Strategies for Improving the Social Integration of Children with Asperger's Syndrome

This paper was originally published in the journal autism, volume 4, pages 85-100. The journal is published by SAGE and the National Autistic Society. They currently allow authors to place the abstract and up to 50% of the full text article on their own website. The journal autism is an excellent source of articles on Asperger’s Syndrome.

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Abstract
There is general agreement that children with Asperger's Syndrome have difficulties in social integration with their peers. Our current understanding of the nature of these difficulties is explained and specific strategies are described that are designed to encourage greater competence in the skills that are necessary to achieve effective social integration. While we do not have any clear scientific evidence of whether and how these strategies are successful, they provide a source of ideas for future examination by academic research and provisional remedial programs for practitioners

Introduction (see original paper)

Characteristic Difficulties in Social Integration
The current diagnostic criteria define the characteristic difficulties of social integration as especially conspicuous when the child is interacting with their peers. There is an inability or lack of desire to interact with their peers or a failure to develop peer relationships appropriate to the child's developmental level. When the child is engaged in social interaction, one is aware of several conspicuous characteristics, such as a lack of reciprocity, little appreciation of social cues and failure to share enjoyment, interests or achievements with other people. Other characteristics include a failure adequately to use eye gaze, facial expressions, body posture and gesture to regulate the social interaction. There can also be socially and emotionally inappropriate behaviour and a difficulty reading emotion from the facial expression of the child. (American Psychiatric Association, 1994, Gillberg and Gillberg, 1989, Szatmari, Brenner and Nagy, 1989, World Health Organisation, 1993).

As we have only recently defined the characteristics of the syndrome, there are very few research studies that have included an analysis of the difficulties of social integration of subjects with a clear diagnosis of Asperger's Syndrome. Prior, Leekam, Ong, Eisenmajer, Wing, Gould and Dowe (1998) conducted a study that suggests that in comparison to children with typical autism, children with Asperger's Syndrome can actively look for friendship but in a clumsy and not very successful way. As one of the central diagnostic criteria is a failure to develop peer relationships appropriate to the child's developmental level, clinicians examine how the child conceptualises and demonstrates friendship skills. Normal children's conception of friendship changes over time and it is noticeable that children with Asperger's Syndrome often have an immature or unusual definition of friendship (Botroff, Bartak, Langford, Page and Tonge, 1995) Their definition may include an opinion on what a friend should not do but the child has little idea of what a friend should do.

While there is a lack of research studies in this area, additional knowledge may be obtained by accepting the theory of a continuum or spectrum of autistic disorders (Wing 1988) and incorporating research studies using children with autism who have been described as high functioning. While it is not the purpose of this paper to discuss the potential differentiation between Asperger's Syndrome and High Functioning Autism, it is important to consider similarities as well as differences between these two groups, especially as research and clinical experience confirms an overlap of symptoms in the area of social interaction (Ehlers, Nyden, Gillberg, Dahlgren Sandberg, Dahlgren, Hjelmaquist and Oden, 1997). The research on subjects with High Functioning Autism suggests they are less competent than normal controls in the understanding and expression of complex emotions (Capps, Yirmiya and Sigman, 1992, MacDonald, Rutter, Howlin, Rios, Le Conteur, Evered and Folstein, 1989). Clinical experience of children with Asperger's Syndrome suggests a similar difficulty, especially in the area of the facial expressions, with a tendency for partial expression, such as only moving their eyebrows to indicate the nominated emotion, odd expressions and taking considerable time and apparent intellectual effort with this task.

