Examining the Effectiveness of Naturalistic Social Skills Training in Developing Social Skills and Theory of Mind in Preschoolers with ASD
Journal of Autism and Developmental Disorders
Examining the Effectiveness of Naturalistic Social Skills Training in Developing Social Skills and Theory of Mind in Preschoolers with ASD
Grzegorz Szumski 0 1 2
Joanna Smogorzewska 0 1 2
Paweł Grygiel 0 1 2
Ann‑Marie Orlando 0 1 2
0 Department of Psychiatry, Center for Autism and Related Disabilities, University of Florida , Golebia 24 st., PO Box 100234, Gainesville, FL 32609 , USA
1 Institute of Education, Faculty of Philosophy, Jagiellonian University , Golebia St. 24, 31-007 Cracow , Poland
2 Department of Educational Sciences, The Maria Grzegorzewska University , Szczesliwicka St. 40, 02-353 Warsaw , Poland
3 Grzegorz Szumski
We compared the effectiveness of two programs for developing social skills, 'Play Time/Social Time' (PT/ST) and 'I Can Problem Solve' (ICPS), in improving the social skills and theory of mind (ToM) of preschoolers with ASD. The experiment took place in a classroom setting. Fifty-two children attended and data were analyzed with latent growth curve models. Comparison with a control group indicated that both programs were effective in developing social skills. The PT/ST program was more effective than ICPS in developing interaction skills; both programs improved children's ability to cope with difficult social situations. The ICPS program was marginally effective in developing ToM when compared with PT/ST and control condition. These results are relevant to children with ASD and their teachers.
Preschoolers with ASD; Social skills; Social skills training; Theory of mind
Social skills and theory of mind (ToM) are two of the most
important determinants of social competence in children
with autism spectrum disorder
(ASD; Baron-Cohen et al.
. Unfortunately, children with ASD show delayed
development and impairment in both domains
et al. 1985)
. Difficulty with social contact is one of the
diagnostic criteria for ASD, and for many years, a delayed ToM
was considered the reason why children with ASD
developed limited social relationships and was regarded as an
essential feature of autism
(Baron-Cohen et al. 1985; Leslie
and Frith 1988)
. In recent work on empathizing-systemizing
(E–S) theory, Baron-Cohen (2014) emphasized that
problems with social contact and communication among persons
with ASD are caused by delays in development of empathy.
Theory of mind is a cognitive component of empathy, an
ability to understand mental states of other people.
However, empathy is not only a matter of understanding
others’ feelings, but also an ability to react properly in
different social situations, which is called ‘emotional empathy’
(Baron-Cohen 2009, 2014; Grove et al. 2014)
empathy and ToM are often targeted in interventions to
improve social skills among children with ASD.
Unfortunately, although interventions aimed at developing ToM
improve performance on formal ToM tasks they have not
been shown to improve real understanding of other people,
or to influence the social functioning of people with ASD
(Hadwin et al. 1997; Ozonoff and Miller 1995; Swettenham
. This might be because programs designed to develop
ToM place too much emphasis on the development of ToM
per se, rather than on applying ToM in real-life social
situations. Based on this argument, we investigate whether ToM
could be developed using naturalistic programs designed
to develop social skills. We assessed the effect of
developing ToM in this way on the social functioning of children
with ASD in interactive situations. To develop children’s
social skills and ToM, we used two well-known programs for
developing preschool children’s social competence: ‘I Can
Problem Solve’ ICPS
and ‘Play Time/Social
(Odom et al. 1997)
Social Skills of PreschoolA‑ge Children
Social competence is a very ambiguous concept
et al. 2010)
. In recent years, multidimensional hierarchical
conceptions have become popular. For example, Vaughn and
colleagues (2009) have stated that competent social behavior
is based on a constellation of cognitive, behavioral, and
emotional factors. Because social competencies are not
universal, the capacity to behave appropriately in a variety of social
contexts depends, at least in part, on other skills as well as
on social competence of a person.
Cillessen and Bellmore
argue that social competence should be treated as a
two-factor construct, with the first factor being pro-social
behavior and cooperation with others and the second
relating to the achievement of personal or group goals in social
situations. Pro-social behavior requires abilities connected
to ToM (i.e., accurate perception of others, the ability to take
another person’s perspective, and the ability to understand
others’ emotions). Achieving one’s personal aims in social
situations requires self-confidence and the ability to argue
convincingly and to manipulate other people intelligently.
The multidimensional nature of social competence means
that it can be measured with several instruments that provide
overlapping information about social functioning
(McConnell and Odom 1999; Vaughn et al. 2009)
Social skills are very important to children’s
development. Children’s social skills usually include showing an
interest in others, initiating and sustaining interactions,
taking part in group play or goal-directed group activities,
responding appropriately to peers’ aggressive behavior, and
effectively solving social problem
(Jamison et al. 2012;
Odom et al. 1999; Van Hecke et al. 2007)
. These skills are
required for positive relationships with peers, which satisfy
the need to belong, protect against victimization, and
promote cognitive and social development
(Miles and Stipek
2006; Parker and Asher 1987)
. Social skills are also
important to the development of children with ASD. There is a
large body of evidence that the social isolation of people
with ASD is not due to lack of motivation for contact with
people, but due to poor social skills
(Rumsey et al. 1985;
White et al. 2007)
Theory of Mind
One of the main determinants of competence in social
interactions is the ability to take another person’s perspective
. ToM is the awareness of the
thoughts, beliefs, and desires of other people, and is
considered a specific aspect of social competence. ToM involves
perceiving others as being capable of independent thought
and emotion, with their desires and beliefs and the capacity
to function independently. ToM also involves an
appreciation that a person’s inner state influences his or her behavior
(Schaffer 2004; Steerneman et al. 1996)
. ToM can be
considered the cognitive dimension of social skills, as well as
the awareness of social rules (Southall and Campbell 2015).
