when the complexities of the social milieu are compounded by hormonal changes associated with puberty (Tantum, 2000). Table 38.1 lists those abilities that are compromised by having difficulties with joint attention (Prizant, Schuler, Wetherby, & Rydell, 1997; Prizant et al., in press; Volkmar et al., 2000). The second diagnostic criterion in the DSM-IV, qualitative impairments in communication (American Psychiatric Association, 1994), otherwise referred to as the capacity for symbol use, also has a deleterious impact on an individual’s drive toward social communicative competence. For individuals with HFA and AS, the relatively intact structural language skills and sometimes advanced vocabulary, reading decoding, or subject knowledge often masks the degree of difficulty experienced in semantics and higher level, nonliteral language use and connected discourse. Individuals with these social disabilities may fail to get “ the gist ” or “read between TABLE 38.1 979 the lines.” Thus, assimilating and accommodating new information, making connections to other knowledge, and integrating these in ways that provide them with a coherent sense of the world can be challenging (Landa, 2000). Additionally, the capacity for symbol use reflects an individual’s ability to understand and adhere to the social “rules” of pragmatic discourse, which vary depending on the social context and the accepted standards of a social group, that is, “rules” that are, in a sense, symbolic expectations for conversational form. Through social experience and symbolic understanding, individuals typically learn to adapt their strategies for initiating, maintaining, and terminating conversation depending on the social setting (e.g., a friendly discussion at a picnic versus a formal debate in an academic course), the status of their social partner (e.g., a friend versus a teacher or a coworker versus an employer), or the purpose that they are trying to fulfill (e.g., persuade, humor, or impress). At more sophisticated levels, changes are also made in response to the cultural background of a social partner because conventions for conversational discourse vary greatly from one culture to the next (Carpenter & Tomasello, 2000) and because of other more subtle social parameters. For individuals with HFA and AS, these variations in symbolic conventions across social partners and settings can be incomprehensible. Core Social Communication Challenges in HFA and AS The Capacity for Joint Attention Understanding the communicative intentions and emotional state of a social partner Interpreting and using nonverbal communicative signals (e.g., facial expressions, prosody, body orientation and proximity, and gestures) as they relate to one’s attentional focus, affective state, and intentions Considering appropriate topics of conversation, maintaining information, sharing across turns, and repairing communicative breakdowns based on the social context and a listener’s perspective Modifying interpretation of more ambiguous language forms (e.g., sarcasm, humor, figurative expressions, etc.) depending upon the intentions or perspective of one’s social partner The Capacity for Symbol Use Acquiring higher-level linguistic rules, grammar and syntax, that clarify one’s intent (e.g., subordinate clauses and conjunctions) across social partners and environments Understanding and using verbal conventions for initiating, exchanging turns, and terminating interactions across different social partners and social situations (e.g., rules of politeness) Interpreting and using language in a f lexible manner by responding to language that may contain: multiple meaning words, non-literal language, and irony Using language as a tool for emotional regulation (e.g., preparing for changes in routine, preparing for the expectations of different social contexts, and using appropriate means to request assistance and comfort across social settings and social partners) 980 Interventions This pattern is largely due to concurrent vulnerabilities in the capacity for joint attention, as an individual needs to consider another’s perspective to gauge the stigmatizing impact of unconventional social communicative behavior. As a result, it is not uncommon for an adherence to a more specific and unchanging set of “rules” of social discourse to develop over time (Klin & Volkmar, 1997). This extreme literalness or rigidity, as some would call it, is a common profile resulting from symbolic impairments in individuals with social learning disabilities. Table 32.1 presents those abilities typically impacted by challenges in the capacity for symbol use in individuals with HFA and AS (Attwood, 1998; Prizant et al., 1997, in press). Specific deficits in the developmental capacities for joint attention and symbol use in individuals with HFA and AS do not remain stable throughout development. Rather, challenges in these capacities “may take different forms as a function of ongoing development ” as well as a function of the negative impact that a social disability may have within that individual’s social network (Schuler, 1995, p. 21). Since social interaction always involves others to some degree, secondary effects arise as a result of the atypical social communicative profile of the affected individuals. Potential social partners often perceive the unusual and/or lack of social overtures of individuals with HFA and AS as deviant or odd. Partners may avoid opportunities for interaction and/or react in a negative way (e.g., bullying and teasing). In some instances, these factors can hasten the development of social isolation (Schuler, 1995; Schuler & Wolfberg, 2000). Other children, adolescents, or adults may interpret limited initiations, responsiveness, or persistence as signs of a lack of interest or, worse, unfriendliness. They may see unusual and idiosyncratic communication styles and social bids as off-putting or “ uncool,” and they may react negatively to maladaptive behavioral outbursts, failing to appreciate their peers’ inability to cope and express intentions or feelings in more socially appropriate ways. As a result, the very individuals who need the most practice with social interaction and communication often have fewer opportunities to do so (Lord, 1984). Thus, it is evident that individuals need to not only demonstrate developmental capacities in joint attention and symbol use to achieve social competence but also actively engage in social experiences across a range of social settings and social partners if they are to develop these skills. It is these social experiences as well as developmental capacities that facilitate an ability to interpret another’s perspective and modify the individual’s use and interpretation of language accordingly, taking into account the social context, critical factors in the achievement of social communicative competence. CORE CHALLENGES IN EMOTIONAL REGULATION Competencies in joint attention and symbol use are not the only prerequisites for the achievement of social communicative competence. Being able to attend to the most relevant information in a social setting, to problem solve, and to process information ( both verbal and nonverbal) also rely on an individual’s ability to maintain a state of active engagement, that is, an optimal state of arousal (Anzalone & Williamson, 2000; Degangi, 2000; Williams & Shellenberger, 1996). These abilities are reliant on an individual’s capacity for emotional regulation, a developmental process that supports the attainment and maintenance of a steady internal state and facilitates adaptive functioning and active engagement across contexts (Wetherby, Prizant, & Schuler, 2000). Emotional regulation is believed to be critical for the development of socioemotional and communicative skills as well as for the development of relationships (Prizant & Meyer, 1993; Stern, 1985). This is due, in part, to the fact that emotions “emerge from and provide the foundation of human attachment and social communication” (NRC, 2000, p. 107). Emotional regulation is not synonymous with the suppression of emotion. Rather, it involves experiencing and utilizing all emotions effectively and fluidly in transactions with social partners while playing, while learning, and while in the pursuit of social goals with respect to situational demands (NRC, 2000). If an individual is able to regulate his or her emotions in an efficient manner, he or she is better able to interact with a variety of social partners in a variety of social contexts. In contrast, if individuals are not efficient Communication Skills in Individuals with High-Functioning Autism and Asperger Syndrome in managing their emotions, they are prone to emotional overreaction, inattention, and avoidance of social interactions (Prizant et al., in press). Difficulty in regulating emotions can lead to an individual’s experiencing a heightened emotional state, which can undermine the development and mastery of new skills as well as the application of previously mastered skills (Bolick, 2001; Prizant & Meyer, 1993). This is particularly true for the development of social communication because the capacity for joint attention and the capacity for symbol use are contingent on attention, memory, and executive functioning, all of which are widely regarded as products of efficient regulatory skills and the resulting ability to maintain a state of optimal arousal (Lyon, 1996; NRC, 2000). Since individuals with HFA and AS find identifying and interpreting emotional states ( both internal and external) particularly challenging, their ability to engage in emotional regulation across contexts is often vulnerable. These emotional regulatory challenges manifest themselves in a variety of ways, ranging from difficulties maintaining social engagement and sustaining focused attention, to challenges with recognizing and interpreting their own and others’ physiological and emotional states (Attwood, 1998). The underlying factors contributing to these regulatory difficulties are varied and are the subject of ongoing debate in the literature. However, factors that are generally recognized include challenges TABLE 38.2 981 in social communication (i.e., difficulties with joint attention and understanding symbolic conventions; Wetherby et al., 2000), neurophysiological factors (e.g., sensory sensitivities, difficulty differentiating relevant stimuli in the environment from extraneous stimulation; Anzalone & Williamson, 2000; Asperger, 1944; Kientz & Dunn, 1997; Ornitz, 1989), and differences in the acquisition of motor skills (e.g., motor clumsiness and difficulties with visual-spatial perception; Anzalone & Williamson, 2000; Attwood, 1998). Tronick (1989) differentiates emotional regulatory capacities into self-regulation skills and mutual regulation skills. Self-regulatory skills are regarded as strategies that are self-initiated and self-directed for the purpose of managing an individual’s own arousal, emotions, behavior, and attention. Mutual regulatory skills are defined as strategies used to secure assistance from another as well as the ability to respond to assistance provided in an effort to maintain a well-regulated state. Both of these capacities are often significantly compromised in individuals with HFA and AS. Table 38.2 lists areas that are compromised because of