The Best Treatment for Teenagers on the Autism Spectrum

By Mark Hutten, M.A.
“My husband is ashamed and embarrassed that our oldest son has autism (high functioning) and is not what he calls normal. If my husband knew that I was typing this, he would become very irate and the yelling would start between the two of us as he does not like it when I try and seek help. James is 15 and in the years gone by He has called him a retard to his face, he even used to hit him across the back of the head. James does not seem to get along with our 13-year-old and often hurts himself as well as our other son. Because of this, I try not to leave the two of them home alone. The other evening, I went to visit my parents for two hours leaving them with their dad. Apparently, the boys started into each other and instead of separating them and talking with them, he told the oldest with the problem. ‘I wish you would just beat the shit out of him and teach him a lesson’. When I found out about this, I became very irate and tried to explain to Michael [husband] that he just gave James permission to beat up his brother. He does not really understand right from wrong at times. 
 
So now I wait for the day they fight and he says, ‘dad said I could’ without realizing the damage he could cause or the consequences. My husband refuses to seek help, says he reads up about what is going on but I find that hard to believe otherwise he would know better how to deal with issues. Is there anything you can suggest in the way for treatment for James? I can’t change his dad but maybe I can get James some help for his disorder. I am starting to think that my feelings do not matter and I need to put my children first and remove Michael from my home so that our eldest will have a home that understands him. Even our 13 year old understands him better than his own dad. ppls help!”

 
RE: "Is there anything you can suggest in the way for treatment for James?"

 The best treatment for high-functioning autistic (HFA) children and teens is definitely “social skills training” (SST). Social skills training is a form of behavior therapy used by therapists to help these young people who have difficulties relating to other people.

A major goal of social skills training is teaching the youngster (who may or may not have emotional problems) about the verbal and nonverbal behaviors involved in social interactions. There are many teens and preteens on the autism spectrum who have never been taught such interpersonal skills as making "small talk" in social settings, the importance of good eye contact during a conversation, etc. In addition, many of these individuals have not learned to "read" the many subtle cues contained in social interactions (e.g., how to tell when someone wants to change the topic of conversation or shift to another activity). 
 

Social skills training helps these young people to learn to interpret these and other social signals so that they can determine how to act appropriately in the company of others in a variety of different situations. Social skills training assumes that when individuals improve their social skills or change selected behaviors, they will raise their self-esteem and increase the likelihood that others will respond favorably to them. The child or teen learns to change his social behavior patterns by practicing selected behaviors in individual or group therapy sessions.

Another goal of social skills training is improving the child’s ability to function in everyday social situations. Social skills training can help these children and teens to work on specific issues that interfere with their school or daily lives.

Techniques in social skills training—

Therapists who use social skills training begin by breaking down complex social behaviors into smaller portions.

Next, they arrange these smaller parts in order of difficulty, and gradually introduce them to the clients. For example, a therapist who is helping an HFA teen learn to feel more comfortable at parties might make a list of specific behaviors that belong to the complex behavior called "acting appropriately at a party" (e.g., introducing oneself to others, making conversation with several people at the party rather than just one other guest, keeping one's conversation pleasant and interesting, thanking the host or hostess before leaving, etc). The teenager would then work on one specific behavior at a time, rather than trying to learn them all at once.

Such specific techniques as instruction, modeling, role-playing, shaping, feedback, and reinforcement of positive interactions may be used in social skills training. For example, instruction may be used to convey the differences among assertive, passive, and aggressive styles of communication. The technique of monitoring may be used to ask clients to increase their eye contact during a conversation. In role-playing exercises, group members have the opportunity to offer feedback to one another about their performances in simulated situations. For example, two members of the group may role-play a situation in which a customer is trying to return a defective purchase to a store. The others can then give feedback about the "customer's" assertiveness or the "clerk's" responses.

Some of the goals for social skills group training are helping autistic kids and teens to:
  • read the body language of others
  • play and have fun
  • learn to cope with mistakes
  • learn strategies for developing peer relationships
  • learn peer group problem-solving
  • become aware of their emotions

Kids on the spectrum are pliable to treatment because they tend to be compliant. Although their ritualistic behavior and rigidity may create obstacles to treatment, most of these kids are able to learn the nuances of feelings, body language and behavior to assist them in their everyday functioning.