An initial stage of ToM develops until the fifth year of
life, emerging from the capacity for symbolic play through
understanding of others’ points of view to an eventual
understanding of other people’s mental states. Typically
developing children display basic skills related to ToM in the
fifth year of life
(Wellman et al. 2001)
, but many scholars
agree that the beginnings of ToM can be observed in
toddlers during the first year of life
(c.f., Poulin-Dubois and
. Components of ToM typically emerge in the
following order: (a) diverse desires
(DD)—understanding that people can have different thoughts about the same
objects; (b) diverse beliefs (DB)—understanding that people
can have different beliefs about the same objects; (c)
knowledge access (KA)—understanding that when people do not
see something, they do not know about it; (d) false belief
(FB)—understanding the false beliefs about hidden objects;
and (e) hidden emotion (HE)—understanding that displayed
emotions are different from hidden emotions
. The development of ToM is delayed in children
with ASD, even when compared with children with other
developmental delays, and this has given rise to the belief
that ToM impairment is the main reason for the difficulties
people with ASD have with social interaction
et al. 1985)
Relationship Between ToM and Social Skills
ToM is commonly regarded as a form of social cognition
that is responsible for competent social behavior, alongside
knowledge of social rules and behavioral norms. At the same
time, social skills are a predictor of ToM abilities
and Watson 2001; Slaughter et al. 2002; Werner et al. 2006)
The relationship between ToM and competent social
behavior is, however, a complex one.
In many cases, young children show many pro-social
behaviors, such as helping, comforting, sharing and
defending, which are voluntary, intentional, spontaneous, and
(Grusec et al. 2010)
. However, pro-socially
directed children often are unable to solve tasks designed
to assess ToM
(Astington 2003; Dunn 1991)
. It might be
that these tasks are too abstract for young children and not
emotionally engaging. In addition, it is easy for children to
understand people’s emotions and needs when they are
easily observed. However, referring to one’s own beliefs and
knowledge in contrast with others’ beliefs might be too
difficult for young children
(Astington 2003; Peskin and Ardino
In some studies, the converse phenomenon has been
observed. That is to say, that the presence of antisocial
behaviors in individuals with a well-developed ToM
et al. 1999)
might indicate an advanced understanding of
others that can be used as a basis for manipulating and
exploiting others for one’s own, egoistic goals
Keller 2009; Gini 2006; Heerey et al. 2005)
Social factors such as parenting style, sibling status,
social position in the peer group, and individual factors such
as temperament and type of attachment between parents and
child mediate the relationship between levels of social skills
(Arranz et al. 2002; Carpendale and Lewis 2004;
Cassidy et al. 2005; Hoglund et al. 2008; Hughes 2011;
Meece and Mize 2010)
. In summary, although the nature of
the relationship is not well understood, it is well established
that a relationship exists between social skills and ToM. This
is why the simultaneous development of both is regarded as
important to children’s development.
Development of ToM and Social Skills Among
Children with ASD
Many interventions have been designed to develop both ToM
and social skills in children with ASD; however, evidence
on the effectiveness of these interventions remains
(Reichow and Volkmar 2010; Southall and Campbell
2015; White et al. 2007)
. One of the first systematic reviews
of the effectiveness of social skills programs for preschool
children with ASD showed that interventions for this group
(d= 0.66–0.87; Vaughn et al. 2003)
this analysis covered only two studies in which the relation
between intervention and measurement of social skills and
accomplished effect was not controlled. While the number of
interventions of this type using group designs has increased
(Reichow and Volkmar 2010)
, there is still insufficient
evidence to draw firm conclusions about their efficacy.
and Volkmar (2010)
concluded that none of the various
intervention programs aimed at preschool children with
ASD included in their systematic review could be regarded
as evidence-based. However, they did point to evidence for
the efficacy of other programs for developing social skills,
such as those based on Applied Behavior Analysis (ABA),
naturalistic techniques, and peer training. An earlier
systematic review concluded that only video-modeling
interventions met the criteria for an evidence-based practice
(Wang and Spillane 2009)
. The same review concluded that
the effects of programs based on social stories and
peermediated interventions are ambiguous and depend on the
method of implementation. Cognitive behavior training was
described as a promising technique for developing social
skills that has not been studied sufficiently.
The most recent meta-analysis of effectiveness of ToM
training, covering 45 studies and over 1500 children, showed
that these interventions are fairly effective
(Hedges’ g= 0.75;
Hofmann et al. 2016)
. This meta-analysis did not, however,
analyze the type of disability or method of intervention as
moderators. Therefore, it is not clear which ToM training
programs or which methods are most effectiveness for
children with ASD. A systematic review of various ToM
programs for children with ASD concluded that most produced
improvements in perspective-taking skills
. Unfortunately, the improvements in
perspective-taking skills produced by ToM training rarely
generalized to real-life situations, and therefore, do not improve
children’s ability to interact with their peers or with adults
(e.g., Begeer et al. 2011; Ozonoff and Miller 1995; Fisher
and Happe 2005)
Many studies of the effectiveness of programs intended
to produce improvements in social skills, such as the
ability to cope with difficult social situations
(Solomon et al.
(Chin and Bernard-Opitz 2000)
found that they did not improve ToM. However, a deeper
analysis of these studies included in the review revealed
distinct interventions that can improve ToM task-solving and
(Feng et al. 2008; Mackay et al. 2007)
These ‘naturalistic’ interventions contained tasks for
developing ToM and different aspects of communication, such
as listening, conversation, and cooperation skills. However,
some flaws, such as a modest number of studies, rather small
samples (except for the study of Mackay and colleagues),
different ways of ToM assessment and differentiated
intensiveness of interventions do not allow inferring about the
effectiveness of the interventions for improving ToM and
social skills among children with ASD. Further research into
the efficacy of naturalistic interventions using a combination
of practices is needed to improve understanding of the
factors that influence the efficacy of educational interventions
and to identify methods for which there is a good evidence
base, and can thus be recommended to teachers.
The purpose of this study was to assess the efficacy of
two programs designed to develop the social skills of
preschool-age children: Play Time/Social Time (PT/ST) and I
Can Problem Solve (ICPS). To assess the efficacy of these
programs, we used measures of social skills as well as ToM
to determine the extent to which the effects of instruction
using these programs could be generalized. We observed
changes in social skills (i.e., interactional skills and coping
with difficult social situations skills) and in theory of mind
development in both the experimental and in control groups,
as well as correlations between interactional skills, abilities
of coping with difficult social situations, and ToM.
Both programs have already been evaluated, but there has
not been a comparative study of their efficacy in developing
social skills and ToM in children with ASD
(Odom et al.
