Running Head: Article Critique

Article Critique

Lindsay Birchall
University of Calgary

Practice Evaluation in School Psychology-EDPS 612.03

Dr. Yvonne Hindes
June 24th, 2015

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RCT of a Manualized Social Treatment for High-Functioning Autism Spectrum Disorders

Purpose of the Study
This study evaluated the efficacy of a social skills group intervention for children with high
functioning Autism Spectrum Disorder (HFASD).
Literature Review & Methodology
Strengths. Social dysfunction is an ongoing area of difficulty for children with ASD which
often persists into adolescence and adulthood. Repetitive, ritualistic and stereotyped behaviours can
further restrict social learning opportunities. For example, a child with ASD may only be able to
sustain a one-sided conversation about a restricted area of interest. Therefore, there is a substantial
need for social skills interventions for children with HFASDs. Research supports that children
show better skill acquisition when targets are specific and concrete; this intervention targets faceemotion recognition, interpretation of non-literal language and interest expansion using a skills
streaming approach. This sequential instructional framework, moves from basic to more complex
skills, (e.g. direct instruction, modeling, role-playing, feedback and transfer of learning).
The sample size was adequate, including 36, 7-12 year olds, 77.8% of which were
diagnosed with Aspergers disorder. A three tier screening measure ensured participants had
adequate cognitive and language capacities; children who were aggressive were excluded. There
were no significant demographic differences found between treatment and control groups and
gender ratios were consistent with the prevalence of ASDs. Both broad and specific areas of
performance were assessed pre and post treatment. Importantly, all outcome measures had adequate
validity and reliability. Researchers utilized multiple informants; single informants are more prone
to bias. Notably, measures of direct observation were included (participants completed a vignette
test) and instructors met with children after each practice session to discuss what social skills they
used; this provided opportunities to evaluate the participants skill acquisition and insight. To reduce

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unwanted and interfering behaviours a cost-response system was added. Researchers ensured
stringent measures of treatment integrity; 90% fidelity was reported for social and behavioural
procedures. Inter-rater observers scored 97.2% agreement during this process.
Limitations. Unfortunately, the evidence base is sparse for social skills interventions for
children with HFASD. Comparing studies is difficult because most lack control groups, random
assignment, manualized approaches, monitoring of treatment fidelity and often use small sample
sizes. Intervention efficacy is also shows mixed results. Notably, there is no previously documented
evidence for this particular intervention. Also, results from this study have limited generalization
because the majority of participants were Caucasian, male and middle class. Researchers used
edible reinforcement as daily reinforcers for participants; more individualized reinforcers could
have been offered. The end of the week outing was used as an opportunity to generalize skills, but
also as a group reinforcer. Authors failed to address when or if children may be excluded from this
reinforcer due to poor behavioural performance. Essentially, the outing may have devalued as a
reinforcer because work was associated with reward. Lastly, the authors did not provide a rationale
for choosing a response-cost system instead of a traditional reinforcement system.
Statistical Analysis & Conclusions
Strengths. The researchers used a between groups ANCOVA to assess changes in both
treatment and control groups for primary measures. They also implored repeated-measures ANOVA
to analyse secondary measures for the treatment group. These procedures are appropriate for the
data set because there were multiple independent variables and only one dependent variable.
Moreover, ANCOVA can be used to increase statistical power of the data set by reducing withingroup error variance; this is essential for smaller sample sizes, such as this study.
The authors ensured the 95th confidence interval was used for all assessments. Results
indicated the intervention was effective across a number of direct child measures and third-party

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ratings. Of the seven primary outcome measures, five were statistically significant and all seven
yielded potentially substantive effect size estimates in the hypothesized direction. Direct measures
also showed significant post-treatment results. Moreover, parent ratings suggested that children had
generalized skills outside of the treatment setting.
Limitations. The authors reported ANCOVA results using corrected means. Although this
method is appropriate it often yields lower effect sizes, resulting an underestimation of true
statistical power. Stringent alpha corrections were also implored to avoid Type 1 errors. Utilizing a
larger sample size would have enhanced statistical power and made smaller effects more detectable.
Notably, parent and instructor ratings were overall higher than participants for program satisfaction
and intervention outcomes. Also, specific measures showed more positive outcomes then broad
measures. This indicates the potential for bias, which the authors did not rule out. Interestingly,
during pre-test measures, staff ratings were generally lower then parent ratings. But, because
researchers did not use staff ratings for waitlist participants, it is impossible to assess bias here.
Potential Ethical Issues & Suggestions for Improvement
The use of informed consent was reported and the study was approved by a review board.
The only obvious ethical issue was the lack of normative data for participants over 11 years old on
the measure of Comprehensive Assessment of Spoken Language Idioms subtest. If normative data
for younger ages was utilized for 11 year olds, scores would have been positively inflated. Ethically,
the authors should have made every effort to find an alternative assessment. Researchers did caution
their results from this subtest.
Greater participant demographic diversity would be beneficial in future research. Longer
term follow up measures would also be helpful in evaluating skill generalization outside of clinical
settings. Although the inclusion of fidelity measures was as asset to this research, only 13.9% of

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session time was actually examined. Open ended questions could have also been added to the parent
and child satisfaction surveys to obtain more breadth and depth of information.

