A Systematic Review of Group Social Skills Interventions, and Meta-analysis of Outcomes, for Children with High Functioning ASD
Journal of Autism and Developmental Disorders
A Systematic Review of Group Social Skills Interventions, and Meta- analysis of Outcomes, for Children with High Functioning ASD
J. Wolstencroft 0 2 3
L. Robinson 0 2 3
R. Srinivasan 0 2 3
E. Kerry 0 2 3
W. Mandy 0 2 3
D. Skuse 0 2 3
0 R. Srinivasan
1 J. Wolstencroft
2 Division of Psychology and Language Sciences, Faculty of Brain Sciences, University College London , 1-19 Torrington Place, London WC1E 6BT , UK
3 Institute of Psychiatry, King's College London , 103 Denmark Hill, London SE5 8AF , UK
Group social skills interventions (GSSIs) are a commonly offered treatment for children with high functioning ASD. We critically evaluated GSSI randomised controlled trials for those aged 6-25 years. Our meta-analysis of outcomes emphasised internal validity, thus was restricted to trials that used the parent-report social responsiveness scale (SRS) or the social skills rating system (SSRS). Large positive effect sizes were found for the SRS total score, plus the social communication and restricted interests and repetitive behaviours subscales. The SSRS social skills subscale improved with moderate effect size. Moderator analysis of the SRS showed that GSSIs that include parent-groups, and are of greater duration or intensity, obtained larger effect sizes. We recommend future trials distinguish gains in children's social knowledge from social performance.
Social skills; Social competence; Social responsiveness scale
The social difficulties in autism spectrum disorders (ASD)
are characterized by deficits in social cognition, interaction
(American Psychiatric Association
. These deficits are often referred to collectively as
The Great Ormond Street Institute of Child Health,
University College London, 30 Guilford Street,
London WC1N 1EH, UK
Many competing definitions and theoretical models of social
(Elliott and Gresham 1987; Gresham 1986;
Merrell and Gimpel 2014; Nangle et al. 2010)
, but the core
features invariably include behaviours that are performed in a
social context (McFall 1982) and entail person to person
(Cordier et al. 2015)
Social skills deficits are an important target for
intervention because they have a significant impact on academic,
adaptive and psychological functioning
(Coie et al. 1995;
Elliott et al. 2001; Spence 1995)
. Group social skills
interventions (GSSIs) are often recommended for children with
high functioning ASD. As their name indicates they aim
to improve social skills, suggesting that well-designed
programmes aim to improve both social performance and social
knowledge. Their use has increased substantially in the last
(Volkmar et al. 2004; Reichow and Volkmar 2010;
Reichow et al. 2012; Kasari et al. 2012; Matson et al. 2007)
The content, teaching strategy, mode of delivery and
intensity of therapy provided by GSSIs is variable.
Manualised group GSSIs typically include behavioural modelling
of a specific social skill, practising the skill through
roleplay and individualised feedback on performance. Some
teaching strategies are ‘didactic’, with structured lessons.
Others elicit social skills through play; these are called
(Kaat and Lecavalier 2014)
mode of delivery differs between GSSIs, and can require a
combination of parent, peer or teacher involvement. Some
programmes are intense, requiring 12 or more 90 min
sessions, delivered weekly. Others require attendance at
Effectiveness of GSSIs
Despite the popularity of GSSIs, evidence for their
effectiveness is limited
(Schneider 1992; Beelmann et al. 1994)
part because of weak study methodology
(White et al. 2007;
Cappadocia and Weiss 2011; Ferraioli and Harris 2011; Rao
et al. 2008; Reichow and Volkmar 2010; McMahon et al.
. Objective analysis has been hindered because
outcomes are often measured by just one mode (e.g.
questionnaire or observation) and by a limited range of informants
(often parents, and/or teachers). Both the choice of
outcome measures and the choice of informants can influence
expectancy biases and mask or exaggerate treatment effects
(McMahon et al. 2013)
. Parents are the most commonly used
informants, but their reports are prone to expectancy bias
(McMahon et al. 2013)
. They may also find it difficult to
characterise their child’s social limitations in comparison to
other (typical) children
(Schneider and Byrne 1989)
Besides parents, other potential sources of information
about treatment effectiveness include ratings of outcomes
by the participants themselves, the study’s own
administrators, teachers, peers, study staff and blind observers.