difficulties with self- and mutual regulation. As noted previously, these vulnerabilities are related, in part, to core challenges in communicating with and relating to others. Compromised abilities in the areas of joint attention (e.g., difficulty appreciating and sharing both emotional states and intentions) and symbol Core Emotional Regulation Challenges in HFA and AS Mutual Regulation Self Regulation Understanding and interpreting the emotional state of self and others Recognizing and interpreting one’s own physiological and emotional state Interpreting affective cues (e.g., facial expressions and gestures) as they relate to the intentions of social partners Emotional reactivity and variable arousal state due to physiological factors (e.g., sensory sensitivity) Expressing emotions in a socially conventional manner as a means to request assistance from others Responding to assistance offered by others secondary to difficulties processing the verbal and/or nonverbal social cues of social partners Maintaining social engagement and focused attention due to variability in arousal states Attending to relevant information in a social setting in order to problem solve, focus, and process information Grading reactions to coincide with the expectations of the current social situation Ability to use effective behavioral strategies (e.g., sensory-motor regulatory strategies) that are deemed socially acceptable Ability to use cognitive strategies, such as “inner language” to anticipate and cope with potentially dysregulating events 982 Interventions use (e.g., difficulty understanding and expressing emotions in a socially conventional manner) impact the process of mutual regulation, making it difficult for an individual to solicit assistance from others and compromising the ability to utilize and interpret nonverbal communication (Volkmar et al., 2000). Often, these social communicative challenges, in conjunction with variable arousal states, interfere with the individual’s ability to attend to social conventions and to benefit from inherent opportunities for learning within social interactions. In turn, these difficulties also negatively impact the ability to develop appropriate expressions of emotional states (Prizant et al., in press). Therefore, individuals with HFA and AS often lack both range and refinement of expression and typically exhibit an all-or-nothing reaction when displaying emotions (Attwood, 1998; McAfee, 2002). Difficulties establishing shared attention with a social partner and communicating in a socially conventional manner further compromise the development of self-regulation and self-control in individuals with HFA and AS. These capacities are typically achieved through a process of socialization, in combination with biological predispositions. The emergence, and later mastery, of these skills is closely tied to adaptive functioning and social communicative competence (Degangi, 2000; NRC, 2000). Selfregulatory abilities that are typically evident in early development involve behavioral strategies (e.g., sensory-motor means) of regulating arousal level and emotions (e.g., seeking out comforting objects and modifying activity level) and are often elicited in response to state changes (e.g., hunger, fatigue, heightened emotions). As individuals continue to develop and their executive functioning capacities emerge, they begin to use their language and cognitive skills to assist with regulation of emotional and behavioral reactions, adding to those sensorymotor means previously acquired. Early capacities in this area include the ability to use “inner language” for self-regulation (Vygotsky, 1978), understanding of activity schedules, and the employment of avoidance strategies. This internal linguistic shift occurs with the developmental transition to symbolic communication, as inner language reflects an ability to represent events in memory and to problem solve through inner symbolic means. Inner language serves to organize social experience and behaviors, allowing the individual to think about and learn from past social events and plan for future social events. These abilities facilitate an individual’s capacity to attend to social and environmental stimuli, plan a response, and anticipate social consequences. With limited ability to use inner language for these cognitive functions, it is less possible to plan for dysregulating events or to reflect on past experience in a manner that supports active engagement and emotional regulation across activities. These difficulties play a significant role in the presence of unpredictable reactions to daily social events often exhibited by individuals with HFA and AS. Social communicative challenges also compromise the ability of individuals with HFA and AS to understand emotional concepts, particularly those that rely heavily on social norms or conventions (e.g., guilt, embarrassment, pride). An individual’s ability to interact in a reciprocal manner with others is critical for developing the concept of emotional identification. It is through interactions with their social partners that individuals learn to “map” emotional words and concepts onto their own visceral states and experiences and, therefore, derive emotional meaning and affective concept development (NRC, 2000; Prizant & Meyer, 1993). For individuals with HFA and AS, difficulty attending to and deriving meaning from these interactions translates into difficulties understanding those emotions that reflect aspects of social relationships and complex interpersonal experiences. To understand “embarrassment,” for example, an individual must develop a sense of self-consciousness by obtaining and using feedback in social contexts. Because individuals with HFA and AS have difficulty with these emotional concepts, their ability to anticipate and interpret the emotional reactions of others is compromised; thus, their acquisition of skills essential for the development of self-control and other sophisticated regulatory abilities is hindered (NRC, 2000). An individual may, for example, exhibit a limited ability to modify bids for communication to match the emotional states of communicative partners. When this concept of emotional reciprocity and viewing others’ Communication Skills in Individuals with High-Functioning Autism and Asperger Syndrome emotional states as different from, but related to, the individual’s own is compromised, the individual often has difficulty with social interactions and tends to dominate conversations without regard for social partners’ feelings, preferences, or opinions (Prizant et al., in press). These affective difficulties contribute, in part, to the ongoing challenges in forming peer relationships experienced by individuals with HFA and AS. In addition to social communicative difficulties, neurophysiological factors complicate the process of maintaining a well-regulated state for individuals with HFA and AS. References to sensory sensitivity (e.g., hyperresponsivity to environmental stimulation) and resulting fluctuations in arousal level and physiological state are prevalent in the literature (Anzalone & Williamson, 2000; Attwood, 1998; Kientz & Dunn, 1997). Asperger (1944) himself described the individuals profiled in his initial works as having difficulty differentiating relevant from irrelevant stimuli in their environments. Additionally, developmental studies illustrate that individuals who present with hyperresponsive reactions to stimuli early on are at greater risk later in life for being socially withdrawn and anxious (Kagan, Reznick, & Snidman, 1987; Kagan & Snidman, 1991; Kagan, Snidman, & Arcus, 1998), characteristics often demonstrated in individuals with HFA and AS (Tantum, 2000). Variable physiological responses to environmental and internal stimuli often cause strong emotional reactions. If an individual is sensitive to tactile information (e.g., a peer inadvertently bumping into him or her while making the transition from one class to another), this stimulus may elicit an increase in arousal level as well as a strong fear response. In conjunction with the previously mentioned difficulties in interpreting intent, individuals with HFA and AS may have difficulties regulating their reaction and response to this innocuous event. Many factors contribute to arousal changes, including the social context, constitutional variables, repertoire of self- and mutual regulation strategies, and communicative partner style (Prizant et al., in press). Social interaction itself can have a dysregulating effect on the arousal level and emotions of an individual with HFA or AS. Interaction styles that are primarily verbal in 983 nature pose challenges to individuals with HFA because of their difficulties processing transient auditory information (Schuler, 1995). Similarly, individuals with AS are particularly challenged by nonverbal communication and dynamic visual information (Klin & Volkmar, 1997) and, thus, may respond with a heightened state of arousal when touched by a social partner, when a caregiver establishes close proximity, and/or when gestures are used without verbal language as a means of communicating an intent (see discussion of unique learning style differences later). Challenges in maintaining an optimal state of arousal experienced by many individuals with HFA and ASDs often result in high levels of anxiety. An individual’s attempt to cope with an overwhelming inability to modulate levels of arousal or anxiety may lead to a strong preference for routines and frequently to restricted areas of interest, as represented within the final diagnostic criteria identified in the DSM-IV for the disorders (American Psychiatric Association, 1994). Individuals with HFA and AS frequently engage in repetitive and restricted patterns of behavior, such as a preoccupation with a particular topic of conversation, academic subject area, or the completion of a manipulative task in a self-absorbed manner. These behaviors often reflect the individual’s attempt to cope with an overwhelming inability to modulate levels of arousal or anxiety (Attwood, 1998). Attwood acknowledged that the greater level of stress an individual experiences, the greater is the likelihood that the intensity of a restricted area of interest will increase proportionately. Therefore, at times, behaviors that are often viewed by peers and caregivers as socially inappropriate and odd may actually serve an adaptive function, facilitating order, consistency, and relaxation (Attwood, 1998; Tantum, 2000). THE IMPACT OF DIFFERENCES IN LEARNING STYLE ON INTERVENTION PLANNING Notwithstanding the common pattern of impairments in social communication and emotional regulation across the different subtypes of PDD, there is increasing evidence to suggest that there are “different pathways to social 984 Interventions learning disabilities” (Volkmar & Klin, 2002; Volkmar et al., 1994). Greater knowledge about the neuropsychological profile of strengths and needs in individuals with HFA and AS has led to useful gains in our understanding of what modalities, methods, and strategies are more effective in accommodating these distinct learning challenges within an individualized intervention program. The neuropsychological literature available provides suggestive evidence of several significant differences