1997; Shure and Spivack 1982; Szumski et al. 2016)
and his colleagues improved the structure and content of
Play Time/Social Time for a few years to reach the mostly
optimal set of lessons and activities
(Odom et al. 1997)
a Polish study on effectiveness of PT/ST for social skills
development, it turned out that this method was effective
for children with different forms of disabilities as well as
those without disabilities, showing very strong effect size
for both group (η2 = 0.70). The Time x Group interaction
also was significant with a substantial effect size of η2 =
0.32, indicating that children with disabilities made greater
improvement in social skills in comparison to children
without disabilities. Children with ASD have shown the smallest
changes in comparison to other children, but the differences
were marginal (η2 = 0.15, p = .06). However, there was no
control group in this study, which significantly limits its
(Szumski et al. 2016)
. A study by
Shure and Spivack
on effectiveness of ICPS has shown promising results
in developing children’s social skills and reducing problems
in behaviors. However, the participants in their study were
African-American children without disabilities. Thus, it is
necessary to determine the effectiveness of this program for
children with disabilities.
Fifty-two preschoolers from ten inclusive preschools in
Warsaw and its suburbs participated in the study. All
children were native Polish speakers. All children had a
clinical diagnosis of ASD, were verbal, and had IQ’s above
70. Fourteen children took part in the PT/ST program (10
boys and 4 girls) and 12 participated in the ICPS program
(8 boys and 4 girls). The control group of 26 children (18
boys and 8 girls) received no specific training in social skills
development other then the standard preschool curriculum.
There were no differences between groups in sex
distribution (F(2, 51) = 0.032; p = .97). The mean age of participants
was 5,10 years (SD = 1.12, range 3,6–7,6). The mean age
for each of the three groups was as follows, PT/ST group:
5,4 years (SD = 0.83, range 4,6–7,3); ICPS group: 5,0 years
(SD = 1.2, range 4,0–7,2); control group: 4,9 years (SD = 1.2,
range: 3,6–7,6). There were no significant group differences
for age (F(2, 51) = 0.72; p = .49.).
We used an adaptation
(Pisula et al. 2010)
of the Autism
Spectrum Quotient: Children’s Version
Auyeung et al. 2008)
to compare the groups for the intensity of
core features of autism spectrum disorder. The AQ-Child is
a parent-report instrument consisting of 50 items to which
responses are given using a four-point Likert scale
ranging from ‘definitely agree’ (0) to ‘definitely disagree’ (3).
Higher scores indicate the presence of stronger features
of ASD. The overall mean score for our sample was 75.10
(SD = 16.76). The means for each group were PT/ST group:
76.07 (SD = 14.24); ICPS group: 74.72 (SD = 21.14); and
control group: 74.71 (SD = 16.64). The intensity of the
features was similar in all three groups (F(2, 51) = 0.03;
p = .97). The mean results approximated the recommended
(Auyeung et al. 2008)
. However, it is important to
highlight that we did not use the measure for diagnosis of
ASD and, as the authors stated, the cut-off should be used
with caution. Even if our results were slightly lower than the
recommended cut-off, all children participated in the study
because they had a previous clinical diagnosis of ASD.
We used group-based social skills training programs because
this method of delivery provides opportunities for children
to learn social skills in a naturalistic milieu and promotes
interactions with other children
(Barry et al. 2003)
chose programs for which there is a manual and formal
curriculum because these programs are replicable and easy
for teachers to use
(White et al. 2007)
. It is important for
future programs implemented in schools to be evaluated and
assessed based on their evidence-based and their ease of use
for teachers. Most of the programs evaluated previously were
delivered by researchers, and it can be difficult for teachers
to achieve similar effects
(Wang and Spillane 2009)
a program for which there is a manual and a formal
curriculum makes it easier to ensure that the program is delivered
in a standardized fashion, in accordance with the manual
(McKenna et al. 2014)
Many methods of classifying programs for developing
social skills and ToM have been used
(Reichow and Volkmar
2010; Vaughn et al. 2003)
, and consist of a combination of
components. Although the programs we chose make use of
several components, for this study, the most relevant
components of the PT/ST program are the behavioral components
so the program can be classified as ABA. The ICPS program
relies primarily on cognitive methods.
Play Time/Social Time. PT/ST is aimed at children
3–7 years of age with a disability who have significant
problems with social skills development. The PT/ST program is
used to teach specific social skills to children of preschool
age, starting with the initiation and maintenance of
interactions with peers. Specifically, the social skills targeted are:
sharing toys, persistence in initiating social interactions,
requesting to share objects, play organizing, agreeing with
others, and helping other children. The program consists of
structured play-based tasks, in which the teacher verbally
prompts children to use social skills so that they can have
more ‘fun’ interacting with other children. Social
interactions in this intervention are not only ‘common play’. During
play, the children could talk to each other, exchange
materials (e.g., toys), and take turns.
The original version of PT/ST was designed to last
100 days and organized into several phases, during which
children perform the activities mentioned above. After 25
social skills sessions, teachers should start to use
non-verbal reinforcements (e.g., pictures with ‘Happy Faces’). The
reinforcements are mitigated with time—at first the pictures
are shown to children when a proper behavior appears, then
the pictures are no longer shown to children, but there is a
discussion about them at the end of the class, and during
the last five sessions also the discussion is discontinued.
Each session lasts 15–20 min and is based on a role-play
performed in dyads. Each dyad consists of a child with a
disability and a child without a disability. Sessions took place
(see also Odom et al. 1997; Szumski et al.
I Can Problem Solve (ICPS). The program has been
designed for children in preschool, kindergarten and
elementary school, but the version we were using in the study
is devoted to children from 3 to 6 years of age. The aim of
the ICPS program is to teach children to solve problems
and resolve social conflicts using dialogue. The program
consists of 59 sessions, one per day. The program was
created for children with special educational needs as well as
for typically developing children. Children were grouped in
teams with 6–8 children. In the beginning of the program,
sessions last no longer than 10 min, and sessions increase in
duration with subsequent session lasting 20 min. The
sessions consist of play, games, stories, role-playing activities.
Children learn how to solve conflicts, to identify their own
and others’ emotions, to understand the point of view of
another person, and to recognize the reasons for their own
behavior and the consequences thereof. As well as giving
scenarios for the sessions, the program also includes tips for
improving children’s interactions during routine educational
situations in preschool.