Teachers and blinded study administrative assessors can report on
whether changes of performance generalise to other settings,
outside the family
(White et al. 2007; Gates et al. 2017)
Self-report is particularly valuable to evaluate gains in social
Whilst blind-rated observations of behavioural change are
potentially the most objective measures of outcome,
questionnaires are used more frequently
(Kaat and Lecavalier
. Questionnaires can yield biased data, for instance if
rated by parents who are subject to expectancy effects. For
that reason, they are sometimes combined with cognitive
measures, behavioural observations and sociometric tasks
(McMahon et al. 2013; Kaat and Lecavalier 2014)
mode of reporting has advantages and disadvantages.
Observations invariably encompass only a brief period of data
collection, in limited environments, so may lack external
validity unless repeated observations are obtained in different
settings. In contrast, self-report of increases in knowledge
and parental-reports of behavioural change, whilst reflecting
broader environmental contexts, are both subject to positive
expectancy biases. Teacher reports, whilst less subject to
expectancy bias, may in contrast reflect a lack of sensitivity
to real change, due to limited opportunities to identify social
behaviour and potential problems associated with their
interpretation and scoring of measures.
made a useful distinction between social
skills acquisition deficits (an individual lacks the knowledge
to perform a social behaviour) and social skills performance
deficits (the individual has relevant skills knowledge but fails
to apply that knowledge in real-life situations). There is
evidence to support a theoretical distinction between social
performance and social knowledge
(Lerner and Mikami 2012;
Lerner et al. 2012; Lerner and White 2015)
Several recent reports have conducted meta-analyses
on the effectiveness of GSSIs
(Gates et al. 2017; Reichow
et al. 2012)
. Reichow et al. (2012) found evidence for
modest improvements in social competence on both
parentreport measures and self-report measures of friendships.
Gates et al. (2017) found self-reports of knowledge
acquisition were associated with large effect sizes in contrast to
small effect sizes for parent and observer reports of
performance (both blinded and non-blinded). Non-significant
effects were observed for teacher reports. The self-report
effect sizes appeared to be driven by increases in social
knowledge rather than improvements in social performance
(Gates et al. 2017). As indicated, a risk with participants
rating themselves is that they tend to overestimate perceived
improvements in their social skills
(Gates et al. 2017; Kaat
and Lecavalier 2014)
In this review, the assessment of social skills acquisition
is focused on changes in social performance as measured
by parental report, because the GSSIs meeting our criteria
for inclusion had in common parent-rated outcomes. We
acknowledge that a more complete account would include
social knowledge acquisition
relevant data were lacking. Parents are the most frequently
used informants. Among parent-rated measures employed by
studies of GSSI effectivness, the social responsiveness scale
(Constantino and Gruber 2012)
and the social skills
rating system (SSRS)
(Gresham and Elliott 1990)
(Crowe et al. 2011; Kaat and Lecavalier 2014; Matson
and Wilkins 2009)
To date, GSSI reviews have assumed that diverse social
skills outcome measures reflect the same underlying
constructs, hence they have assumed that it is legitimate to
combine the scores of a wide range of different tools for the
purpose of outcome analysis
(Reichow et al. 2012; Gates
et al. 2017)
. As discussed, because social skills encompass
distinct dimensions of, at least, social knowledge and social
performance, this approach is not ideal (Kaat and
Lecavalier 2014). We have taken advantage of the fact there are
recently published well-designed studies on performance
change using the same outcome measures (SRS and/or the
SSRS), hence an opportunity to conduct a new meta-analysis
with higher internal validity.
Inclusion and Exclusion Criteria
In this review, we conducted a meta-analysis focussed on
individual parent-report measures of outcome, with a focus
on the degree to which change in SRS and/or SSRS scores
is mediated by a GSSI.