in learning style between individuals with HFA and individuals with AS (Volkmar & Klin, 2000, p. 52), a finding that has critical implications for our intervention planning. For example, results of the DSM-IV Autism / Pervasive Developmental Disorder Field Trial conducted by Volkmar et al. suggested that in some aspects of learning, individuals with AS performed better than individuals with HFA and, in other areas, the converse was the case. While individuals with AS demonstrate relatively preserved, if not precocious, verbal abilities, they often demonstrate significant vulnerabilities in nonverbal concept formulation, visual-spatial perception, and visual memory (Volkmar & Klin, 2000). For individuals with AS, vulnerabilities in these aspects of learning compromise their ability to attribute meaning to nonverbal social cues, process inflection and the emotional contours of voice, and integrate sequences of visual information to create a social and affective context. It is interesting that the presence of strong verbal skills in an individual with AS often provides an ideal modality for intervention because the individual can incorporate the use of verbal mediation throughout his or her day. This refers to the use of explicit, verbal instruction to facilitate awareness of the subtleties of social and emotional behavior that unaffected individuals typically learn incidentally through ongoing observations of nonverbal social cues in their environment during meaningful interactions (Attwood, 1998; Jahr, Eldevik, & Eikseth, 2000; Klin & Volkmar, 2000; Stewart, 2002). For individuals with AS, verbal language, in fact, often becomes a lifeline for learning about themselves and about the expectations of the social world. Although developing an awareness of the subtleties of social and emotional behavior is also challenging for individuals with HFA, differences in the contributing neuropsychological vulnerabilities are evident. Individuals with HFA demonstrate relative strengths in visual-spatial perception and visual memory while their verbal abilities (i.e., expressive language, comprehension, and verbal memory) are likely to be more impaired (Ozonoff & Griffith, 2000; Volkmar, Klin, & Cohen, 1997). Although difficulties with processing nonverbal social cues clearly exist in individuals with HFA, these challenges are more likely a result of a preference for static or nontransient visual information over fast-paced or transient visual cues, rather than a limited ability to process visual-spatial information (Schuler, 1995). Additionally, individuals with HFA, unlike individuals with AS, often present with a gestalt, as opposed to an analytic learning style (Prizant, 1983), which further compromises their abilities to break down larger units of information into smaller units of meaning (e.g., individual words within a verbal utterance, subtle social cues such as a change in facial expression, and variations in intonation), particularly when that information is transient in nature (e.g., fast-paced social cues and verbal language). Therefore, the provision of static visual cues is an appropriate accommodation when supporting individuals with HFA in their awareness of social conventions (Groden & LeVasseur, 1995; Hodgdon, 1995). Verbal mediation strategies, although often helpful with individuals with AS, may prove to be less effective for individuals with HFA given that this modality is transient and requires analytic processing, two identified areas of relative weakness in HFA (Klin & Volkmar, 2000; Prizant & Schuler, 1987). Despite these significant differences in learning style, the commonalities that individuals with HFA and AS demonstrate with respect to impairments in social communication and emotional regulation speak to their need for similar accommodations within an educational program. Difficulties understanding the communicative intentions and emotional states of a social partner, compounded by difficulties recognizing social conventions across contexts, contribute to a common preference for learning within predictable routines, for very explicit instruction, and for explanation about implicit social messages (Schuler, 1995). It is these Communication Skills in Individuals with High-Functioning Autism and Asperger Syndrome common learning preferences in individuals with both HFA and AS that require differentiation of the salient from nonsalient features of social interactions and an increase in recognition that when a person is anxious or overwhelmed, as is often the case within more novel or unstructured social contexts, learning is unlikely to take place. Thus, individuals with HFA and AS, as well as individuals with other types of social learning disabilities, will benefit from programs that incorporate: (1) accommodations that foster an individual’s ability to remain well regulated and, therefore, less anxious as he or she traverses through the constant flow of social interactions within each day, (2) accommodations that support an awareness of the intentions and affective states of the individual’s social partners, and (3) accommodations that facilitate an awareness of the predictable aspects of more novel social events (e.g., the temporal flow, the social conventions, and communicative intentions of those involved). Additionally, it is appropriate to consider the common modalities that appear to be effective methods of supporting social communicative competence in individuals with both HFA and AS. Although visual-spatial perception can be challenging for individuals with AS, we know that reading, that is, the written word, is often a relative strength secondary to their strengths in word recognition and verbal language (Rourke & Tsatsanis, 2000). Individuals with HFA also share this relative strength in reading because the written word in contrast TABLE 38.3 985 to oral language is nontransient and visual by nature, and their ability to process the written modality often far exceeds their ability to process oral language (Wetherby et al., 2000). Regardless of the origins of this learning strength, it has led to a number of universal strategies for intervention including the provision of visual supports incorporating the written word for: (1) increasing an individual’s preparedness for and independence when making transitions across activities, (2) progressing through steps within tasks, (3) making choices, and (4) accepting changes in routine (Dalrymple, 1995; Myles & Simpson, 1998). Written cues have also been helpful, in some cases, for supporting social conversational skills within classroom settings (Freeman & Dake, 1997; Krantz & McClannahan, 1998) as well as for enhancing an awareness of social conventions and perspective taking (Gray, 1995; Gray & Garand, 1993; Hagiwara & Myles, 2001). Although the effectiveness of each of these individual strategies may vary from one individual to the next, an understanding of an individual’s learning strengths and preferences should clearly form the basis of an appropriate intervention plan (NRC, 2001). Table 38.3 provides a summary of the impact of distinct neuropsychological learning differences between individuals with HFA and AS and our understanding of what modalities, methods, and strategies are more effective within an individualized intervention program. In addition to these unique neuropsychological patterns, the impact that challenges in The Impact of Learning Style Dif ferences in HFA and AS on Modalities of Intervention High Functioning Autism (HFA) • Strengths in visual-spatial perception and visual memory • Preference for nontransient or static information • Weaknesses in expressive and receptive language and verbal memory Implications The provision of static visual cues is an appropriate accommodation when supporting individuals with HFA in their awareness of social conventions. Verbal mediation strategies, although often helpful with individuals with AS, may prove to be less effective for individuals with HFA secondary to the transient and languagebased nature of this modality of learning. Asperger Syndrome (AS) • Weaknesses in visual-spatial perception and visual memory • Strengths in expressive and receptive language and verbal memory Implications The strong verbal abilities skills characteristic of AS often provide an ideal modality for intervention, as the use of verbal mediation can be incorporated throughout his or her day. This refers to the use of explicit, verbal instruction to facilitate awareness of the subtleties of social and emotional behavior that unaffected individuals typically learn incidentally through ongoing observations of nonverbal social cues in their environment. 986 Interventions emotional regulation may have on learning style (e.g., attention, social engagement, problem solving, executive functioning) has critical implications for developing an individualized intervention plan. Therefore, when designing an educational program designed to support social communicative competence, it is essential to address the core emotional regulatory challenges faced by individuals with HFA and AS throughout their daily routines (Myles & Simpson, 1998; Prizant et al., in press). Addressing these problems will enhance the efficacy of programming, promote social acceptability among a network of peers and, thereby, increase the capacity to engage in positive social experiences across settings and partners. The development of both the capacity for self-regulation and the capacity for mutual regulation ensures that the individual with a social disability and his or her social partners develop an ability to engage in reciprocal interactions where both partners are actively engaged, provide clear expressions of emotional state, and utilize effective and socially appropriate coping mechanisms that reduce anxiety and variations in arousal and emotional state. Fostering emotional regulation may require social partners to modify both their interaction styles and the environment so that an individual can remain actively engaged in a particular social setting (see later discussion on transactional supports). However, the goal is for the individual to manage independently in these areas, thereby decreasing the need for environmental modifications. Appropriate goals to be addressed may include, but are not limited to, the following: (1) increasing the individual’s ability to acquire and use socially acceptable behavioral strategies to support engagement and attention in daily activities and to cope with unexpected schedule changes and transitions, (2) increasing the individual’s ability to use socially acceptable nonverbal and verbal expressions for social control and expressing his or her emotional state, and (3) increasing the individual’s ability to acquire and utilize cognitive-linguistic strategies to support his or her attention to activities and daily routines (e.g., through the use of rehearsal and selfregulatory language, by reference to visual supports; Prizant et al., in press). For individuals with HFA and AS, it is also critical to foster abilities in the areas of emotional identification and emotional understanding so that they are more able to grade their emotional reactions to specific events or incidents and to display their emotions in more conventional ways. Therefore, the following goals are viewed as critical for fostering increased social communicative and emotional regulatory competence: 1. Increasing the individual’s acquisition of conventional verbal and nonverbal communication forms for requesting assistance and/or organizing supports. 