We used three measures in this study. Two of the
measures were used to measure social skills and one was used
to assess theory of mind development. The measures are
Scholars of social skills agree that these skills should be
measured using multiple instruments or instruments with a
(McConnell and Odom 1999)
For this reason, we used Polish adaptations
(Smogorzewska and Szumski 2015) of two questionnaires that
measure slightly different aspects of social skills. The Teacher
(TIS; Odom et al. 1997)
assesses a child’s
ability to enter an interaction and to play with peers. The
Taxonomy of Problematic Social Situations questionnaire
(ToPSS; Dodge et al. 1985)
assesses a child’s ability to
cope with difficult social situations and identifies situations,
which are especially troublesome for the child.
The Teacher Impression Scale (TIS) was developed
by Odom and colleagues (1997). It is a teacher-report
instrument consisting of 16 items to which responses are
given using a five-point Likert scale, ranging from 1—the
child never displays this skill, to 5—the child frequently
displays this skill. The final score is the sum of score on
individual items and score are based on observations. Higher
scores represent better social skills. The reliability of the
scale was high (Cronbach’s α = 0.97).
The Taxonomy of Problematic Social Situations for
(ToPSS; Dodge et al. 1985)
is used to measure various
aspects of social functioning: peer group entry, response to
provocation, response to failure, response to success, social
expectations, and teacher expectations. The ToPSS is a
teacher-report instrument consisting of 44 items to which
responses are given using a five-point Likert scale, ranging
from 1—this situation is never a problem for the child, to
5—this situation is almost always a problem for the child.
Lower scores represent better social skills; the lower score
the better improvement in child’s behavior. The reliability of
the scale was very high (Cronbach’s α > 0.97).
Theory of Mind (ToM) was assessed using a scale
Wellman and Liu (2004)
, and revised by Peterson,
Wellman, and Liu in 2005, then again by Peterson, Wellman,
and Slaughter in 2012. The scale consists of six tasks related
to understanding of diverse desires, diverse beliefs,
knowledge access, false beliefs, hidden emotions, and sarcasm.
We have added one task, measuring second-order ToM,
to the original scale. The ‘Chocolate’ task was developed by
Hughes and colleagues (2000) and based on a task designed
by Sullivan, Zaitchik, and Tager-Flusberg (1994). The tasks
in the scale are ordered from the easiest to the most difficult
to prevent a ceiling effect. The instructions for the easiest
task in the scale are as follows:
Here is a lady. This lady wants her morning tea. Here are
two foods, a carrot and a biscuit. Pretest Question: Which
do you like best? That’s a good choice. But the lady doesn’t
like [biscuits]. She likes [carrots]. She loves to eat [carrots]
best of all. Test Question: So now the lady can choose only
one food. Which will she choose? [If no answer prompt: Will
she choose a carrot or a biscuit?] (Correct answer = food
the adult likes, always opposite to child’s own preference)
(Peterson et al. 2005)
The instructions for the most difficult task in the scale
are as follows:
The girl and boy are going on a picnic. It is the boy’s idea.
He says it will be a lovely sunny day. But when they get the
food out, big storm clouds come. It rains and the food gets
all wet. The girl says: ‘‘It’s a lovely day for a picnic.’’ Pretest
question: Is it true, what the girl said? Test question: Why
did the girl say ‘it’s a lovely day for a picnic?
Comprehension control question: Was the girl happy about the rain?
(Peterson et al. 2012)
The content of all tasks with the right answers can be
found in Peterson et al. 2005 and 2012, and in Hughes et al.,
For this study, we prepared color pictures for all seven
tasks to illustrate the stories as they were presented to
children. Color pictures of objects (i.e., a carrot, a cake, bushes,
a garage) and people (i.e., a girl, a boy, group of children)
were shown to the participants. For each task in which the
child correctly answered every question, s/he received one
point. All seven tasks were assessed in the same way.
Children could earn from 0 to 7 points. The correctness of the
tasks was assessed by the second author of the article. As
there is no room for one’s own interpretation it is not
necessary to ask more than one person for independent
assessment. The assessment was done in accordance with the
original scoring instructions
(Hughes et al. 2000; Wellman
and Liu 2004; Peterson et al. 2005, 2012)
. The reliability
of the seven tasks is acceptable (i.e., Cronbach’s α = 0.80).
We produced Polish translations of the instruments using
the back translation technique, translating them into Polish,
then once again into English and comparing both English
versions to be as similar as possible. Discrepancies between
the original and back-translated versions were discussed and
resolved. All instruments were validated in a larger
sample and demonstrated high reliability; therefore, they were
considered suitable for assessing and detecting changes in
preschoolers’ skills during the course of the study
(Smogorzewska and Szumski 2015)
We conducted the study during the 2014–2015 school year
in preschools that had volunteered to take part in the
project. Fifty-five preschools from Warsaw and suburbs, which
cooperated with us in other, previous projects, received an
e-mail detailing the study. To be accepted for the project, the
preschool designee had to agree to take part in the study and
send permission forms to the children’s caregivers. Twenty
preschools from Warsaw and suburbs answered; however,
only 10 of the responding preschools had children with
ASD in attendance. All parents of children attending the 10
preschools gave permission for their children to participate.
Preschools’ groups were assigned randomly to experimental
or control groups. Those assigned to the control group were
offered the opportunity to follow one of the intervention
programs at the end of the study. Forty graduate students
who were in the final year of a masters degree in special
education and supervised by the children’s preschool
teachers delivered the intervention programs. The students follow
an inclusive education program at their University, in that
during each year of their studies, they had at least 60 h of
field practice in inclusive preschools. The preschool
teachers supervise the students during their field practice. All
supervising teachers graduated from universities. Before
the programs began, both teachers and students underwent
specific training provided by one of the project leaders, who
has experience using the programs with children. She holds
a masters degree in education and psychology, and a
doctoral degree in education. She teaches college courses on
developing social skills and provides social skills trainings.
She also has wide experience leading research in the field
of social skills development as a principal investigator. The
one-day training lasted for five hrs. During the training, the
preschool teachers and students learned about the aims of the
project and the methods used in program, which the students
then implemented. A separate training session was provided
for each experimental group. Materials and manuals were
provided. At the beginning of the project, teachers assessed
the children’s social skills, and doctoral students in special
education assessed children’s ToM. Although the teachers
were not blind to their assigned study group, they did not
choose the program in which they participated. They also
did not lead the lessons. We asked them to assess children’s
behaviors in different social situations and during different
activities, inside and outside the classroom. Also, just after
each assessment process we asked them to return the
assessment sheets, so that they could not review them and use them
for the next assessment process.
