AutPlay® Therapy Play and Social Skills Groups

A 10-Session Model

Robert Jason Grant, Tracy Turner-Bumberry

• Publisher: Routledge
• Year: 2020
• ISBN:
  9781000179477
• Edition: 1
• Topic: Psychology
• Subtopic: Autism Spectrum Disorders
• Index: Psychology

AutPlay® Therapy Play and Social Skills Groups provides practitioners with a step-by-step guide for implementing a social skills group to help children and adolescents with autism improve on their play and social skills deficits in a fun and engaging way.

This unique 10-session group model incorporates the AutPlay Therapy approach focused on relational and behavioral methods. Group setup, protocol, and structured play therapy interventions are presented and explained for easy implementation by professionals. Also included are parent implemented interventions that allow parents and/or caregivers to become co-change agents in the group process and learn how to successfully implement AutPlay groups.

Any practitioner or professional who works with children and adolescents with autism spectrum disorder will find this resource to be a unique and valuable guide to effectively implementing social skills groups.

1
Autism Spectrum Disorder

The Autism Society of America (2019) described autism spectrum disorder (ASD) as a complex developmental disability with signs typically appearing during early childhood. ASD affects a person’s ability to communicate and interact with others. ASD is defined by a certain set of behaviors and is a “spectrum condition” that affects individuals differently and to varying degrees. There is no known single cause of autism, but increased awareness and early diagnosis with intervention and access to appropriate services lead to significantly improved outcomes. Some of the behaviors associated with ASD include:

• Delayed learning of language.
• Difficulty making eye contact or holding a conversation.
• Difficulty with executive functioning, which relates to reasoning and planning.
• Narrow, intense interests.
• Obsessive behaviors.
• Rigid cognitive processing.

ASD is classified as a neurodevelopmental disorder that can be detected within the first three years of life. Typically, there are impairments in communication and social functioning. Those diagnosed with ASD can also have struggles with processing sensory information, deficits in play skills, motor impairments, repetitive behaviors, and challenges with change and unexpected occurrences.

The Centers for Disease Control and Prevention (2019), proposed that ASD is a developmental disability that can cause significant social, communication, and behavioral challenges. There is often nothing about how people with ASD look that sets them apart from other people, but people with ASD may communicate, interact, behave, and learn in ways that are different from most other people. The learning, thinking, and problem-solving abilities of people with ASD can range from severely challenged to gifted. Some people with ASD require a great deal of assistance in their daily lives; others need far less. A diagnosis of ASD now includes several conditions that used to be diagnosed separately: autistic disorder, pervasive developmental disorder not otherwise specified (PDD-NOS), and Asperger syndrome. These conditions are now all under the term autism spectrum disorder.

Children and adolescents with ASD may have some similar unifying problem areas, but the severity of their difficulty and the presence or absence of other features will vary, such as intellectual deficits, increased or decreased verbal output, and social strengths (Coplan, 2010). ASD is a spectrum disorder meaning there are many manifestations or ways a child or adolescent could be affected by autism. Siri and Lyons (2010) suggested that ASD is difficult to define; no two children have the same set of symptoms. Each child may broadly share common general manifestations but the triggers and causes for these manifestations may vary greatly from one child to another.

Children and adolescents with ASD are often misunderstood and mis-labeled, especially when odd or unwanted behavior manifests. It is typical for children with ASD to struggle with behavioral issues. Behaviors can include shutting down behavior, refusing to participate, not following rules, avoidance, aggression, and executive functioning challenges, but are certainly not limited to just these behaviors. A variety of behavioral manifestations can accompany an autism diagnosis. Many of the behavior challenges that children with autism experience are due to emotional regulation problems, sensory challenges, and social functioning issues. Often children do not have the skill level to navigate situations successfully and the result is unwanted behavior.

When children with ASD begin to display unwanted behaviors, many adults working with them mislabel the behavior as purposeful or planned; behavior the child could control if they wanted. This is a dangerous mis-label as children with autism are often not in control when they are displaying unwanted behavior. In fact, it is a very out of control state for the child and usually a very frightening experience. Behavior struggles are to be expected when working with children and adolescents with ASD. It is critical that adults working with this population understand the dysregulation-driven behaviors children with ASD present, while also working to address the real issues creating the behavior rather than incorrectly labeling the child.

Academic and school related challenges are common issues with which children and adolescents struggle. The school environment could arguably be the most challenging environment for children with autism. The typical school environment presents social complexities, sensory experiences, rapidly changing processes, and adherence to a multitude of new people, activities, and routines. This presents a great challenge to children with ASD. Many children become dysregulated by the school environment and exhibit negative behavior, which at times, can manifest as large aggressive behaviors that produce additional problems. Some children are able to manage their way through a dysregulating school day and once they are home, explode into a meltdown. Many children with ASD will have an individualized education program (IEP) or a 504 plan which might provide accommodations to help the child navigate the school day more smoothly, but in reality, most schools struggle to meet the needs of children with autism and thus school challenges are a common occurrence.