2. Increasing the individual’s ability to use specific vocabulary or conversational devices to express emotional state and arousal level. 3. Increasing the ability to identify and express emotional state and arousal level as well as using regulating strategies, with and without the use of visual supports. 4. Increasing social understanding and social expectations through language-based strategies (see later discussion on transactional supports). Because expression of emotional state and coping strategies are person and context specific, these goals and supports should be implemented throughout an individual’s day across a variety of social partners and social settings. EDUCATIONAL PROGRAMMING FOR INDIVIDUALS WITH HIGH-FUNCTIONING AUTISM AND ASPERGER SYNDROME To make informed decisions about the curriculum and methodology of an educational program designed to foster social communicative competence in individuals with HFA and AS, you must maintain an awareness of the state of the science in the field, particularly in relation to empirical studies demonstrating the efficacy of specific approaches, curricula, or methodologies. This is especially critical when working with this population, as a number of specific, programmatic approaches are available reflecting different philosophical views, and, in some cases, proponents of these programs have made Communication Skills in Individuals with High-Functioning Autism and Asperger Syndrome claims that their approach is superior to other approaches (Green, 1996; Smith, 1996). Although there remains great controversy in the field as to which intervention approach is the most appropriate, it is premature to claim that “any one approach is more effective than other approaches” (Prizant & Rubin, 1999, p. 199). Empirical research has, in fact, demonstrated the effectiveness of a range of approaches that vary in their curriculum and methodology (Dawson & Osterling, 1997; Rogers, 1996); and, perhaps more importantly, a number of studies suggest that “no one approach is equally effective for all children” (Prizant & Rubin, 1999, p. 199). Thus, it is critical to create an educational program that fosters success with a specific individual, his or her family, and that individual’s social network. The Committee on Educational Interventions for Children with Autism was a panel formed by the NRC (2001) to review empirical research in the field, literature from model programs, and literature from general education and child development. Their charge allowed the committee to formulate specific recommendations for educational programming, provide guidelines to direct public policy, and indicate the need for more ecologically valid outcome measures (described further later). The findings of the committee support the notion that “effective services will and should vary considerably across individual children, depending on a child’s age, cognitive and language levels, behavioral needs, and family priorities” (NRC, 2001, p. 220). Educational Guidelines When developing an appropriate educational program for an individual with HFA or AS, individualization of curriculum, learning accommodations, and settings are of paramount importance. Social skills do not exist in a vacuum, and to teach them effectively, the individual must be considered as a whole from a developmental perspective. His or her strengths and needs, learning style, specific interests, preferences, and regulatory capacities and vulnerabilities should be understood and planned for when organizing the program. Likewise, the Committee on Educational Interventions for Children with Autism provided a number of 987 recommendations for programming and outcome measures to guide our work. These include, but are not limited to: (1) addressing functional and spontaneous communication, (2) implementing supports for social communicative competence across a range of social settings, and (3) providing opportunities for guided instruction within natural contexts (e.g., peer interactions, inclusion opportunities). Additionally, consideration of the range of factors that may be contributing to problem behaviors is considered critical as a means of supporting each individual’s personal responsibility for his or her social behavior (NRC, 2000, 2001, p. 221). Last, the committee strongly recommended that meaningful outcome measures be incorporated on an ongoing basis (i.e., 3-month intervals; NRC, 2001, p. 220), as part of each individual’s educational program, as a way of assessing generalization of gains across social partners, social settings, and activities (NRC, 2001, p. 228). Thus, social competence cannot be measured without attention to an individual’s adaptation and success within day-to-day activities in natural contexts. Despite this recommendation and our clinical awareness of what we want to achieve, it is not uncommon in programming for social communication skills that different target goals and objectives are treated as discrete entities and/or that provision of designated social opportunities at specific times of the day (e.g., Circle of Friends, Lunch Bunch, or social skills groups) is considered to encompass and to address the social needs of an individual. While many of the specific goals or activities are appropriate and beneficial components of an educational program, fostering social communication must be understood as integral across an individual’s day (e.g., each class at school, lunch, recess, transition times), across contexts (e.g., school, home, and community), and across social partners (e.g., peers, teachers, siblings and parents, coworkers, and members of shared groups). Facilitating social skill development does not rest solely with the speech-language pathologist, occupational therapist, social worker, psychologist, counselor or paraprofessional, nor does it rest only with the parents. Rather it is shared among all those coming into contact with the individual, including peers, coworkers, and members of 988 Interventions the community. Although certain team members will have more responsibility for developing and implementing aspects of the social programming than others, a critical piece in the program planning is to integrate and make the connections among what is being taught; why the skills are needed; how, when, and where to use them; and, most importantly, with whom. This cohesive and comprehensive approach should be at the core of facilitating social communicative competence, since the ability to integrate and apply learned skills and the capacity to generalize them forms the essence of social understanding that is so challenging for individuals with HFA and AS. Skills being taught should, therefore, not be considered the end product but need to be worked on with attention to: (1) the contexts in which they occur naturally, (2) the reciprocal adaptations demanded by social partners, and (3) the ability to then generalize the skills to other contexts and individuals. The complexity of planning an educational program that integrates social skills across settings is not to be underestimated. Nevertheless, the outcomes are more likely to have ecological validity and real life payoff. For any given individual, the planning of a social skills educational program must be individualized and take into account the lifestyle and demands that will dictate priority needs, supports to be developed within the community, choices of materials and activities, and individuals to be included. The success of any educational program should include measures of its relevance and functional impact on an individual’s day-today life, that is, meaningful outcome measures. Schwartz (2000) discusses the notion of using “membership” as an important measure of whether an educational program designed to support social communicative competence has been successful. Schwartz pointed out that social skills are not a goal in and of themselves; rather, the objective is to support the learning of social behaviors, including social communication, that permit and promote the development of meaningful relationships that are culturally relevant. Based on a 5-year multisite project using natural settings to support children’s social relationships conducted by Meyer, Grenot-Scheyer, Schwartz, and Harry (1998), the following guidelines for socially and ecologically valid interventions were suggested. Interventions should be: 1. Consistent with the social expectations of a given context; 2. Feasible with respect to available resources—personnel, expertise, and materials; 3. Sustainable over time; 4. Owned and operated by the constituency or community within which they occur (teachers, parents, and students); 5. Culturally inclusive; and 6. Intuitively appealing. Primary Dimensions of Intervention In the case of social learning disabilities, we must remember that the social impairment is not solely due to the developmental vulnerabilities and learning style differences of the individual with HFA and AS; rather, the “social impairment is shared” with all of those attempting to engage or, for that matter, disengage with the individual (Gray, 2001). As noted earlier, social isolation can be hastened by the negative perceptions that idiosyncratic styles of communication often create among a larger peer network (Lord, 1984; Schuler, 1995). Additionally, the success of any given social exchange relies not only on an individual’s ability to adhere to social conventions, remain actively engaged, and accurately consider another’s intents but also on the social partner’s ability to adapt his or her interpersonal style and the environment to match the needs of the individual with the social disability. As Gray indicated, we, as social partners, “are part of the problem” and, thus, should be “part of the solution” as well. An additional factor is the impact of a social disability on that individual’s family, with respect to not only their interpersonal style and the home environment but also their emotional well-being or adjustment. Recent studies have shown that more positive outcomes are associated with the provision of family support and mechanisms for coping with the stress of raising and living with an individual with a social disability (NRC, 2001). The Social Communication Emotional Regulation Transactional Supports (SCERTS) model provides a comprehensive Communication Skills in Individuals with High-Functioning Autism and Asperger Syndrome framework to follow when designing an educational program to foster social communicative competence in individuals with social communication disabilities (Prizant et al., in press). This framework includes the following dimensions designed to foster social communicative competence in individuals with HFA and AS: (1) interpersonal supports across social partners (e.g., communicative style adjustments with peers, teachers, family members, and members of the community); (2) learning and educational supports (e.g., visual /written supports and environment arrangement /modifications); and (3) family supports (e.g., educational support as well as