To make the duration of the two programs comparable,
we shortened the PT/ST program to 67 sessions, cutting
some sessions altogether and extending the duration of
others from 6 to 10 min. However, we did not omit content from
the program, so as not to influence fidelity. In the PT/ST
group, children were playing in pairs: child with
disabilitychild without disability. There were up to six pairs
playing together at one time. In the case of the ICPS program
whole preschool groups participated in each lesson. That is
why in the ICPS group more children without disabilities
attended the lessons than in the PT/ST group. Lessons were
conducted every weekday, Monday to Friday, in the
morning or during time, which was mostly suitable for children.
Each lesson took no more than 20 min and was part of a
daily routine. In the ICPS program manual, suggestions are
provided on ways to incorporate the method into the regular
preschool program. Lessons took place in the classroom,
appropriately prepared for activities (i.e., with needed toys
or games). Each lesson was led by one student. There was
also a teacher and a teacher assistant in the classroom to
help the student as needed. The role of the student was to
encourage children to play in pairs with toys they were given
and follow the instruction (PT/ST) or to be actively engaged
in the class (i.e., playing short games, answering questions,
giving ideas, thinking about consequences, etc.; ICPS).
The student’s role was also to facilitate children’s play and
engagement by giving them verbal and nonverbal
reinforcements, but not praising them or telling them the right answer
or showing the proper behavior. We reassessed the children’s
social skills and ToM at the end of the first phase (i.e., after
28 days in the case of PT/ST; after 33 days in the case of
ICPS) and at end of the experiment (after 67 days in the case
of PT/ST and 59 days in the case of ICPS).
To monitor the fidelity of program delivery, a random
sample of sessions were observed by doctoral students, who
completed a specially prepared observation sheet. Its
content was prepared in accordance with clues mentioned in
Odom et al. (2010
Harn et al. (2013
) with reference to
quantity and quality, structure and process of the
interventions’ implementation. The observation sheets with Likert
scales were used to record the structure of the sessions,
duration and course of the sessions, adherence to the planned
scenario, leader’s (graduate student) behavior during
session (i.e., the way of conducting lesson, giving instructions,
reinforcements and support to children), children’s
behavior during session (i.e., the motivation to take part in the
lesson, reactions to instructions), and interactions between
the children and adult. Observers could give a maximum of
16 points in all assessed categories. Higher points on the
measure indicated better fidelity and meant better
accordance with programs’ instruction, structure and content. The
results of the observation were always compared with the
instruction and content of the concrete lesson. For each
experimental group, 12 observations were completed. An
analysis of variance (ANOVA) showed that overall, the
sessions conducted during the study were consistent with the
programs’ assumptions, and there were no statistical
differences between groups (see Table 1). The given data indicate
that the fidelity was high and close to maximum. Analyses
show that such a level of fidelity is acceptable and should
not negatively affect the effectiveness of the intervention
(Durlak and DuPre 2008)
. Moreover, it is worth noting that
teachers who also attended the training upon implementing
the programs constantly supervised students who led the
classes with preschoolers. It could be a reason for the high
level of fidelity. However, if the observer saw any incorrect
procedures during the session, there was always a brief
discussion afterwards, during which observer as well as leader
could express their thoughts and doubts. In such case the
observation was repeated to check whether the quality of
the lesson changed for the better. This observation, though,
was not included in the fidelity data. It is also important to
note that in all groups the programs were completed and we
did not observe any significant changes in the programs’
implementations in time.
To determine if ToM correlated positively with the
interactional skills of children with ASD, we used Pearson’s
product-moment correlation coefficient. To compare the rates
at which with ASD assigned to either the experimental and
control groups developed interactional skills, coping skills,
or ToM, we employed a series of latent growth curve
(LGCMs; Bollen and Curran 2006; Duncan and Duncan
2004; McArdle and Epstein 1987)
. LGCMs are one of the
main ways of analyzing level and change in longitudinal
data. They provide information about the growth or decline
in variables at the participant level by estimating an
underlying temporal trajectory for each individual.
The basic idea behind these models is that the change
in a participant’s scores on the measures (i.e., growth or
decline) on a given variable is a function of a latent random
intercept (i.e., the average initial value at the start of the
longitudinal change process) and a latent random slope (i.e.,
the average individual rate of change over time). LGCMs
also allow for estimation of the variance in the intercept
(i.e., the individual variability around the group baseline
parameter) and slope (i.e., the individual variability around
the group change parameter). Statistically significant
variance indicates that participant trajectories of change do not
follow the same pattern.
An important advantage of LGCMs is that they enable
the study of predictors of change in a participant’s scores
over time (i.e., variance in growth processes between
subgroups can be examined). In other words, LGCMs can be
used to investigate whether, and to what extent, predictors
can account for variance at baseline and change over time. In
this study, we evaluated intervention type (i.e., PT/ST, ICPS,
control) as a predictor of both slope and intercept constructs
(i.e., TIS, ToPSS, ToM). A dummy code approach was used
to compare the impact of PT/ST (dummy code = 1), ICPS
(dummy code = 1) and the control condition (i.e., reference
group; dummy code = 0) on intercept and slope dependent
As an initial analysis, we ran separate unconditional
models (i.e., models without covariates) to describe the
baseline values and rates of change of the three constructs under
investigation (i.e., TIS, ToPSS, ToM). We then examined the
associations between baseline values and rates of change in
TIS, ToPSS and ToM. After this, we investigated whether
we could predict the baseline values and rates of change
by running conditional models including predictors such as
intervention type (see Fig. 1).
Statistical analyses were performed using Mplus 7.4
Muthén and Muthén 2012
) and Bayesian estimator
de Schoot et al. 2014)
. We used Bayesian statistics because
they perform well in small samples and are robust against
non-normality in the data
(Van de Schoot et al. 2015)
this meant that well-known fit indices (e.g., chi-squared,
RMSEA, CFI, TLI) were not available
(Byrne 2011; Geiser
. We therefore used the posterior predictive p-value
(PPPV) as an index of goodness of fit. Small, significant
(p < .05) values of PPPV indicate poor model fit. In
specifying the linear growth model, we constrained the factor
loadings of the intercept to 1 and the factor loadings of the slope
to 0, 1 and 2 (time-lags between assessments).