Further information on the characteristic difficulties in social integration can be obtained from consideration of one of the theoretical models used to explain the nature of autism and Asperger's Syndrome, and the associated research literature. One of the most significant advances in our understanding of autism and Asperger's Syndrome has been due to the research of Uta Frith, Simon Baron-Cohen and Francesca Happé which supports the hypothesis that children with autism and Asperger's Syndrome have an impairment in the fundamental ability to "mind read" (Baron-Cohen, 1995). From the age of around four years, children understand that other people have thoughts, knowledge, beliefs and desires that influence and explain their behaviour. In contrast, children with autism and Asperger's Syndrome have considerable difficulty conceptualising and appreciating the thoughts and feelings of another person. In other words, they lack the ability to think about thoughts. This has a major impact on the child's social reasoning skills and behaviour, for example, in distinguishing whether someone's actions are intentional or accidental, or how their actions or comments affect the thoughts of others. Finally, we know that Attention Deficit Hyperactivity disorder is a comorbid condition with Asperger's Syndrome (Ehlers and Gillberg, 1993, Eisenmajer, Prior, Leekam, Wing, Gould, Welham and Ong, 1996) and Pierce, Glad and Schreibman (1997) examined whether attentional deficits were related to impairments in the social functioning of nonretarded autistic children. These subjects had not been diagnosed as having Asperger's Syndrome but the results of the study may be applicable to this population. They investigated the effects of the number of social cues on the ability to interpret social situations. The presence of these additional cues assisted the control subjects= interpretation of social behaviour while for those subjects with autism, the additional cues impeded their performance. They also noted that the subjects with autism often attended to irrelevant stimuli such as the presence of a chair or the movements of the person's legs and considered these cues as relevant to social interpretation. Thus when designing specific strategies to achieve social integration, one must consider the potential aspects of an attention deficit and whether, as with autism, the more cues there are available, the more confused they may be, and one must ensure they are attending to the relevant cues.

Specific Strategies to Encourage Social Integration (see original paper)

Opportunities to interact with normal children
The first strategy is to ensure the child has opportunities to observe and interact with ordinary children at their school. This is to ensure that their peers not only demonstrate appropriate social/emotional behaviour but also are sufficiently socially skilled to know how to modify their social behaviour in order to accommodate and support the child with Asperger's Syndrome. Some children with Asperger's Syndrome attend schools for emotionally disturbed children; such circumstances may not provide an appropriate peer group.

Knowledge of the nature of Asperger's Syndrome
The mother of a young boy who had recently been diagnosed as having Asperger's Syndrome was asked by another mother if having the diagnosis had changed the child. Her reply was no, but that she had certainly changed, both in her attitude and level of understanding. This had a significant positive effect on her management strategies and ability to explain the child's behaviour to others and thereby facilitate their social integration. As children with Asperger's Syndrome have no distinct physical characteristics to indicate their disorder and their intellectual and physical abilities are perceived as within the normal range, other people may not be able to conceptualise the genuine difficulties the child has with the social/emotional aspects of life. Their errors in the skills necessary for social integration can be misinterpreted as having deliberate malevolent intent. We now have written material for parents and professionals that explains the nature of Asperger's Syndrome (Attwood, 1998, Howlin, 1998, Myles and Simpson, 1998), practical guides for teachers (Cumine, Leach and Stevenson, 1998, Thomas, Barratt, Clewley, Joy, Potter and Whitaker, 1998), and material to explain this disorder to other children. For example, Carol Gray (1993) has written a program for school children called the Sixth Sense, ie. the social sense. A series of activities highlights each sense and demonstrates how the sixth sense works. They are then encouraged to imagine what it must be like to have an impaired social sense and not fully understand the perceptual, cognitive and emotional perspective of others. For example, they are asked - would it be easy or difficult to take turns if you did not know what the other person is thinking or how they feel? Would it be easy or difficult to make friends? Finally, the children are encouraged to identify how they might assist their classmate with Asperger's Syndrome. There is also material to explain this disorder to the child themselves (Gray, 1996(a), Ives, 1999).

Teaching Theory of Mind skills. 41006. (see original paper)

Social Stories (see original paper)

Comic Strip Conversations (see original paper)