ongoing emotional support). TABLE 38.4 989 Specific accommodations and learning strategies are discussed next as they relate to these primary dimensions. Table 38.4 summarizes these accommodations. Interpersonal Supports To foster success within social interactions between the individual with HFA and AS and his or her social partners, the emphasis should not solely be on the individual with a social learning disability. Rather, a critical emphasis needs to be placed on supporting a partner’s ability to make communicative style adjustments to support the interaction. Communicative style adjustments relate to the specific Transactional Supports for Individuals with HFA and AS I. Interpersonal supports a. Identify the qualities of a social partner’s use of verbal and nonverbal forms of communication that are either facilitative or provide barriers to an individual’s attempts to engage in reciprocal social communicative exchanges and maintain active engagement. b. Implement communicative style adjustments to adapt to the unique learning style differences of an individual with HFA and AS. For example, the use of explicit and clear expressions of one’s intentions and emotional states, devoid of idioms and sarcasm, often supports the processing abilities of an individual with HFA or AS. In contrast, the use of a high rate of nonverbal social cues (e.g., raising one’s eyebrows to indicate distaste) when interacting with individuals with AS or the use of verbal language in the absence of static visual cues (e.g., concrete gestures) with an individual with HFA may actually provide barriers to achieving successful communicative exchange. Consideration should also be given to factors such as vocal volume, rate of speech, prosody, proximity, and physical contact. c. Coordinate communicative style adjustments across all of the individual’s social partners (e.g., peers, teachers and professionals, family members, and members of the community). II. Learning and educational supports a. Design visual and organizational supports to foster social communication and emotional regulation across social partners and social contexts (e.g., understanding the communicative intentions and emotional state of another, understanding of time and activity structure as a means of preparing for potentially dysregulating events, and identifying one’s emotional state and socially acceptable coping strategies). b. Arrange and modify the physical environment to support social communication and emotional regulation. For example, accommodations such as clear physical boundaries for activities, clear temporal structure, reducing levels of auditory and visual stimulation, if appropriate, and providing opportunities to engage in social interactions in small group contexts. Consideration should also be given to the demands of a given environment, as expectations should be appropriately matched to an individual’s unique challenges and learning style (e.g., curriculum modifications, reduced expectations for homework). III. Family support a. Specific accommodations should be developed across all family members who interact with the individual with HFA and AS. A particular emphasis should be placed on fostering an understanding of the nature of the disability and the communicative style adjustments, learning supports, and environmental arrangements that can be implemented in order to facilitate more positive social exchanges and development in the areas of social communication and emotional regulation. b. Emotional support should also be provided in both one-to-one and group contexts by supporting each family member’s ability to cope with the stress and challenges of raising or interacting with an individual with HFA or AS. A particular emphasis should be placed on supporting an ability to identify priorities and develop appropriate expectations and realistic, achievable goals for the family as a whole as well as the individual’s ongoing development and drive toward social communicative competence. 990 Interventions modifications that a social partner might make with respect to interpersonal style, use of expressive language, and use of nonverbal forms of communication (e.g., gestures, facial expressions, and intonation) to match the unique needs of the individual with HFA or AS (Prizant et al., in press; Quill, 1995). Identifying those aspects of interactions that either support or interfere with an individual’s ability to engage in successful, self-initiated, and reciprocal interactions allows for greater attunement when facilitating interactions across social partners and settings. These interpersonal supports should be targeted across parents, peers, teachers, professionals, and other members of the community, and may vary depending on the partner’s role in enabling the development of each individual’s social competence throughout his or her daily routine. Because the impact of a social disability on family members is unique to that of other social partners, providing family support is discussed in greater detail. Interpersonal Support for Peers Individuals with HFA and AS often demonstrate an interest in peers, and, particularly as they mature, they yearn for friendships and social acceptance. The nature of their social impairment, however, compromises their understanding of the social conventions necessary for entering into play-based interactions, joining in social conversations, and/or engaging in the repartee that comes so naturally to their peers (Schuler & Wolfberg, 2000). These challenges reinforce a tendency that already exists for those with HFA and AS to become adult-directed and to turn toward their teachers, caregivers, or employers rather than their peers as partners in interactions. Because children learn through observation, imitation, and collaboration with peers, more typical learning strategies are less common in HFA and AS. Consequently, there is a dual risk of social isolation, that is, limited opportunities for learning within social interactions with peers and learned helplessness—an overreliance on adults for prompting or cueing of behaviors. In a school setting, simply being alongside peers in an integrated classroom will not allow students with HFA and AS to develop social skills and engage in interactions or form friendships (Kohler, Strain, & Shearer, 1996). The individualized educational plan with its social goals and objectives should, therefore, be designed to develop the individual’s capacity for joint attention and understanding of symbolic conventions (see Table 32.1) to maximize the likelihood that the individual is equipped to use opportunities, both created and naturally occurring, for practicing and engaging in positive bids for social interaction. The other essential part of the equation is to provide the peer group with specific strategies and support. Peer training and support is required to foster a level of understanding as well as communicative style adjustments for supporting and engaging the individual with a social disability in ways that are sensitive, pleasurable, and appropriate for the context. When thoughtful approaches to peer-mediated intervention are implemented, as in the use of peer-implemented pivotal response training, integrated play groups, play organizers, and buddy skills training programs (discussed in greater detail later), research shows that the interactions between individuals with HFA and AS and their typical peers tend to increase across contexts and that, on occasion, those interactions extend to other students as well (English, Goldstein, Shafer, & Kaczmarek, 1997; Goldstein & Wickstrom, 1986; Oke & Schreibman, 1990; Pierce & Schreibman, 1995; Strain, Kohler, Storey, & Danko, 1994; Wolfberg, 1988). This results in an enlarged social network and expands the frequency with which the affected individual will have the opportunity to practice and experience social success through his or her day and over time. Failure to include the individual’s peer network in a support program may contribute to peers’ misinterpretation or anxiety about unexpected behaviors and responses or, for those affected individuals whose style is more passive, to peers’ decreased expectations and attempts to engage them socially, thereby reducing the very opportunities for interaction that they need. Likewise, you must observe and seek the input of typical peers to ensure that the social conventions being fostered are relevant and age appropriate because acceptance into a given network or community of social partners requires expertise in the particular interpersonal styles used within a given context Communication Skills in Individuals with High-Functioning Autism and Asperger Syndrome and peer group. Particularly during the adolescent years, these conventions (e.g., the language used, the style of dress, and preferred topics of conversation) may vary from group to group or time to time. Failure to attend to these important nonverbal and verbal features may jeopardize successful attempts to engage. It is important to deemphasize the role of teacher as instructor and increase the peers’ responsibility for the successful social interaction (Brown & Conroy, 2002). In many instances, it appears that not only can peer-mediated interventions be as effective as teacher-based instruction but also, more importantly, there may be some generalization of spontaneous social bids across peers and settings, as the students begin to recognize each other as potential partners independent of the adults around them (Oke & Schreibman, 1990; Pierce & Schreibman, 1995; Strain et al., 1994). It is important to keep in mind that while peers become more active as facilitators, they continue to require support and supervision from the adults who develop the students’ skills and understanding of how best to promote interactions. In addition, staff must try to ensure that the individuals with HFA or AS do not become passive or reliant on their peer supports and that they are seen as partners with responsibilities within the interactions. The involvement of a peer network depends, in part, on the developmental level and the settings in which the students are engaged. Younger peers, for example, may simply need reassurance regarding the reasons for a given individual’s difficulties with emotional regulation, how to reinforce more positive and adaptive responses, and how to simply redirect to desirable or regulating activities. Likewise, these peers would benefit from explicit training and support in how to modify their use and interpretation of language and nonverbal forms of communication when engaged in communicative exchanges with the individual with HFA or AS. Social skills programs and play-based groups that incorporate simple cues for peers, such as the integrated play group model presented by Wolfberg (2003), play organizers offered by Odom et al. (1999), the buddy skills training program presented by English et al. (1997), and pivotal response training presented by Pierce and Schreibman 991 (1995, 1997), foster social partners’ ability to modify their communicative style by acting more responsively; providing social overtures such as prompting, choices, and praise; and using natural reinforcement appropriate to the given social context. Older peers may receive more explicit information about the nature