To provide appropriate effect sizes, differences in rate of
change (slope) between conditions (experiment vs. control,
dummy-coded) were estimated using StdY standardization
parameters. These coefficients express the expected change
in standard deviations of the dependent variable (a random
slope) when the independent variable (experiment vs.
control) changes from zero to one. Because the independent
variables are all coded as dummy variables, the coefficients
are directly comparable as they indicate the relative impact
of the related independent variable. Therefore, these effect
sizes can be interpreted as similar to Cohen’s d.
Preliminary Analyses (Correlations and Unconditional LGCM)
Correlation matrix between variables. The data in Table 2
show that TIS scores were not correlated with ToPSS scores
in any of the assessments (see the intersection of columns
2–4 and rows 5–7). TIS scores and ToM, however, were
correlated in all the assessments (r = ~ 0.6) (see the
intersection of columns 2–4 and rows 8–10). Thus, ToM correlates
positively with the interactional skills of children with ASD.
Latent growth curves without covariates (unconditional
models). We first calculated separate latent growth curves
without covariates to describe the baseline and rate of
change in TIS, ToPSS and ToM.
LGCM for TIS
The PPPV for TIS was not significant (p= .548), indicating
that the linear growth curve described the data accurately
(see Table 3). The means for the baseline and average rate
of change (see Table 3) were 44.64 and 3.77 (SD = 0.70,
p < .001) respectively, indicating that TIS scores increased
over time. Analysis of the variance in baseline and rate of
change revealed differences between individuals with respect
to both baseline and average rate of change (184, p < .001),
which justified the addition of variables that might account
for individual variation in trajectory. The TIS intercept and
change factors were uncorrelated (p > .05).
LGCM for ToPSS
The unconditional LGCM for ToPSS was also an excellent
fit to the data (PPPV p= .53). The mean of the intercept or
baseline for ToPSS was 2.90 (p < .001) and the variance was
0.57 (p < .001). The mean for the estimated slope of ToPSS
was − 0.13 (different from zero: p < .01), indicating that the
average ToPSS score decreased over time. There also was
individual variance in the slope parameter (0.04, p < .001),
indicating that the rate of change in ToPSS varied amongst
the children. The covariance between the latent intercept
and slope was negative, but non-significant (−.06, p > .05).
Table 2 Means, standard
deviations, and correlations
2. TIS 1
3. TIS 2
4. TIS 3
5. ToPSS 1
6. ToPSS 2
7. ToPSS 3
8. ToM 1
9. ToM 2
10. ToM 3
TIS Teacher Impression Scale, ToPSS taxonomy of problematic social situations for children, ToM theory of mind. Parameters are
***p < .001, **p < .01
As in the case of the other dependent variables, the
unconditional LGCM for ToM was a good fit to the data (PPPV
p = .36). The mean baseline value for ToM was different
from 0 (2.16, p < .0001) and varied between participants
(3.08, p < .001). There was an increase in ToM over time
(mean rate of change = 0.30, p = .01) that varied between
participants (0.15, p < .001). As in the TIS and ToPSS
models the baseline value for ToM was not related to the rate of
change (p > .05).
Main Analysis (Conditional LGCM)
Because the main aim of the study was to assess whether
the PT/ST and ICPS programs were effective in improving
children’s social skills and ToM, the next step in the analysis
was the estimation of LGCMs in which being in the
intervention group was a predictor of: (a) baseline value, and (b)
change in all the dependent variables (TIS; ToPSS; ToM).
We start by describing the analysis of the TIS model,
which was a good fit to the data (PPPV = 0.15, see
Table 4). Table 4 shows that at pre-test, TIS scores were
similar in the experimental groups and the control group.
In the case of PT/ST and ICPS, the regression coefficient
for initial status of TIS was insignificant (ps > 0.05). The
rate of change in TIS was faster in the PT/ST group than
in the control group, indicating that the PT/ST program
accelerates the development of abilities measured by TIS
(βSTDY = 1.48, p < .01). The ICPS group showed a similar
rate of change in TIS to the control group (βSTDY = 0.63,
p > .05). In fact the PT/ST program was more effective
than the ICPS program, which did not improve the aspects
of social skills captured by the TIS.
It is worth noting that adding predictors of pre-tests and
change to the model did not lead to homogenization of
variance in either baseline or rate of change. Both coefficients
were still statistically significant (p< .001). In the case of
TIS Teacher’s Impression Scale, ToPSS taxonomy of problematic social situations for children, ToM theory of mind, PT/ST play time/social
time, ICPS i can problem solve. Regression and correlation coefficients are standardized (STDY for regression; STDYX for correlation). All
others paramteres are unstandardized
***p < .001, **p < .01, *p < .05
Fig. 2 Estimated growth curves for Teacher’s Impression Scale (TIS)
over time. Note TIS Teacher’s Impression Scale, Control control
group, PT/ST play time/social time, ICPS i can problem solve
TIS, the interventions are not sufficient to account for the
variance in trajectories (Fig. 2).
We observed clearer situations for the ToPSS model
(PPPV = 0.19; see Table 4). First of all, both intervention
groups had higher (i.e., worse) pre-test ToPSS scores than
the control group (see Table 4; Fig. 3; PT/ST: βSTDY = 0.83,
p < .01; ICPS: βSTDY = 1.20, p < .001). Both
intervention groups showed a greater decrease in ToPSS scores
over time than the control group (PT/ST: βSTDY = − 1.65,
p < .001; ICPS: βSTDY = − 1.18, p < .001). In other words, in
both groups the reduction in inappropriate behaviors during
the course of the experiment was larger than in the control
Fig. 3 Estimated growth curves for taxonomy of problematic social
situations for children (TOPSS) over time. Note ToPSS taxonomy of
problematic social situations for children, Control control group, PT/
ST play time/social time, ICPS i can problem solve
In this context, it is important to note that when
intervention type was used as a predictor of change in ToPSS the rate
of change of intercepts was not significant, indicating that
taking part in the intervention decreased problematic
behaviors among children. At the same time, the variance in
pretest for the ToPSS and in rate of change of ToPSS remained
significant (p< .001), which indicates that the intervention
variable was not sufficient to account for pre-test differences
in ToPSS or the changes in ToPSS during the course of the
There were no group differences in ToM in the pre-test
(see Table 4; Fig. 4). In the case of PT/ST and ICPS the
Fig. 4 Estimated growth curves for theory of mind (TOM) over time.
