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Teaching Social Skills to Children with Pervasive Developmental Disorders

22q11.2 Deletion Syndrome Conference
Marjorie Solomon, Ph.D., Assistant clinical Professor U.C. Davis Health System M.I.N.D. Institute Elwyn March 2007

Presentation Outline
1.

Individuals with Pervasive Developmental Disorders

Diagnostic characteristics Other similar disorders

2.

Features of PDDs
Social and Emotional Characteristics (Emotion and Face Processing), Theory of Mind Cognitive Characteristics (Executive Functions)

3.

Remediation Strategies Research and Practice

Academics Social Functioning
Teaching teens social skills with movies

Children with 22q11.2 Deletion Syndrome and Social Skills

High rates of PDD in children with 22q11.2 deletion syndrome (50%) Social problems widely reported (Debanne, Glaser, David, Feinstein, & Eliez, 2006) ASD interventions can be used profitably with children with PDD (Solomon, Hessl, Chiu, Hagerman, & Hendren, in press)

DSM-IV-TR: Core Features in Autistic Disorder and ASDs

Impairments in Social Interaction Impairments in Verbal and Nonverbal Communication Restricted and Repetitive Patterns of Behavior

Social Symptoms in PDD

poor regulation of social interaction through eye
contact, facial expression, gesture, posture, intonation failure to develop age-appropriate peer relationships limited social-emotional reciprocity

empathy aloofness

Communication Symptoms in PDD

repetitive or idiosyncratic language

echolalia (including delayed) neologisms overly formal or pedantic language difficulty taking listeners perspective limited reciprocity

poor conversational abilities

Repetitive Behavior Symptoms in PDDs

encompassing preoccupations

unusual topics focus on details, difficulty differentiating relevant from irrelevant information

insistence on sameness, ritualistic behavior stereotyped body movements preoccupation with parts or sensory aspects
of objects

Autistic Disorder
the most common PDD > 6 symptoms from DSM-IV-TR list

2 social 1 communication 1 restricted/repetitive behavior

onset before age 3

Aspergers Disorder
ruled out if criteria for autism met < 6 symptoms from DSM-IV

2 social 1 restricted/repetitive behavior

normal IQ (> 70) no history of language delay

Pervasive Developmental Disorder Not Otherwise Specified (PDDNOS)

used when criteria for other PDDs not met

subthreshold
number of symptoms pattern of symptoms severity

atypical
age of onset uncommon symptoms

PDDNOS, continued
must demonstrate symptoms in at least 2 areas, one of which must be social
social + communication social + behavior typographical error in DSM-IV, p. 77

PDDNOS often misdiagnosed

approximately 30% meet criteria for autism >40% do not meet criteria for any PDD (source: DSM-IV Field Trials) PDDNOS is also found as a feature of other diagnoses including childhood onset schizophrenia Sporn et al., ADHD (Verte et al.), fragile X Syndrome (Hagerman, 2001) and 22qll.2 deletion syndrome (Vorstman et al., 2005)

Whats in a Name? NLD

NLD is a term coined by neuropsychologists who interested in brain hemisphere laterality Some, but not all, children with ASDs have NLD cognitive profiles

The typical pattern in children with autism is actually PIQ>VIQ

This information about relative strengths and weaknesses is useful for educational and treatment planning Not all children meeting the criteria for NLD have social deficits that are as pronounced as children with ASDs

Whats in a Name? Semantic Pragmatic Disorder

Rapin & Allen (1983) coin the term semantic pragmatic disorder syndrome They have trouble understanding discourseThe children usually have an intact or superior auditory memory and are fluent. They may repeat whole sentences verbatim or recite TV comercials their speech (has) a loose, tangential or somewhat inappropriate quality A subcategory of PDDNOS? A bridge between language impairment and autism (Bishop, 2000)

Whats in a Name? Sensory Integration Dysfunction

Parents of many children with ASDs report that their children experience sensory stimuli in atypical ways Parents of many children with general behavioral dysregulation also report their children have sensory issues Many parents of children with ASDs report that OT is extremely helpful for their children Empirical work about sensory issues in children with ASDs and OT treatment efficacy is needed (see Baranek, 2002; Stackhouse et al., 2003)

Features of ASDs: Clinical and Research Observations

Deficits in Emotional Awareness and Understanding

Emotion perception and comprehension (Downs & Smith, 2004; Hobson, 1986; Fein, Lucci, Braverman & Waterhouse, 1992) Experiencing relationship-based emotions (Hobson, 1993, 2002, 2005). Labeling and explaining their own emotions (Capps, Yirmiya, & Sigman, 1992), and those of other children (Yirmiya, Sigman, Kasari, & Mundy, 1992) Individuals experience jealousy, but understanding is less complex and nuanced than typically developing children (Bauminger, 2004) Predicts difficulty in developing affective closeness and intimacy.