of HFA and AS within a broader context of appreciating differences and increasing tolerance for these within the school community as a whole. Approaches such as the Circle of Friends and peer networks capitalize on the sensitivity of typical peers, as their curricula are designed to foster awareness of learning style differences across individuals and to teach the critical communicative style adjustments that can allow for more positive social exchanges both within social group settings and outside the school environment (Haring & Breen, 1992; Kamps, Potucek, Lopez, Kravits, & Kemmerer, 1997; Whitaker, Barratt, Joy, Potter, & Thomas, 1998). Some peer group programs targeting academic, as opposed to social skills and play, have led to secondary gains in social interaction between participating students. In studies using classwide peer tutoring (Kamps, Barbetta, Leonard, & Delquadri, 1994) and cooperative learning groups (Kamps, Leonard, Potucek, & Garrison, 1995), students with HFA and their typical classroom peers worked cooperatively to improve reading skills (fluency and comprehension), understanding of vocabulary, and question comprehension by participating in academic-based games for practice of skills. An important part of the process was role reversal—each student took the role of trainer and trainee at different points, providing an opportunity for equal status and for perspective taking. Outcomes included gains in the targeted academic areas, but perhaps more importantly, greater engagement in the academic process, more peer interaction and integration, and greater duration of engagement in social interaction. Results indicated that use of peers proved as effective an outcome as teacher-delivered intervention, and it was felt that the inherent structure of the tasks promoted the communicative style adjustments that were needed to foster successful engagement across the individuals with HFA and their peers. 992 Interventions Last, a number of peer support programs and curricula have been developed to foster success within groups of children working on common social learning objectives and goals, strategies which are also applicable within integrated settings. The I LAUGH model presented by Winner (2002) and Navigating the Social World presented by McAfee (2002), for example, provide a framework for addressing vulnerabilities in social communication by incorporating learning style accommodations and communicative style adjustments across the day as well as within group learning contexts with peers with difficulties with social cognition. Relationship development intervention (RDI; Gutstein, 2000) is another curricular model that approaches the building of capacities for social relationships from a developmental perspective by placing an emphasis on fostering genuine pleasure from social interactions with others, replicating the progression in affective-emotional development of typical infants and children. In the RDI approach, children are often paired with other children with similar social communication challenges, at least initially. The rationale for this accommodation is due, in part, to the notion that typical peers are so adept at social interactions that they simply take too much responsibility, potentially increasing learned helplessness within the children with HFA and AS. Within the structure of the sessions, “experience-sharing” activities and games are designed to promote awareness of and attunement to the other children, in contexts where they are actively enjoying themselves, while also developing their sense of self- and mutual regulation. This approach aims to promote the underpinnings for social relationship building that will increase the individual’s desire to initiate, maintain, and extend interactions with others. Key elements of these curricula and intervention models are their appreciation of the transactional nature of social communication, as support is provided both to the individual with the disability as well as his or her peers, partners, and larger social network. Interpersonal Supports for Teachers and Professionals Within a comprehensive educational program designed to foster social communicative competence, it would be appropriate for interpersonal supports to be developed across all teachers, professionals, and paraprofessionals who will be working directly with the individual with HFA or AS as well as those who come into regular, albeit less frequent, contact. In a manner similar to peer-mediated interventions, a critical first step will be to identify the qualities of a specific teacher’s or professional’s use of verbal and nonverbal forms of communication that are either facilitative or provide barriers to attempts to engage in reciprocal social communicative exchanges and maintain active engagement. Communicative style adjustments should then be developed to adapt to the unique learning style differences of an individual with HFA and AS. For example, the use of explicit and clear expressions of an individual’s intentions and emotional states, devoid of idioms and sarcasm, often supports the processing abilities of an individual with HFA or AS. In contrast, the use of a high rate of nonverbal social cues (e.g., raising the eyebrows to indicate distaste) when interacting with individuals with AS or the use of verbal language in the absence of static visual cues (e.g., concrete gestures or written language) with an individual with HFA may impede the achievement of successful communicative exchanges. Consideration should also be given to factors such as vocal volume, rate of speech, pause time for processing and formulation of a response, prosodic variations, proximity, and physical contact. In middle school and high school settings, this assessment process can be complicated because the number of teachers and professionals that a student will likely come in regular contact with increases significantly from elementary school settings. Consequently, careful consideration should be given to the composition of a student’s educational team because the unique learning style differences of individuals with HFA and individuals with AS require a significant commitment on the part of the educational staff to provide accommodations such as modifying the use of nonverbal versus verbal discourse for a particular individual. As with any other job or occupation, there are individuals whose natural temperaments and interests make them the ideal candidates for working with individuals with HFA and AS, and there are others who, through no fault of their own, may be less suited to Communication Skills in Individuals with High-Functioning Autism and Asperger Syndrome this work. It is important for both staff and recipients of training to be honest about their strengths and what they find more challenging in the task of teaching this population. Characteristics that may increase the likelihood of becoming a positive facilitator for an individual with HFA or AS include, but are not limited to, curiosity about learning style differences, a capacity for organization and temporal structure, and flexibility with respect to the interactive style adopted with individual students. Additionally, those teachers and professionals who present with more than usually well-developed social skills, affective attunement, and unlimited patience when faced with unconventional social behavior are often the most adept at reflecting, analyzing, and putting into place effective interventions. These interventions can help in preventing a high frequency of social communicative breakdowns and social and environmental antecedents that lead to states of emotional dysregulation for individuals with HFA and AS. It is also important to be able to share some of the responsibilities, to have a capacity to supervise, and to appreciate the experience of parents, welcoming them as part of the team. Training of educators should be paramount and should include all members of the school community. The degree of training may vary, however, depending on the level of responsibility for the implementation of the individualized educational programming. Those with direct responsibility such as special education teachers and therapeutic personnel (e.g., school psychologists, speech-language pathologists, occupational therapists), for example, should have specific expertise in HFA and AS and would benefit from knowledge of the core challenges that compromise the development of social communicative competence in these social disabilities (e.g., core challenges in social communication and emotional regulation). These staff members should also be familiar with the specific modalities, methods, and strategies that are the most effective in accommodating the distinct learning challenges associated with these social disabilities within an individualized educational program. Other personnel such as paraprofessionals, regular education teachers, and administrators should receive in-service training on the unique learning styles and developmental 993 profiles of students with social learning disabilities in order to foster greater awareness of how to teach to their strengths, how to understand and read their reactions, and how to support their academic and social growth in the mainstream or nonacademic arenas in which they will be placed. Those personnel who may be less visible, but are frequently in charge during the more challenging parts of the day (e.g., bus drivers, crossing guards, cafeteria workers, and recess monitors), also need to be familiar with the specific communicative style adjustments that facilitate positive social communicative interactions and those that may result in communicative breakdowns and frustration on the part of students with HFA and AS. These staff members are, in fact, critical because students with HFA and AS are vulnerable during times of transition (e.g., riding a bus or walking to school), when their time is unstructured as it often is during recess, and when the social demands are particularly high such as in a cafeteria setting. For this group of staff, there will likely be very specific routines/demands that occur during their time with the student (e.g., lunch routines, traveling on the bus). An analysis of what happens and how a student manages these routines will allow for planning and staff support so that action plans, visual supports, environmental modifications, and practice of the events can occur. Should difficulties arise, an understanding of the elements that may be interfering can lead to changes and modifications that allow for greater success. For example, where a student sits on a bus, who sits next to him or her, having the student meet the driver, and ensuring that he or she knows the routine for getting to and from the bus will likely alleviate anxiety and promote a smooth transition. Some students may benefit from having something that they can do on the bus—listening to music, looking at a favorite book, or having a preferred toy to play with—allowing them to cope with the trip more comfortably. Interpersonal Supports for Members of the Community Although the family and those close to the individual with HFA and AS form their community at an early age, the range of opportunities that are age appropriate and culturally typical greatly expand as an