Social Skills Groups
There has been some success reported in the research literature for social skills groups for children, adolescents and young adults with autism and Asperger's Syndrome (Andron and Weber, 1998, Marriage, Gordon and Brand, 1995, Mesibov, 1984, Ozonoff and Miller, 1995, Williams, 1989). This strategy provides group tuition on why certain skills are important and practice applying those skills using modelling, role play, video recordings and constructive feedback. The courses have focused on conversation skills, reading and interpreting body language, understanding the perspective of others and friendship skills. A variation on this approach, focusing on the development of emotional intelligence, has been conducted by Linda Andron and Elizabeth Weber (1998) who have conducted social skills groups using family members, especially siblings, as participants. Their curriculum emphasises the development of appropriate affect in social situations. At present it is extremely difficult to determine whether social skills groups are an effective means of improving the social integration skills of children with Asperger's Syndrome. Outcome measures have primarily been qualitative and we do not know if this technique can change specific skills in natural settings. Nevertheless, experience has shown that the groups are perceived as valuable by parents, teachers and participants. In particular, the participants have appreciated the opportunity to meet people similar to themselves who share the same confusion and experiences, and this can be the basis of subsequent friendships and self help groups.

Project on specific emotions (see original paper)

Imitation
Some individuals with Asperger's Syndrome can be quite ingenious in using imitation and modelling to camouflage their difficulties with social integration. For example, in her autobiography, Liane Holliday-Willey (1999) describes her technique.

I could take part in the world as an observer. I was an avid observer. I was enthralled with the nuances of people's actions. In fact, I often found it desirable to become the other person. Not that I consciously set out to do that, rather it came as something I simply did. As if I had no choice in the matter. My mother tells me I was very good at capturing the essence and persona of people (p.22).

Conventional speech and drama lessons can be used to encourage the child how to act in social situations. The child observes someone who is competent in social integration skills in natural settings, and watches video taped examples, taking note of what they do and say. They then rehearse the social script, taking on the persona of someone they know to be successful in social integration.

Accommodate the child's cognitive skills
Preliminary experiences of teaching social integration skills suggest that one must accommodate the child's profile of cognitive skills. A formal assessment of intellectual ability using standardised tests can establish whether the child has a significant discrepancy between their verbal and performance intelligence (Ehlers, Nyden, Gillberg, Dahlgren Sandberg, Dahlgren, Hjelmquist and Oden, 1997). One can then determine how the training material can be modified for children with conspicuous verbal skills, for example, using social stories and discussion, or with conspicuous visual reasoning skills, emphasising Comic Strip Conversations and role play activities. Thus knowing whether a child is a "verbaliser" or "visualiser" can be an important factor in the design of the remedial programs. It is also important to recognise the time taken for the child with Asperger's Syndrome to process social information and to modify the pace and presentation of activities according to their capacity to process social information.

Conclusion
Difficulties in social integration are a fundamental component of Asperger's Syndrome, yet we have only just begun to describe the nature of the characteristic difficulties let alone develop remedial programs to encourage greater competence in this area. While this paper has outlined strategies without a body of research evidence to substantiate their effectiveness, there is an increasing demand for intervention programs. Clearly research must occur in step with the development of these strategies, especially as they have potential application in areas other than social integration. We know that some children with Asperger's Syndrome lack insight into their social and emotional problems (Pomeroy, 1998) but many become acutely aware of their difficulties with social integration. Clinical experience of such children suggests that this is one of the major contributory factors for a secondary diagnosis of depression and other mood disorders. Strategies to improve social integration could be a valuable component of Cognitive Behaviour Therapy programs. It should also be noted that the strategies are likely to be pertinent for all children at the high functioning range of the autistic spectrum, irrespective of whether the child has a diagnosis of Asperger's Syndrome.

The final point is that we must remember that some adults with Asperger's Syndrome never had the opportunities available to the current and future generations of children, yet they succeeded in acquiring the ability to be socially integrated to a level where other people would not easily perceive the difficulties they encounter in every day social interactions. They have eventually learnt what others appear to have acquired with so little thought. This is illustrated by the autobiography of Liane Holliday-Willey (1999).

Looking far over my shoulder, I can call to mind people who must have been interested in friendship. I can see a boy I knew as if it was yesterday. I can remember his face and the expressions he made as we talked. Today if he looked at me like he did then, I believe I would have seen the kindness and gentleness that was his. I never did much with this boy when I had the chance. I missed his offer of friendship. I would not miss that offer if it was made today. His face would make sense to me today (p.50).

We need to establish what strategies they found aided or hindered their successful social integration so that we can diminish the qualitative differences that make such children so conspicuous and confused.

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