Note ToM theory of mind, Control control group, PT/ST play time/
social time, ICPS i can problem solve
regression coefficient for baseline was not significant
(p > .05). There was also no difference between the PT/
ST and control groups with respect to rate of change
in ToM (βSTDY = 0.21, p = .35). It is less clear whether
the ICPS program had any influence on ToM
development (βSTDY = 0.94, p = .07). The regression coefficient
ICPS→ToMRateOfChange was not different from zero using
the standard p < .05 criterion for statistical significance;
however, if we use a more liberal criterion (p < .1), we
cannot reject the possibility that the ICPS improved ToM
development. Marginal effectiveness of the ICPS program
indicates a 95% confident interval (CI) of estimated
coefficient, which only insignificantly includes 0 [−0.35, 2.15].
A positive regression coefficient would indicate faster
positive changes in ToM in the ICPS group in comparison
with the control group.
To determine whether or not the calculated p value was
caused by a small number of participants
post-hoc power analysis was performed based on Monte
(Muthén and Muthén 2002)
. With a sample
size of 51 and the results of the study as population values
with 100,000 replications, a simulation indicated that given
the observed magnitude of interesting coefficient, the sample
size, and α = 0.05, the calculated power was 0.94.
statistical power estimates (i.e., 0.8 and
above), this means that, under these conditions, there was a
94% chance that this coefficient would be proven to be
statistically significant (it should be statistically insignificant).
This result reaffirms that the p value of regression coefficient
obtained in our analysis emerges from a small sample.
Obviously, replicating the results on a larger sample is needed to
confirm the conclusions we have reached.
An indirect argument, showing the effectiveness of
ICPS method, is that the intervention variable in the model
causes that the ToM intercept rate of change is statistically
insignificant. In other words, if we had not conducted the
interventions (i.e., all predictors had a 0 value), there would
have been no change in the children’s ToM level. The results
indicate that the ICPS intervention was relatively more
effective than the PT/ST.
As in the case of the other dependent variables, the
intervention variable did not completely account for pre-test
differences in ToM or the changes observed during the course
of the experiment. Both parameters remain statistically
significant (p< .001).
We assessed whether two different intervention programs
were more effective than the standard preschool curriculum
in developing social skills (i.e., interactions with peers,
coping with difficult social situations) and ToM in preschool
children with ASD. The given results are discussed with
reference to three main issues: the relation between two
aspects of social skills and ToM in the examined groups,
the effectiveness of two programs in developing social skills
and the effectiveness of these programs in developing ToM.
We showed that ToM is correlated with the ability to
initiate contact with peers. ToM and TIS scores were highly
correlated in each of the measurement times as well as between
the measurement times. These results corroborate previous
research showing that ToM is important for establishing
and maintaining positive relations with others, because an
understanding of other people and their thoughts, beliefs and
behaviors is what makes an individual capable of reacting
and responding to others
(Astington 2003; Cutting and Dunn
2006; Davies and Stone 2003; Howe et al. 2002)
At the same time, we found that children’s ToM
development was not related to the frequency with which they
displayed problematic social behaviors. In other words,
having a more developed ToM does not prevent difficulties in
social contact with peers, and a poorly developed ToM is
not a predictor of problematic social behavior. A previous
study on the relationship between ToM development and
preschoolers’ ability to cope with solving difficult social
situations produced ambiguous results
(Capage and Watson
. Although such a relationship was observed, it is weak
and disappears after controlling for some variables (e.g., age
and language skills)
(Capage and Watson 2001)
Not all difficult social situations relate to interactions;
some situations concern adjustment to social norms and
fulfillment of standard social roles, such as being a student
(Dodge et al. 1985; Servik et al. 2010)
. ToM, however,
evinces mostly in interpersonal situations and in
interactions important for both partners, which require
understanding of the partner’s thoughts, emotions, and goals. However,
some interpersonal situations have negative contexts (e.g., a
peer’s provocation). The ability to regulate one’s emotions,
self-efficacy with respect to contacts with others and the
ability to generate many solutions are much more important
factors in coping with this kind of situation than insight into
others’ thoughts and feelings (Dodge et al. 1985). Although
the relationship between ToM and social skills was not a
main subject of this study, the results are important for better
understanding of ToM significance for social functioning of
children with ASD. They support a well-established belief
that the level of ToM development is strongly connected
with interaction skills, but it is not important for ability to
cope with difficult social situations.
Two conclusions can be drawn from our comparison of
the effectiveness of two programs in developing the social
skills of children with ASD. First, it is worth emphasizing
that we found evidence that the programs produced positive
improvements in children with ASD, even though it is often
difficult to achieve positive results with social developmental
interventions in this population
(Hadwin et al. 2015;
Southall and Campbell 2015; Vaughn et al. 2003)
Second, the PT/ST program, based on behavioral
methods and peer interactions in natural settings, produces more
general effects than ICPS—a cognitive program. The ICPS
program only improved social problem solving, whereas
the PT/ST program influenced both interaction skills and
social problem solving, which makes it more effective. Our
results are in line with those from previous studies
demonstrating that behavioral interventions based on naturalistic
techniques and peer training are amongst the most effective
methods of improving social skills of children with ASD
(see: Reichow and Volkmar 2010)
. For children with ASD,
those taking part in the PT/ST program interaction skills
improved almost one-and-a half standard deviations more
than the control group (βSTDY = 1.48, p < .01). Also, problems
in coping with difficult social situations decreased over
oneand-a half standard deviations (βSTDY = − 1.65). The changes
are strong, with visible clinical importance. However, it is
not easy to compare them directly to effects received in most
previous interventions focused on improving social skills
among children with ASD. The reason for this is that most
of the studies were single-case research
(Bellini et al. 2007;
Reichow and Volkmar 2010)
, for which quantitative
methods of effect size assessment are in progress and are
incomparable with measures used in studies of bigger groups.
Results of meta-analysis of single-case studies highlight
that effects of programs developing social skills among
preschool children with ASD are moderate (Bellini et al. 2007).