A diagnosis of ASD can be thought of as a family diagnosis. Some children present in therapy with an isolated issue that primarily is impacting the child, but autism issues very much permeate throughout and affect the whole family. Many popular ASD approaches involve working with parents and other family members. Parents often participate in parent trainings to be better equipped to parent their child with autism. Siblings often participate in their own individual therapy to address the unique issues they may be experiencing having a sibling with autism. The impact of ASD changes the social and functional atmosphere of the family. Often times, the family’s mindset, focus, process, and protocols revolve around the child with autism. Empowering and supporting families affected by ASD should be a developed component of any protocol designed to work with children affected by autism.

ASD is a Diagnostic and Statistical Manual 5th Edition (2014) diagnosis that is usually given after a thorough psychological evaluation; wherein, the evaluator measures the child or adolescent’s behavior across a myriad of tests, assessments, and observations. The disorder is a spectrum disorder meaning the symptoms vary in intensity from severe to mild. Common terms used to describe the variance include low to high functioning, or severe to mild impairment. A synopsis of the manual’s criteria for receiving an ASD diagnosis is presented in the following:

1. Persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following, currently or in history:
   1. Deficits in social-emotional reciprocity, ranging, for example, from abnormal social approach and failure of normal back-and-forth conversation; to reduced sharing of interests, emotions, or affect; to failure to initiate or respond to social interactions.
   2. Deficits in nonverbal communicative behaviors used for social interaction, ranging, for example, from poorly integrated verbal and nonverbal communication; to abnormalities in eye contact and body language or deficits in understanding and use of gestures; to a total lack of facial expressions and nonverbal communication.
   3. Deficits in developing, maintaining, and understanding relationships, ranging, for example, from difficulties adjusting behavior to suit various social contexts; to difficulties in sharing imaginative play or in making friends; to absence of interest in peers.
2. Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two of the following, currently or by history:
   1. Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple motor stereotypies, lining up toys or flipping objects, echolalia, idiosyncratic phrases).
   2. Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior (e.g., extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need to take same route or eat same food every day).
   3. Highly restricted, fixated interests that are abnormal in intensity or focus (e.g., strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interest).
   4. Hyper- or hypo-reactivity to sensory input or unusual interests in sensory aspects of the environment (e.g., apparent indifference to pain/temperature, adverse response to specific sounds or textures, excessive smelling or touching of objects, visual fascination with lights or movement).
3. Symptoms must be present in the early developmental period (but may not become fully manifest until social demands exceed limited capacities or may be masked by learned strategies in later life).
4. Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning.
5. These disturbances are not better explained by intellectual disability (intellectual developmental disorder) or global developmental delay. Intellectual disability and autism spectrum disorder frequently co-occur; to make comorbid diagnoses of autism spectrum disorder and intellectual disability, social communication should be below that expected for general developmental level.

The DSM 5 Three Levels of Support for ASD diagnosis:

• Level 3: Requiring Very Substantial Support—Severe deficits in verbal and nonverbal social communication skills cause severe impairments in functioning, very limited initiation of social interactions, and minimal response to social overtures from others. For example, a person with few words of intelligible speech who rarely initiates interaction and, when he or she does, makes unusual approaches to meet needs only and responds to only very direct social approaches. There is inflexibility of behavior, extreme difficulty coping with change, or other restricted/repetitive behaviors markedly interfere with functioning in all spheres. Great distress/difficulty changing focus or action.
• Level 2: Requiring Substantial Support—Marked deficits in verbal and nonverbal social communication skills; social impairments apparent even with supports in place; limited initiation of social interactions; and reduced or abnormal responses to social overtures from others. For example, a person who speaks in simple sentences, whose interaction is limited to narrow special interests, and who has markedly odd nonverbal communication. There is inflexibility of behavior, difficulty coping with change, or other restricted/repetitive behaviors appear frequently enough to be obvious to the casual observer and interfere with functioning in a variety of contexts. Distress and/or difficulty changing focus or action.
• Level 1: Requiring Support—Without supports in place, deficits in social communication cause noticeable impairments. Difficulty initiating social interactions and clear examples of atypical or unsuccessful responses to social overtures of others. May appear to have decreased interest in social interactions. For example, a person who can speak in full sentences and engages in communication but whose to-and-fro conversation with others fails, and whose attempts to make friends are odd and typically unsuccessful. Inflexibility of behavior causes significant interference with functioning in one or more contexts. Difficulty switching between activities. Problems of organization and planning hamper independence.