individual 994 Interventions matures. These unique social experiences coupled with developmental capacities in social communication and emotional regulation set the stage for social awareness and growth. Such opportunities can facilitate an ability to interpret another’s perspective as well as an ability to modify the use and interpretation of language based on the perspectives of those involved and/or the social context. These opportunities for active engagement across a range of social partners and social settings are, indeed, a critical factor in the achievement of social communicative competence and may form the basis for important leisure time activities and group membership. Selection of community-based activities, however, should be based on the preferences and unique learning style strengths of an individual with HFA and AS, as well as a consideration of the social demands related to the activity. Since communicative style adjustments should be embedded within these community settings and across the social partners within them, it is essential to predetermine who will be running, teaching, or organizing programs and whether they will be open and willing to adjust their use of nonverbal and verbal forms of communication when interacting with the individual with HFA or AS to facilitate successful social exchanges and maintain emotional regulation. Parents may find that their role as assistant coach, volunteer parent, or administrative assistant allows for the additional interpersonal support necessary for successful inclusion in clubs, sports, and/or extracurricular activities. For many, though not all individuals with HFA and AS, team sports are particularly challenging because they require both motor skills and social awareness for team playing. In particular, team experiences at the schoolage, middle school, and high school levels are clearly challenging because the player needs to cooperate, integrate temporal motor movements with visual tracking, and simultaneously attend to verbal and nonverbal cues during fast-paced (i.e., transient) social interactions. The competitive nature of these events also diminishes the likelihood that peers will be tolerant of “someone learning on the job.” Interpersonal supports such as having a social partner modify his or her use of nonverbal or verbal discourse are not likely to occur in these fast-paced and competitive contexts. Sports such as swimming, martial arts, skiing, and horseback riding are more individualized, yet occur within social group settings. Since interactions with peers are less fast-paced in these contexts, they may allow for communicative style adjustments and time to foster positive social communicative exchanges. These activities may, as a result, build self-esteem and confidence and can be lifelong pastimes that allow for shared experiences. Likewise, Special Olympics, bowling leagues, chess clubs, and music/drama groups provide many teens and young adults with typical social and physical opportunities that are structured and offer genuine pleasure and a sense of achievement. The experience of being competent and adept provides a more balanced base from which to interact and may, therefore, allow for somewhat different and more “ typical” social opportunities. Social coaching for both partners in the interaction may facilitate further development of social relationships that are mutually satisfying. The need for interpersonal supports will continue to be essential as the individual with HFA and AS matures and transitions from high school into postsecondary educational settings, supported living arrangements, and/or group homes (if appropriate). Once again, knowing what the social and communicative demands are in a given situation can allow for tailoring of specific skills to help the individuals to fit in and feel capable of meeting the expectations of the new situation. Additionally, educational opportunities for the broader community (e.g., law enforcement agencies, religious institutions, and vocational settings) can be beneficial when ensuring the long-term goal of providing interpersonal supports that foster social communicative competence for an individual with HFA and AS. For example, education programs designed to foster awareness among law enforcement agencies provide a critical aspect of community teaching, since individuals with ASDs are not immune from situations in which they may be involved with the legal system. The stress involved in situations such as minor car accidents, misunderstandings, or having been led unwittingly into a situation involving some illegal activity places tremendous burdens on self-regulatory capacities, interper- Communication Skills in Individuals with High-Functioning Autism and Asperger Syndrome sonal skills, and the ability to communicate and advocate effectively for oneself. Having a police department with staff who are informed about social disabilities and psychiatric disorders is essential if the situation is to be understood and resolved in an informed, accurate, and fair manner. It is also critical to have advocates and lawyers who can be available to ensure that individuals are aware of their rights, to provide an accurate account of their role, and to ensure that their intents as well as their actions are both assessed and understood. As adults, individuals with these social disabilities will still greatly benefit from the support of professionals and mentors with specific training who can ensure that communicative style adjustments are implemented across all social partners and across daily routines and settings (e.g., academic settings, living arrangements, and places of employment). Learning and Educational Supports As discussed previously, there are significant differences as well as commonalities in learning styles between individuals with HFA and AS. Designing appropriate learning and educational supports to facilitate social communicative competence requires a careful consideration of the individual’s unique profile of strengths and needs, the expectations of a given social context, as well as the priorities of the family (NRC, 2001). With respect to the commonalities in core challenges in social communication and emotional regulation among individuals with HFA and AS, they will need a similar range of learning accommodations. These supports tend to fall within two primary categories: visual and organizational supports and environmental modifications (Prizant et al., in press). Visual and Organizational Supports Visual and organizational supports should be designed to foster an individual’s capacities for social communication and emotional regulation across social partners and social contexts based on core challenges in these domains (e.g., understanding the communicative intentions and emotional state of another, understanding of time and activity structure as a means of preparing for potentially dys- 995 regulating events, and identifying an individual’s emotional state and socially acceptable coping strategies). Although individuals with HFA and AS can be different with respect to their abilities to process verbal language and visual-spatial information (as discussed previously), they share a common area of relative strength in processing the written word (Rourke & Tsatsanis, 2000; Wetherby et al., 2000). This common modality has led to the development of a number of effective visual and organizational supports for individuals with HFA and AS. The implementation of visual and organizational supports will depend, in part, on the current goals of the educational plan for an individual with HFA and AS. When fostering the understanding and use of verbal conventions for initiating, exchanging turns, and terminating interactions across different social settings, supports such as dialogue scripts (Krantz & McClannahan, 1998) capitalize on the common modality of the written word as a learning strength and foster an individual’s ability to engage in basic social conversations as well as conversational discourse within unique social contexts (e.g., dating and attending family celebrations). Modifications to these dialogue scripts, however, are often appropriate to ensure that an individual attends not only to his or her verbal discourse but also to the verbal discourse of his or her social partner. Thus, learning supports that involve a review of the content exchanged within these social conversations clearly serve to augment these social communicative exchanges. These include, but are not limited to, the use of comic strip conversations (Gray, 1994), video replay (i.e., videotaping and reviewing actual social exchanges with peers and social partners),and video modeling (i.e., the use of videos to model appropriate conversational skills and social conventions). Research has, in fact, documented the effectiveness of the use of video within educational programs designed to foster social communication skills (Charlop & Milstein, 1989). This support fostered an improved rate of skill acquisition, generalization of skills, and maintenance of skills for as long as 15 months. Thus, both dialogue scripts and video-based instruction provide appropriate 996 Interventions visual and organizational supports for enhancing conversational conventions. When fostering an individual’s ability to acquire and use cognitive-linguistic strategies to support attention and active engagement throughout daily routines, visual and organizational supports can be implemented to develop an awareness of the temporal structure and social communicative expectations of specific events. As noted earlier, the use of the written modality allows otherwise transient auditory information to be presented in a way that is static and present long enough to be understood. It also allows for the salient and most necessary information to be presented, while decreasing extraneous stimuli that may distract or confuse. The use of a written schedule, for example, provides a clear sequence that can map the actual unfolding of an event that is far easier to appreciate than the rapidly fading, temporal equivalent of nonverbal social cues and the verbal modality. It, thereby, reduces the load on shortterm working memory and allows for reflection on cause and effect. In addition, with this more permanent way of representing event sequences, it is possible to reduce unpredictability and accompanying anxiety, fostering better emotional regulation, which increases availability for social engagement and reduces maladaptive social behavior (Dalrymple, 1995; Myles & Simpson, 1998). Visual and organizational supports can also be used to foster an awareness of another’s intentions, emotional states, and perspectives. This developmental goal leads to improved social communicative reciprocity as well as increased emotional regulatory capacities, as the individual’s ability to accurately read another’s intents contributes to sustaining a more reciprocal interaction (Prizant et al., in press). Gray and Garand (1993) discussed the use of social stories as a visual modality for enhancing an individual’s awareness of a social partner’s perspective and the impact of this social information on his or her own perspective and social communicative behaviors. This learning support involves consideration of the following critical elements: 1. The perspective of the affected individual, a frequently overlooked variable, although often central to correctly understanding the 2. 