Deficits in Emotional Awareness and Understanding: Face Processing

Mixed results in the literature; simple versus complex emotion distinction; role of VIQ (Robins, Tracy & Solomon, in preparation) Bias towards visual-verbal over visual-affective information when processing facial expressions of emotion (Grossman, Klin, Carter, & Volkmar, 2000) Non-typical neural recruitment in face perception (Boucher & Lewis, 1992; Critchely, Daley, Bullmore et al., 2000; Pierce, Muller, Ambrose, Allen, & Courchesne, 2001; Schultz et al., 2003) Abnormal eye tracking patterns (Klin, Jones, Schultz, Volkmar, & Cohen, 2002)

Deficits in Theory of Mind: What is TOM?

Being able to infer the full range of mental states (Beliefs, desires, intentions, imagination, emotions, etc.) that cause action. In brief, to be able to reflect on the contents of ones own and others minds. (Baron-Cohen, 2000) The ability to represent others mental states and use social cues as a key to interpreting behavior (Casari & Rotheram-Fuller, 2005) The capacity to understand and manipulate the mental states of others and to thereby alter their behavior (Frith & Frith, 1999) Also known as mentalizing, perspective taking, introspective awarenessempathy

Deficits in Theory of Mind: Older and Higher-Functioning Individuals

Difficulty detecting Faux Pas (Baron-Cohen, ORiordan, Stone, Jones, & Plaistad, 1999) Difficulty reading intentions from the eye region of faces (Baron-Cohen, & Hammer, 1997) Poor performance in attributing social meaning to ambiguous visual stimuli (Klin, 2000) Inability to read the mind in the voice (Rutherford, Baron-Cohen, & Wheelwright, 2002) Difficulties on Strange Stories, Cartoons and the Eyes task, but also on control tasks (Brent et al., 2004) High functioning persons with ASDs possess a lateacquired, explicit TOM, which appears to be the result of effortful learning (Frith & Happe, 1999)

Deficits in Executive Functions: What are Executive Functions?

Skills required to prepare for and execute complex behavior Inititiation Planning Inhibition Organization Self-monitoring Mental representation of tasks and goals Cognitive Flexibility Set Shifting

 EF established as an influential theory of autism (Ozonoff, Pennington, & Rogers, 1991) Progression through the 1990s to affirm that autism involves a specific versus a generalized deficit (Chapman & Chapman, 1978) and to document which component processes are impaired using clinical neuropsychology and cognitive neuroscience methods. Impaired are: Planning as assessed by Tower Task (Ozonoff, Pennington, & Rogers, 1991); Set shifting as assessed by WCST and other cognitive flexibility tasks; visual attention shifting Spared are: Working memory, inhibition Some also argue that autism involves spared simple information processes, but impaired complex processing (Minshew & colleagues)

Deficits in Executive Functions: Neuropsychology

Deficits in Executive Functions: Real-Life-Type Problem Solving

Getting stuck on the wrong details of a problem or stimulus overselectivity (Ozonoff, 1998) Difficulty shifting from ineffective to effective strategies (Twachtmann-Cullen, 2000) AS children impaired in recounting the pertinent facts, generating possible high-quality solutions, and selecting optimal, preferred, and socially appropriate solutions (Channon, Charman, Heap Crawford, & Rios, 2001) Difficulty with concept formation versus concept identification (Minshew, Meyer, & Goldstein, 2002)

A few disclaimers
We are further behind in the developing of empirically supported interventions for older high functioning children with PDD Empirically supported is a very high bar Good intervention should involve: assistance with social cognition, verbal and nonverbal communication, increased engagement in appropriate developmental activities, academic skills, fine and gross motor skills, reduction of problem behaviors, independent organization skills (Filapek, Steinberg-Epstein, & Book, 2006) This will be a review of best practices and recent research

Features of Social Adjustment Enhancement (Solomon, Goodlin-Jones, & Anders, 2004)

1 1/2 hours, 1 time/wk for 20 weeks w/concurrent parent group and sibling group 3:10 staff to student ratio Consistent visual schedule including a lesson time, game time, playground time Program operational for 6 years Children ages 5-17 have been served

Brief Overview of Social Adjustment Enhancement: Theoretical Orientation = Eclectic

Cognitive Behavioral
Stress management Problem solving approach Psychodynamic Develop observing ego Behavioral 3 point behavior system Group Feedback and support from other members Family Systems Use family to coach and to stabilize gains

Problem Solving for Parents

Child Characteristics Problems

Oppositionality

Theory of Mind Perspective taking Empathy

? ? ?