Beyond the criteria outlined to receive an ASD diagnosis, children and adolescents with autism typically have additional skill deficits and developmental issues. Splintered skill development is one manifestation that is common in children with developmental disorders. Splinter skills are abilities that are disconnected from their usual context or are very specific abilities that do not generalize to other capabilities. Because they are just a “splinter,” or fraction, of a meaningful set of skills, splinter skills may not be particularly useful in real-world situations. Examples include the ability to memorize a bus schedule without understanding how to get to a bus station or buy a ticket. Another example is being able to memorize a multiplication table but not able to complete a multiplication question on a math test. Children with autism also display uneven development. A child with ASD may be at a developmental level far beyond their chronological age in one area of development and at the same time, far below their chronological age in another other of development. For example, a nine-year-old child with autism may have expressive language ability at an adult level (well beyond their chronological age) but have emotional regulation ability at a preschool aged level (well below their chronological age).

Due to the nature of splintered and uneven development, a child or adolescent with ASD will usually need an individual assessment to accurately identify his or her struggle areas, skill strengths, and skill deficits. Although it is understood that each child with have his or her unique manifestation regarding his or her ASD, there are some common deficit areas that tend to affect most individuals with ASD at varying levels. These common struggle areas include the following:

• Communication skills—Children and adolescents with ASD will vary in their communication strengths and deficits. Most children with ASD will have some level of communication challenges. Some children will present as non-verbal, while others may possess a large vocabulary but lack ability to connect words verbally to their emotions.
• Receptive language—Most children with ASD will have receptive language deficits. Many of these children may display average or above average ability in expressive language. There can be a large discrepancy between receptive and expressive language ability. Receptive language ability refers to the child’s ability to take in or receive language. A child with receptive language deficits will likely not hear or process important pieces of information that are being communicated to him or her verbally.
• Play skills—Children with ASD usually struggle in the areas of pretend or imaginary play and peer or group play. Regarding peer or group play, children and adolescents with ASD typically do desire to participate and interact with other peers in group play but lack the skills to interact successfully and find the experience to be too overwhelming. Thus, most attempts at peer interaction, especially with neurotypical peers, are not successful and may even create additional issues. Regarding pretend and imaginative play, children with ASD often lack the neurological process of understanding pretend, symbolism, and metaphor (Grant 2017).
• Generalization ability—Many children with ASD will struggle with generalizing information. A child may learn a social skill in one context and have a difficult time generalizing the same basic skill to another context. There may be struggles with understanding nuance, learning through concepts, generalities, “it depends” situations, and pulling from an existing knowledge base to apply to new or unfamiliar scenarios. This is an important consideration when working to increase skill development for children and adolescents with ASD.
• Rigid (literal) thinking—Children and adolescents with ASD may think in a rigid way. This means they may be very literal in their thinking, struggle with concepts, prefer more concrete thoughts, and find it difficult to consider alternatives or to accept when things are not how they expected or believed they should be. It can be difficult for children to think ahead and to guess what is going to happen next, which means they may become anxious or confused in some situations, especially new situations. Professionals and parents can assist children by establishing consistent and predictable routines while systematically introducing coping skills designed to help children process changes and manage unpredictable situations.
• Processing speed—Research has shown children with ASD were found to have selective deficits in executive function. Executive dysfunction regarding attention, set shifting, planning, and processing speed have been reported in young children with ASD. Regarding executive function struggles, processing speed was found to be one of the weakest areas for children with ASD. Processing speed deficits present significant challenges for children in educational settings, home settings, or any setting where they are required to take in information and perform task completion.
• Fear of making mistakes—Children and adolescents with ASD are prone to developing an almost pathological fear of failure, errors, or making a mistake. This fear may cause children to be resistant to trying new experiences or participating in treatment programs. Professionals and parents will want to reinforce a child’s abilities and encourage self-confidence (Attwood & Garnett, 2013).
• Regulation ability—A lack of social skills, play skills, ability to regulate emotions, and sensory processing challenges can all manifest a great deal of unrest and unwanted behavioral presentation for the child with ASD (Grant, 2017). This behavior manifestation is typically the result of the child or adolescent becoming too dysregulated. Most children with ASD will lack the ability to recognize when they are becoming dysregulated, lack the ability to regulate their system, and lack coping skills to implement when they are becoming dysregulated. Often, dysregulation behaviors can be misinterpreted as oppositional, defiant or purposeful behaviors.
• Social functioning—Children and adolescents with ASD typically do desire to have friendships and interact with other peers, but simply lack the social ability and skills t...