3. 4. 5. 6. 7. 8. potential causes of social difficulties as well as effective interventions; The use of simple visual cues (e.g., simple pictures, cartoons, written text, and rulebased color coding); Careful attention to the social context to determine what social conventions are appropriate; Extraction of those salient features in a social situation that are the most relevant; Explicit directions as to what behaviors/responses might be appropriate; Inclusion of possible emotional reactions, that is, the social partner’s perspective; Explanation as to why a particular choice of positive behaviors will provide a positive consequence with respect to the perspectives of self as well as others; and An attempt to unravel the complexities of later social relationships and to make positive social choices and decisions. By implementing tools such as social stories prior to an anticipated social event, you can provide an individual with HFA and AS with a cognitive-linguistic strategy to prepare and rehearse socially appropriate conversational discourse and emotional regulatory strategies (Hagiwara & Myles, 2001). As an instructional strategy, social stories were designed with a specific directive to be implemented in a positive rather than a negative manner so that the individual is encouraged to develop more adaptive behaviors, rather than being reminded of those to be extinguished. Perhaps most importantly, these supports should be designed with respect to the specific contexts in which social events are occurring so that the final intervention is personalized and functional for the individual with HFA and AS. Additional strategies using visual /written means to facilitate social problem solving have been developed as part of the I LAUGH model (Winner, 2002), the Teach Me Language program (Freeman & Dake, 1997), and by Roosa (1997), whose Situations Options Choices Strategies and Stimulation (SOCCSS) program provides a sequence to facilitate an individual’s understanding of a social problem, an appreciation of having more than one option for a response, and an awareness that each choice will also have its own consequence. Again, these Communication Skills in Individuals with High-Functioning Autism and Asperger Syndrome approaches foster more flexible thinking, provide more than one perspective, and encourage active participation on the part of the individual so that he or she is empowered to develop social decision making and social cognition. Environmental Modifications A preference for learning within predictable routines and for very explicit instruction of implicit social messages is a common pattern noted across individuals with HFA and AS (Schuler, 1995). This preference is secondary, in part, to persistent difficulties with understanding the communicative intentions and emotional states of social partners and difficulties with maintaining a steady emotional and physiological state of arousal, that is, active engagement in a given social environment. These patterns speak to the need to modify each of the social settings that an individual engages in within daily routines. Special events (e.g., family celebrations or vacations) that fall outside the usual routine will require even more careful consideration. Environments should be arranged or modified to support an individual’s capacities for social communication and emotional regulation. For example, accommodations might include clear physical boundaries for activities, clear temporal structure, reducing levels of auditory and visual stimulation, if appropriate, and offering opportunities to engage in social interactions in small group contexts (Dalrymple, 1995). Consideration should also be given to the demands of a given environment, as expectations should be appropriately matched to an individual’s unique challenges and learning style (e.g., curriculum modifications, reduced expectations for homework). For some children, haircuts, dental appointments, and other necessary life events cause dysregulation because the unusual setting, need for intrusion on the part of novel adults, and, at times, unpleasant physiological response all contribute to high levels of tension and behavioral disruption. Families can be helped by finding professionals in the community who have dealt with children on the spectrum before and whose reputations for patience and understanding precede them. Children can accompany other family members when they have appointments so that the setting, required seating, noises, and smells become somewhat familiar. 997 During these “practice” visits, it might be helpful to have the child sit in the chair, press a button, or turn on the water as real-life opportunities for experiencing cause and effect, experiencing control over some aspect of the environment, which may help to decrease anxiety and give a sense of mastery. Using a social story or simple photo series that explains the sequence of events for the appointment may then allow for a successful first time of the child’s own, one which he or she can then share with extended family and friends. Family Supports An individual initially develops his or her selfconfidence as a social communicative partner through positive social interactions and successful communicative exchanges within the context of interactions with family members (e.g., parents, siblings, and grandparents) and eventually during social experiences across settings and partners. The family and home contexts, in fact, follow an individual throughout his or her life, while specific educational contexts and professionals “come and go” (Domingue, Cutler, & McTarnaghan, 2000, p. 380). Likewise, the experiences of a family unit contribute greatly to an individual’s social communicative competence, as daily family routines (e.g., shopping and going to dinner) and family celebrations (e.g., weddings, birthday parties) provide the context for social and cultural learning (i.e., understanding symbolic conventions). Thus, the individual’s home and family settings are clearly critical contexts for addressing his or her drive toward achieving social communicative competence. Interpersonal supports (e.g., communicative style adjustments) and learning supports (e.g., visual tools and environmental arrangement) for use within the home and family contexts must be part of a comprehensive educational program (Prizant et al., in press). This accommodation, which has been supported by the NRC, requires the provision of therapeutic and educational support to family members with a particular focus on: (1) supporting an understanding of the nature of the social disability consistent with HFA or AS, as appropriate to the individual family and (2) developing specific modifications that 998 Interventions can be embedded across the day to foster social communication and emotional regulation (NRC, 2001, p. 219). All too often, a pattern of interactive breakdown develops, whereby an individual is not able to effectively communicate his or her intent to a family member and/or a family member is ineffective at reciprocating the exchange. This pattern often leads to the perception and often the real experience that interactions with the individual with HFA and AS are stressful and, in some cases, the interactions produce anxiety and frustration for both the individual and his or her family members. When appropriate supports are established, family members will be more likely to experience a sense of competence as effective communicative and social partners with respect to their children or siblings with HFA or AS (Dawson & Osterling, 1997). The role of family support when implementing strategies designed to enhance social communicative competence for an individual with HFA and AS, however, is not limited to the provision of specific training and educational input. Rather, long-term positive outcomes for individuals with social disabilities require sustained efforts to reduce the emotional stress associated with raising or living with an individual with a disability by providing individualized and family-centered emotional support (Dawson & Osterling, 1997; NRC, 2001). “Adaptation to having a child with a disability is a lifelong process that occurs in a vastly different manner from family to family and even among family members within the same family” (Domingue et al., 2000, p. 373). Therefore, the provision of contexts for one-on-one emotional support and counseling to foster appropriate expectations and achievable goals for family life is another critical component of an educational program for an individual with HFA and AS. CONCLUSION Although there is great heterogeneity across individuals with HFA and AS with respect to personal circumstances (e.g., social settings, family life, and culture) and learning style, there is a common pattern of impairments in social communication (i.e., the capacity for joint attention and understanding of symbolic conventions) and emotional regulation (i.e., the ability to maintain a state of active engagement across social contexts) that compromises the ability to achieve social communicative competence. These learning style differences and developmental vulnerabilities remain a significant challenge across all settings throughout an individual’s life and provide potential barriers to achieving social communicative competence that can be, in many cases, devastating to the individual (Volkmar et al., 2000). While the social impairment is attributable largely to the developmental vulnerabilities and learning style differences of the individual with HFA and AS, the “social impairment is shared” across all of those who have social contact, positive or negative, with the individual (Gray, 2001). Therefore, the success of any given social exchange relies not only on an individual’s ability to adhere to social conventions, remain actively engaged, and accurately consider another’s intents, but also on a social partner’s ability to adapt his or her interpersonal style and the environment to match the needs of the individual with the social disability. Thus, comprehensive programming designed to foster social communicative competence must be understood as integral across an individual’s day (e.g., each class at school), across contexts (e.g., school, home, and community), and across social partners. Additionally, it is critical to consider the following sources of information when designing an individualized educational program: (1) our current understanding of the core challenges that compromise social communicative competence that are faced by individuals with HFA and AS, (2) the unique learning style differences often associated with HFA and AS, and (3) our awareness of the critical priorities for developing a comprehensive intervention program designed to foster social communicative competence (e.g., establishing interpersonal supports, learning and educational supports, and the provision of family-centered supports). To develop social communicative competence within functional and natural settings, you must keep in mind the importance of supporting an individual’s capacity for emotional regulation. 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