Content of social skills training—

Social skills training may be used to teach "special needs" children and teens specific sets of social competencies. A common focus of social skills training programs is communication skills. A program designed to improve the teen’s skills in this area might include helping him with nonverbal and assertive communication and with making conversation. It might also include conversational skills that are needed in different specific situations, for example job interviews, informal parties, and dating. The skills might be divided further into such subjects as beginning, holding, and ending conversations, or expressing feelings in appropriate ways. 
 

Another common focus of social skills training programs involves improving a client’s ability to perceive and act on social cues. Many of these teenagers have problems communicating with others because they fail to notice or do not understand other people's cues, whether verbal or nonverbal. For example, some of them become unpopular with their peers because they force their way into small play groups, when a youngster who has learned to read social signals would know that the kids in the small group do not want someone else to join them, at least not at that moment. Learning to understand another person's spoken or unspoken messages is as important as learning conversational skills. A social skills program may include skills related to the perceptual processing of the conversation of others.

Scheduling—

Social skills training may be given as an individual or as a group treatment once or twice a week or more often depending upon the severity of a client’s disorder and the level of his social skills. Generally speaking, kids on the spectrum appear to gain more from social skills training in a peer group setting than in individual therapy. Social skill training groups usually consist of approximately 10 clients, a therapist, and a co-therapist.

Culture and gender issues—

Social skills training programs may be modified somewhat to allow for cultural and gender differences. For example, eye contact is a frequently targeted behavior to be taught during social skills training. In some cultures, however, downcast eyes are a sign of respect rather than an indication of social anxiety or shyness. In addition, girls or women in some cultures may be considered immodest if they look at others, particularly adult males, too directly. These modifications can usually be made without changing the basic format of the social skills training program.

Generalization or transfer of skills—

Current trends in social skills training are aimed at developing training programs that meet the demands of specific roles or situations. This need developed from studies that found that social skills acquired in one setting or situation are not easily generalized or transferred to another setting or situation. To assist clients in using their new skills in real-life situations, therapists use role-playing, teaching, modeling, and practice.

Preparation—

Preparation for social skills training requires tact on the therapist's part, as HFA clients (especially older teens and young adults) may be discouraged or upset by being told that they need help with their social skills. One possible approach is through reading. The social skills therapist may recommend some self-help books on social skills in preparation for the treatment. Second, the therapist can ease the client’s self-consciousness or embarrassment by explaining that no one has perfect social skills. An additional consideration before starting treatment is the possibility of interference from medication side effects. The therapist will usually ask the client for a list of all medications that he takes regularly.

One of the most critical tasks in preparation for social skills training is the selection of suitable target behaviors. It is often more helpful for the therapist to ask the client to identify behaviors that he would like to change, rather than pointing to problem areas that the therapist has identified. The treatment should consider the client’s particular needs and interests. Whereas social skills training for some clients may include learning assertiveness on the job, training for others may include learning strategies for dating. Therapists can prepare clients for homework by explaining that the homework is the practice of new skills in other settings, and that it is as relevant as the therapy session itself. 
 

Aftercare—

Some studies strongly suggest the need for follow-up support after an initial course of social skills training. One study showed that follow-up support doubled the rate of employment for a group of older Aspergers and HFA adolescents, compared to a group that had no follow-up.

Normal results—

Outcome studies indicate that social skills training has moderate short-term effects, but limited long-term effects. Social skills training programs that include social perspective-taking may have greater long-term effects than traditional social skills training programs based on cognitive-behavioral models. In general, social skills training tends to generalize or transfer to similar contexts rather than to contexts that are not similar to the training. Social skills training programs for HFA children and teens should include programming for generalization, so that these clients can transfer their newly acquired skills more effectively to real-life settings. One approach to improving generalization is to situate the training exercises within the client’s school, work, living, or social environment.

The benefits of social skills training programs include flexibility. The treatment can take place either as individual or group therapy, and new trainers can learn the techniques of social skills training fairly quickly. An additional advantage of social skills training is that it focuses on teaching skills that can be learned rather than emphasizing the internal or biological determinants of social adequacy.

Future research should explore (a) the integration of social skills training with the needs of families from different cultural backgrounds, (b) the relationship between social skills training and different categories of mental disorders, (c) the transfer of skills from therapeutic contexts to daily life, and (d) improving the youngster's long-term gains from social skills training.

NOTE: Having said all of the above, while proper treatment for your autistic son is important, it sounds like you have bigger fish to fry (i.e., dealing with an abusive husband). If possible, try to educate him about the disorder so that he can understand your HFA son better - and hopefully show more compassion.
 
 



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