The Efcacy of a Social Skills Group Intervention for Improving Social Behaviors in Children
with High Functioning Autism Spectrum Disorders
Purpose of the Study
This research examined the efficacy of a unique and innovative program, The Social Skills
Group Intervention-High Functioning Autism (S.S.GRIN-HFA).
Literature Review & Methodology
Strengths. Sadly, social deficits in children with HFASD often become more pronounced as
typical peer interactions become more complex; adverse outcomes often persist into adult hood (e.g.
depression, anxiety, victimization, etc.). Deficits are further impacted by maladaptive behaviours
such as narrow interests and rigid thinking. Considering these challenges, there is a momentous
need for social skills interventions supporting children diagnosed with HFASDs. Importantly, the
S.S.GRIN-HFA maintains the fundamental structure and manualization of the original evidence
based Social Skills Group Intervention (S.S.GRIN), but it also incorporates skills more specific to
children with HFASD. Notably, positive outcomes are most evident in programs that teach very
concrete and discrete skills; the current research embraces this recommendation. Evidence also
supports the inclusion of parents as valuable participants. Because children with ASD struggle to
generalize skills, it is an asset that this study incorporates community settings.
Both a treatment and control group were included; the control group received the previously
manualized S.S.GRIN. Parents and children filled out pre and post-test questionnaires, two weeks
before and two weeks after treatment. Notably, the sample size was large, including 55 children
diagnosed with HFASD, ages 8-12 years. Participants and their parents were drawn from a variety
of sources (e.g. schools, parent support groups, pediatricians) and their diagnoses were equally

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balanced between groups: approximately 40% HFASD, 40% Aspergers disorder and 20%
Pervasive Developmental Disorder-NOS. Importantly, the treatment and control groups did not
significantly differ by age, gender, race/ethnicity, income, or maternal education.
Inclusion methods were stringent, using reliable and valid screening tools. Children were
excluded if they were aggressive or if they did not meet specific cognitive, language or diagnostic
requirements. The authors provided evidence of reliability and validity for all specific and broad
outcome measures used. High treatment integrity was reported with an average of 97% of the
manualized curriculum covered. The authors described the S.S.GRIN-HFA intervention in great
detail. Each session included didactic instruction combined with active practice (e.g. roleplaying,
modeling, hands on activities). Specific social skill targets were addressed from each of three
modules. Parents were involved in active practice sessions, at-home and in the community.
Limitations. Despite the clear need for interventions, there has been limited research
exploring group social skill programs for children with ASD. Methodological differences reported
between and within positive outcome studies limit their generalizability (e.g. lack of control groups,
small sample sizes, few studies include parents). Furthermore, the evidence available shows high
outcome variability. This impacts new research and the development of interventions.
The homogeneity of the sample in this research was a significant weakness; children were
primarily Caucasian, middle class and male. Although the gender distribution did reflect the
prevalence of autism, it restricts generalization to females. Both the treatment and control groups
had heavily weighted maternal participation (i.e. 82-96%) and limited paternal influence. Moreover,
all outcome measures were self-report which are prone to bias. Although the inclusion of parents is
commendable, the intense involvement and time commitment required may have increased attrition
rates. Lastly, measures of treatment integrity could have expanded beyond curriculum adherence.
Statistical Analysis & Conclusions

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Strengths. This research conducted an attrition analysis; no significant differences were

found for incomplete data sets. Because statistical sampling error decreases when sample size
increases, the large sample size of this study was an asset. MANOVAs were run to examine group
differences for parent and child report measures; this is an appropriate statistical analysis.
Univariate analysis was also conducted for individual subtests areas (e.g. SRS Motivation Scale),
for both parents and children. Overall, results indicated more positive outcomes in the treatment
group for parents (e.g. greater self-efficacy) and children (e.g. greater social motivation).
Limitations. Some parent report data was excluded because the mother filled out the pretreatment reports and the father completed the post-treatment reports. Interestingly, The Social
Responsiveness Scale did not show significant treatment effects on the social cognition subscale.
Contrary to parent reports, the MANOVA examining group differences for child reports of selfefficacy and feelings of loneliness, did not show a significant treatment change. This could be
attributed to the assessment used or the efficacy of the intervention. Because the control group
showed declines in many social skills post-treatment, the S.S.GRIN may not be a valuable
intervention for HFASD. The authors explain the post-treatment measures may have been taken too
soon, limiting opportunities for children to practice new social skills. Also, the use of specialized
groups may limit valuable observations of typically developing peer models. Furthermore, there is
potential for participants to observe new maladaptive or antisocial behaviours in specialized groups.
Potential Ethical Issues & Suggestions for Improvements
Informed consent was required from both the parents and the children. Notably, the authors
did not identify how they managed individual participant data within the groups, or how they
ethically managed interactions with multiple parents. Unexpectedly, children in the control group
showed worsening outcomes; these results pose a considerable ethical dilemma. Parents of children

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with ASD experience high stress; it is unethical to have parents invest time and effort in an
ineffective intervention.
Including both children with ASD and typically developing children in social skills group
interventions may be more beneficial. Also, the addition of a contingency based behavioural
management system may have positively impacted outcomes. In the future, researchers should
make an effort to include females with ASD and families of multiple demographics in their sample.
Mothers are often overrepresented when parents are involved in interventions. It would be valuable
to actively include fathers or parents as a unit. Lastly, including direct measures would provide a
more diverse perspective on participants achievements.

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9
References

DeRosier, M. E., Swick, D. C., Ornstein Davis, N, Sturtz McMillen, J. & Mattews, R. (2011). The
Efficacy of a Social Skills Group Intervention for Improving Social Behaviour in Children
with High Functioning Autism Spectrum Disorders, J Autism Dev Disord, 41:1033-1043.
Doi: 1007/s10803-010-1128-2
Lopata, C., Thomeer, M. L., Volker, M. A., Toomney, J. A., Nida, R. E., Lee, G. K., Smerbeck, A.
M. & Rodgers, J. D. (2010). RCT of a Manualized Social Treatment for High-Functioning
Autism Spectrum Disorders, J Autism Dev Disord, 40:1297-1310. Doi: 10.1007/s10803010-0989-8