Rigidity Hyperactivity Introversion Extraversion

Executive Function/ Problem Solving Goal direction Motivation Organization

Emotion Awareness and Recognition Knowing ones own feelings Knowing those of others

Anxiety Cognitive Endowment Developmental Level

Autism Spectrum Disorder Deficits

Preparing Students for Change/Social Stories

My Social Story about Recess Time Change Most days we have recess at 12:00. Tomorrow will be a special day because the blacktop is being fixed. Tomorrow we will have recess at 11:00. This means we will skip music time for one day. Recess time will be the same as always. Mrs. Jones will be with us. Our class and the 3rd grade will be together. We will still have all the same equipment.

Group Exercise: Writing a Social Story

Please divide into 3 teams Write the following stories:

Going to a play Why it is important not to belch and fart in public Going to a birthday party

Remediation Techniques: Improving Emotional Understanding and Awareness

Emotion thermometers, comic strip conversations (Gray & Attwood) Computer interventions -- Gaining Face (www.ccoder.com/GainingFace; Emotion Trainer (Silver & Oakes, 2001) Rehabilitation literature -- individual instruction in the use of cognitively based expressive and interactive behaviors (Flaherty-Craig, Barrett, & Eslinger, 2002) Mind Reading interactive systematic guide to emotions in faces and voices produces close, but not distant, generalization (Golan & Baron-Cohen, 2006) However, face processing remediation produces no changes or differences in fusiform gyrus activation (Bolte et al., 2006)

Remediation Techniques: Improving Emotional Understanding and Awareness

Emotion thermometers Bouncing off the walls Body language charades Fun with the digital camera Emotion matching games Role plays

Remediation Techniques: Theory of Mind

Social skills group setting (Ozonoff & Miller, 1995) Teaching Children with Autism to Mind Read (Howlin, et al., 1999) Training on emotion, belief, and pretend play (Hadwin, et al., 1996, 1997) Provide action and emotional cues (Bowler & Stromm, 1998) Thoughts are like pictures in the head & thought bubbles (Swettenham, 1996;McGregor, 1998; Gomez et al., 1996) Training in EF actually improves TOM! (Fisher & Happe, 2005)

Remediation Techniques: Teaching Theory of Mind at M.I.N.D.

Stress the Golden Rule Introductory song w/ personal information Always highlight different perspectives Using teachable moments Friendship party Group name and logo

Remediation Techniques: Teaching Conversation Skills

Tennis ball conversations Recipe for a coversation = 1 starter + 1 comment+ 1 statement of your own + 1 pass. Follow the Rules (an adaptation of Grice, 19 )

Share the Air! Stay on the Same Page Be honest..

Remediation Techniques: Executive Functions Deficits

Contingency based self-management programs (Quinn, Swaggart, & Myles, 1994) Metacognitive strategies that enhance observing ego so childen can grapple with their maladaptive behaviors (for ADHD see Wasserstein & Lynn, 2001) Goal Management Training-- 5 steps to self-monitor results of actions (Levine & Robertson, et al., 2000) Teach external compensatory strategies Flexibility Training (see Sohlberg & Mateer, 2002)

Remediation Techniques: Real-LifeType Problem Solving

Points system Wicked witch visual template Leaders and followers Cognitive flexibility games Use of visual template Graduation projects Running commentary on cause and effect

Teaching Social Skills With Movies

Group Agenda
I. Beginning Circle II. Game or Outside Time Lesson Time/Movie Time/Snack Time Joke Time

# 1

Teen Group: The Beginning Circle

Goals:
To introduce group format and expectations To familiarize group members and leaders

To give members an opportunity to reflect on their own and others identities To serve as a vehicle for promoting progression through therapy process stages

Teen Group: The Beginning Circle -- Mechanics

News or announcements The Questions Discussion of Social Experiment Discussion of Phone Calls Use of Group Mascot

Teen Group: The Beginning Circle The Questions

Questions progress along with the group and ideally relate to topic under study or group stage related phenomena. Beginning questions:

What do you like? What kinds of ice cream/ foods/ pizza/ amusement park rides do you like? What are you like? (Options given) What is your personality like? (Options given)

Beginning Circle: Mid Group Questions

o Tell us about a friendship that youve had. What are two important characteristics in a friend? o What are you like in new situations? What are you like as a friend? o What is a problem youve had and how did you deal with it? o Have you ever been bullied. What did you do?