Rare results of group studies are more promising and show
(Kasari et al. 2006)
and very strong effects
et al. 2007; Smith et al. 2004)
. Comparing effects of
different studies demands a lot of caution, because these studies
represent different ways of understanding social skills and
different ways of assessing them (Rao et al. 2008).
The effectiveness of the ICPS program provides support
for the idea that cognitive programs can improve at least
some aspects of social competence in children with ASD
(Wang and Spillane 2009)
. Problems in coping with
difficult social situations among children taking part in the ICPS
program decreased one standard deviation (βSTDY = − 1.18,
p < .001); however, there is no change in the case of
interaction skills. The ICPS program thus brings less generalized
improvement of social skills than the PT/ST program.
Unlike the PT/ST program, the ICPS program showed
promise as a method of developing ToM in children with
ASD. Analysis indicated that the ICPS program produced a
marginal improvement (p < .1) in ToM, and modeling
indicated that had the ICPS group not been included in the
sample, the overall increase in ToM level would have been much
smaller. Moreover, an additional statistical simulation shows
that the p value in this case is caused by an objectively small
sample size. This result requires some discussion.
First, results of the current study, therefore, are
consistent with results of
BaumingerZviely et al. (2013
) and support a thesis that some social
skill interventions bring more general results and improve
ToM. Replication of this positive result with other social
skills programs can influence the quality of education of
children with ASD. Positive results might also increase ToM
(Begeer et al. 2011; Fisher and Happe 2005;
Ozonoff and Miller 1995)
Second, our study shows that cognitive programs can be
more effective in developing ToM than behavioral programs,
which is logical because ToM is a cognitive ability, in
contrast to the behavioral aspects of social competences
(Langeveld et al. 2012)
. Our study provides support for the notion
that there are two independent aspects of social competence
whose development depends on different experiences.
The focus of the ICPS is on teaching children how to
resolve conflicts with their peers. Resolving conflicts in a
way that satisfies all the parties requires insight into the
needs and wishes of the other parties, as well as one’s own
(Johnson and Johnson 1996)
. The ICPS program makes
extensive use of peer group discussion, which creates plenty
of opportunities for exposure to other people’s arguments.
It is also not unimportant that the ICPS program includes
language activities, which might help to develop
participating children’s language skills. There is some evidence that
children’s ability to solve ToM tasks is correlated with their
(Milligan et al. 2007)
It is worth noting that the ICPS program, like the PT/ST
program, was not designed specifically for use with
children with ASD. Both programs are intended to be use with
inclusive groups consisting of a mixture of children with and
without special educational needs. They can be used in
natural settings in preschools (i.e., be a part of the everyday
preschool routine), which is a great advantage
(Rao et al. 2008)
There is growing demand for inclusive programs of this type
because there is systematic growth in the number of children
diagnosed with ASD
(Goodman and Williams 2007)
, as well
as growth in their participation in inclusive education
(Loiacono and Valenti 2010)
. Many teachers do not
feel prepared for work with children who have ASD and
the availability of programs with a formal curriculum that
is manualized might improve teachers’ ability to meet the
needs of children with ASD
(White et al. 2007)
Before concluding, a few potential limitations of our study
should be mentioned. One of them is the rather small
sample. Additionally, the participants were assessed only with
the AQ questionnaire; we did not use other, more
comprehensive instruments, such as the ADOS-2 or ADI-R.
However, children had a previous clinical diagnosis of ASD and
we used AQ only to compare the intensity of autism features
in the experimental and control groups. Statistical analysis
showed that the groups were comparable in this case.
Although the children taking part in the study were
verbal, we did not assess the preschoolers’ receptive and
expressive language or their communication skills. Therefore, we
do not know whether or not potential problems in
communication lead to weaker results in effectiveness among
individual children. This could impact the effectiveness for the
ICPS program in particular as children communicate
verbally with the group leader. Limited communication skills
can reduce potential effectiveness of the method. The role
of language abilities in methods’ effectiveness should be
considered in the next study.
Due to small number of children within each group and
larger number of boys than girls, we were not able to
determine differences in the effectiveness of the methods in the
case of sex. Although, this factor is worth checking in the
next analysis, there are no theoretical premises to
hypothesize that the programs affect girls’ and boys’ development
An important limitation is that assessments of social
skills were not blind. The teachers who assessed the
children were aware that they were taking part in the experiment
although they were not key players in delivery of the
intervention. Delivery of the intervention was led by graduate
students, as part of their internship.
The most important weakness of our study is the lack of
a formal follow-up. We do not know whether the
improvements we observed were enduring, nor whether they led to
further positive changes in participants’ behavior and
abilities. Such information is very important in determining the
practical value of the programs, as well as from a theoretical
perspective. Moreover, there is a lack of measurement of
generalization of the skills learned. We do not know whether
participation in the project positively changed children’s
everyday functioning in social situations other than preschool.
This issue needs considering during further studies.
In our study, despite some limitations, we were able to
show that the Play Time/Social Time (PT/ST) and I Can
Problem Solve (ICPS) interventions are more effective
than the standard preschool curriculum in developing
interactional skills and in teaching kids how to cope with
difficult social situations. The PT/ST program is more
effective than ICPS in developing interactional skills;
however, both programs are similarly effective in teaching how
to cope with difficult social situations. In contrast, only the
ICPS program develops ToM. Our results are clinically as
well as practically important. They show that it is possible
to improve social functioning of children with ASD, as
well as their theory of mind using educational programs.
Acknowledgments The study has been financed by Ministry of Science
and Higher Education in Poland (Project No. MNiSW/2015/DIR/20/
Author Contributions GS & JS planned the study, wrote and revised
the manuscript. PG prepared the statistical analysis and described the
results. A-MO contributed to the revision of the manuscript.
Compliance with Ethical Standards
Conflict of interest The authors declare that they have no conflict of
Ethical Approval All procedures performed in studies involving human
participants were in accordance with the ethical standards of the
institutional and/or national research committee and with the 1964 Helsinki
declaration and its later amendments or comparable ethical standards.
Informed Consent Informed consent was obtained from all parents of
individual participants included in the study.
Open Access This article is distributed under the terms of the Creative
Commons Attribution 4.0 International License
(http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use,
distribution, and reproduction in any medium, provided you give appropriate
credit to the original author(s) and the source, provide a link to the
Creative Commons license, and indicate if changes were made.
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