There has been no systematic review of the GSSI teaching
(Koenig et al. 2009)
. Few manualised
intervention programmes have been published, but it is thought
that intervention-specific factors such as treatment duration,
intensity, teaching strategy (e.g. didactic or performance)
and parental involvement may moderate program success
(Reichow et al. 2012; McMahon et al. 2013)
. We thus also
aimed to evaluate whether intervention-specific factors such
as type of parent group, method of delivery, or duration have
a moderating impact on specific aspects of social
knowledge or performance improvement, by means of moderation
We hypothesised that specific dimensions of social skills
are responsive to specific aspects of GSSI, providing
support for the relative strengths (and weaknesses) of different
Online electronic searches were conducted on the EMBASE,
Medline (Ovid), PsycINFO and CINAHL databases in
December 2016. Eligibility criteria included medical
subject heading (MeSH) key terms including ‘social skills’ and
‘group interventions’, as well as filters for the age of
participants (filters overlapping with a 6–25 years age range)
and the language of publication (English language). The
complete search strategy can be found in the supplementary
materials. The reference lists of studies included in the
electronic search were screened to identify additional studies.
Two independent reviewers (JW and EK) rated the abstracts
against the eligibility criteria. Disagreements between
reviewers were resolved through discussion. A third
independent reviewer was available for further consultation if
consensus could not be reached, but was not required.
Published studies were eligible if they met the following
criteria: (1) randomised control trials (RCT) using a delayed
treatment control group (2) multi-modal group social skills
intervention including two or more children delivered by
professionals (3) participants aged 6–25 years (4)
assessment of social skills using the SRS and/or SSRS (Box 1).
Only RCTs employing a delayed treatment control group
were retained to reduce heterogeneity and increase internal
The exclusion criteria were: (1) interventions conducted
or assessed in a language other than English (2) studies
including children with intellectual disabilities (Verbal
IQ < 70) (3) reviews, conference proceedings, abstracts,
theses, or protocols. Studies that were not conducted and
assessed in English were excluded in order to reduce the
possibility of changes occurring due to translations or the
cultural context. Studies including children with ID were
also excluded to reduce sample heterogeneity.
The authors of studies using the SRS and/or SSRS were
contacted for missing total and subscale scores.
Quality Assessment: Risk of Bias
Two reviewers (JW and EK) independently assessed the
quality of eligible studies employing the Cochrane
Collaboration Risk of Bias (RoB) v2 tool
The studies were assessed for bias in sequence generation,
allocation concealment, baseline measurements, blinding
or participants and personnel, blinding of outcome
assessments, addressing incomplete outcomes, selective reporting
and other potential biases
Box 1 Properties of the SRS and SSRS
The SRS and the SSRS are both norm-referenced questionnaires. They can be completed in 15–20 min. Both assessments predominantly focus
on social performance. The SRS was designed to measure autistic traits quantitatively and the instrument has convergent validity with other
ASD diagnostic tools
(Constantino and Gruber 2012)
. The SSRS was designed to provide a comprehensive picture of social behaviour rather
than specific ASD traits
(Gresham and Elliott 1990)
. The SRS subscales comprise social awareness, social cognition, social communication,
social motivation, and restricted interests and repetitive behaviour (RRB). The SSRS subscales examine social skills (including cooperation,
assertion, self-control, responsibility) and problem behaviours (including externalising behaviours, internalising behaviours and
materials). Any disagreements between reviewers were
resolved through discussion and consensus was reached on
Two reviewers independently extracted data (JW and EK)
using a bespoke data extraction spreadsheet. The extraction
spreadsheet is available from the authors upon request. Data
were extracted on the intervention characteristics, patient
characteristics, parental outcome measures used, and
subsequent outcome scores. Authors were contacted for additional
information when necessary.
Authors were contacted to provide total scores and
subscale scores of the SRS and SSRS that were not published.
The co-variates were the intervention type, duration (in
hours), intensity (weekly vs summer camp), teaching
strategy (didactic vs performance) and whether (yes/no) there
was parental involvement in the intervention.