Beginning Circle: End of Group Questions

End of Group Questions: How have you changed during the group? In the past year? What have you liked most about the group? What will you miss? What wont you miss What are your summer plans? What do you think you will be doing in 5 years?

Game Time/ Outside Time

Vote on What to Do Indoor or outdoor Goals:

To practice skills required to play simple games To generate enthusiasm for the group and motivation for interacting with others To facilitate smaller group social interaction between different group members

Used as a setting to observe group members in social situations Every week different members volunteers to bring in music to play during game time

Game Time/ Outside Time

Members pair or group together Leaders monitor and assist in conversations, and fade out of interactions Positive behavior reinforced Socially inappropriate or unacceptable behavior used as teaching points Balls and playground equipment used

Opportunity to experience non-threatening athletics (football, races, the worm)

Lesson Time: General Progression of Lesson Topics

o Understanding your own feelings o Understanding the feelings and perspectives of others o First impressions o The meaning of friendship o Conversation skills o Irony, sarcasm, metaphors, figurative language, and subjective vs. objective information o Problem solving o Team Building

Lesson Time/Movie Time

Primary teaching vehicle for first 16 weeks are 10-20 minute film clips These provide a starting point for discussion of focal issues in the lesson and others that arise General progression of topics is the same during groups, however, flexibility is built in so that individual groups and chosen film clips can be tailored to member needs and interests Popcorn is served!

Lesson Time/Movie Time: Sample Themes

First impressions and how they develop (Harry Potter) The meaning of friendship (Holes, Star Wars) Social hierarchies (Holes) Appropriate male/female behavior (Dodge Ball)

Lesson Time/Movie Time: Sample Themes -2 Different Kinds of Comedy (Take the Money and Run; Monty Python & the Holy Grail) Team skills and why teams do and do not work (Miracle, October Sky) Coaches and Bosses (Miracle, Remember the Titans)

Lesson Time/Movie Time

Movie Scene Summary The Dead Poets Society New guy meets his roommate and his friends; roommate and father. 4min. 18 sec; 7min 18 sec into tape First impressions; friendship; personality traits; emotions Roommate wants to be an actor; new guy unsupportive. Discuss new guys introversion. 3min 29 sec; 47 min 05 sec into tape Being a friend; going against authority; problem solving Miracle Friction between players in bar and on the ice, Coach uses to bring team together. 5min 58 sec.; Chap. 4 Holes Caveman finds lipstick case; older boy claims to have found it and gets the day off without dispute. 6min 26 sec; Chap. 11 on DVD Social hierarchy; impressions; bullying Caveman and Zero climb mountain; 6min. 41 sec; Chap. 19 on DVD Zero confesses to Caveman. 4 min 36 sec; Chap. 21 on DVD

Teaching Point

Working as a team; emotions; leadership Players approach coach about replacing them; team/family theme; Christmas dinner. Chap. 10 on DVD; 8min 27 sec

Scene Summary

Teaching Point

Being a team/group; family not in literal terms

Friendship; empathy

Lesson Time/Movie Time

Movie Elf The Princess Bride Heathers

Scene Summary

Buddy the elf goes to work with Dad and in mailroom; Dad takes an important conference call. Chap. 11 on DVD Humor; personality traits

Battle of wits over which cup is poisoned. 5min. 12 sec; 30min 03 sec into tape

Girls croquet game; girl talking with parents; convenience store. 4min. 56 sec; 21 minutes into tape

Teaching Point

First impressions; assumptions

Phony friends; personality; motivation

Also watched: Harry Potter and the Sorcerers Stone; Monty Python and the Holy Grail; Dodgeball; Star Wars; Radio; Billy Elliott; The Breakfast Club; and Lord of the Rings

Joke Time
Goals:

To teach jokes and scaffold the development of sense of humor To continue teaching about irony, sarcasm, metaphors, and figurative language

Members can volunteer to share a joke or read from our books Safe place for feedback

Acknowledgements
For your attention To the teens and parents who participate in our groups To our wonderful volunteers Julia Hales, Neil Cummings, Petrina Kaluzhny and many others, as well as my colleagues Beth Goodlin-Jones, John Brown, Mary Beth Steinfeld, Erin Roseboro who work on social skills