Statistical analysis was conducted using STATA 14. The
standardized mean difference (SMD) and 95% confidence
interval for each outcome measure were used as a summary
statistics. The post treatment measures of the treatment and
delayed control groups were compared across studies. The
SMD was interpreted as a small effect size for values of
0.20–0.50, moderate for values of 0.50–0.80, large for values
of 0.80–1.30 and very large for values above 1.30
The random–effects model was used, as heterogeneity
was suspected in the data. Heterogeneity was assessed using
the Higgins heterogeneity I2 statistic. The degree of
heterogeneity was considered low for values of 25–49%, moderate
for values of 50–74% and high for values of 75% or more
(Higgins et al. 2003)
. Statistically significant heterogeneity
was assumed when p < 0.05.
Publication bias was assessed using funnel plots with
Egger’s test, and the trim and fill method
(Egger et al. 1997)
The electronic search returned 593 articles after duplicates
were removed. Additional articles were identified through
correspondence with authors and by screening reference
lists of review articles picked up in the initial screening
search. Studies were excluded if they did not fit the
inclusion criteria or did not fit this review’s definition of group
social skills interventions (Fig. 1). The screening process
reduced the number of eligible articles to 123 that were
fully assessed for eligibility. 10 studies that met criteria for
eligibility were retained for qualitative synthesis.
The use of outcome measures was assessed in the 10
studies retained for qualitative synthesis. The authors were
contacted for unpublished total and subscale scores.
Following this correspondence there were sufficient data to
conduct meta-analyses on 8 studies (5 used the SRS, 1
used the SSRS and 2 used both the SRS and SSRS).
Five different types of intervention programmes were used,
including established protocols such as PEERS, Children’s
Friendship Training, summerMAX and SENSE Theatre;
as well as an unnamed manualised Cognitive Behavioural
Therapy (CBT) social skills programme. The programmes
varied by teaching strategy, parent assistance, duration
and intensity (Table 1). All but one of the programmes
(SENSE Theatre) took a didactic teaching approach.
SENSE theatre was the only GSSI to employ a
performance teaching strategy.
All GSSIs ran children groups, most interventions also
ran parallel parent groups. Only the SENSE Theatre and
the unnamed CBT social skills programme did not run
parent groups (the CBT intervention did provide a handout
for parents). The summerMAX and the SENSE Theatre
programmes ran intense summer-camp style interventions
where participants were required to attend 4–5 h of
training 5 days a week for 2–5 weeks. The other programmes
were less intensive and comprised 60–90 min sessions
once a week for 10–16 weeks.
Records iden fied through
(n = 639)
Addi onal records iden fied
through other sources
(n = 7)
Records a er duplicates removed
(n = 593)
(n = 593)
Full-text ar cles assessed
(n = 123)
Studies included in
qualita ve synthesis
(n = 10)
Studies eligible for
Sufficient data for
(n = 8*)
(n = 470)
Full-text ar cles excluded
(n = 113)
-Study design (n = 46)
-Age (n = 16)
-Did not fit group mul -modal
Social Skills interven on
defini on (n = 14)
-Ar cle inaccessible (n = 12)
- No SRS or SSRS as parent al
outcome measure (n = 14)
-Not conducted or assessed in
English (n = 7)
-Not peer reviewed (n = 2)
-Popula on ID (n = 2)
The syllabuses of GSSIs varied. Each GSSI emphasised
different domains of social skills. These included social
knowledge, social communication, social cognition and
social emotions. Specifically, the interventions taught
social rules and social cues, pragmatic language skills,
cognitive social skills including problem solving,
cognitive flexibility, social perception and/or perspective taking.
All but PEERS taught non-verbal skills, such as social
eye contact, facial expression, posture and social distance.
Only the summerMAX programme focussed explicitly on
self-perception (e.g. understanding one’s own emotions).
Only SENSE theatre and PEERS addressed the issue of
affect regulation (e.g. how to be a good sport, controlling
emotional impulses or anxiety).
Although the programmes selected for this meta-analysis
must have employed the SRS/SSRS, other parent-rated
measures included the adapted skillstreaming checklist
(ASC), the empathy (EQ) and the behavior assessment
system for children–parent rating scales (BASC-PRS-2)
Interventions—CFT children’s friendship training, PEERS program for the education and enrichment of relational skills, SENSE theatre SENSE
theatre, SSToM social skills and theory of mind
Parent outcome measures—ABAS adaptive behaviour assessment schedule, ASC adapted skillstreaming checklist, BASC-2- PRS behavior
assessment system for children–parent rating scales, second edition, EQ empathy quotient, QSQ quality of socialisation questionnaire, QPQ quality of
play questionnaire, SRS social responsiveness scale, SSRS social skills rating scale, VABS-2 vineland adaptive behaviour system, second edition
(Table 2). We have not examined the psychometric
properties of any of these assessment instruments in detail
Cordier et al. 2015; Matson and Wilkins 2009 for
All of the studies retained for qualitative synthesis used
more than one type of informant, not only parents but
also the participants themselves, study staff and teachers
(Table 2). Two studies reported only on questionnaires
completed by parents and participants; five used socio-cognitive
tasks and three used an idiomatic language task with
participants. Four used self-report questionnaires in
conjunction with a socio-cognitive or idiomatic language task. None
used validated self-report questionnaires in conjunction with
socio-cognitive tasks; participants are best placed to report
on changes in their social knowledge, implying the GSSI
studies reviewed here may not be capturing changes in this
social skills dimension.
Two studies used teacher-report measures (SRS and
SSRS). Two also used observation schedules to measure
social performance. Participants were filmed interacting
with confederate peers, one was blind-rated. The studies that
used staff questionnaires administered satisfaction surveys
that were not validated; the questionnaires were completed
by non-blind observers.
Outcome measures—ABAS adaptive behaviour assessment schedule, ASC adapted skillstreaming checklist, BASC-2-PRS behavior assessment
system for children–parent rating scales, second edition, BASC- 2-TRS behavior assessment system for children–teacher rating scales, second
edition, CASL comprehensive assessment of spoken language, CASP child and adolescent social perception measure, EQ empathy quotient,
DANVA-2 diagnostic analysis of nonverbal accuracy2, FQS friendship qualities scale, NEPSY developmental neuropsychological assessment,
QSQ quality of socialisation questionnaire, QPQ quality of play questionnaire, SELSA social and emotional loneliness scale for adults, SIAS
social interaction anxiety scale, SKA: skillstreaming knowledge assessment, SRS social responsiveness scale, SSI social skills inventory, SSRS
social skills rating scale, TASSK test of adolescent social skills knowledge, TYASSK test of young adult social skills knowledge, VABS-2 vineland
adaptive behaviour system, second edition
Quality Assessment: Risk of Bias
A ‘risk of bias’ analysis was conducted on all the RCTs
(Table 3). Two studies obtained a ‘high risk’ rating in four
or more of the seven risk of bias criteria; these will be
discussed separately. All others obtained a ‘low risk’ or
‘unclear’ rating for the sequence generation and allocation
concealment criteria. The incomplete blinding of outcome
by participants, personnel and outcome assessors
conferred a ‘high risk’ for all of the studies. A few studies did
employ observational outcome measures (where the coders
were blind to the participants’ group status) but these were
always used in conjunction with outcome measures where
the assessors were not blind. The incomplete-outcome
Selective outcome reporting
criteria were rated ‘high risk’ for two-thirds of the
studies, because of participant attrition from either or both the
waitlist control and the intervention groups. The
selective-outcome reporting criterion was rated ‘low risk’ in all
studies. No other sources of bias were detected.
(Corbett et al. 2016; Waugh and Peskin
obtained more ‘high risk’ ratings than others
reviewed here. The Waugh and Peskin (2015) study scored
‘high risk’ for all except selective-outcome reporting
criteria. The baseline measures were ‘high risk’ because SRS
scores differed significantly at baseline between the
control and experimental groups, and this study was excluded
from the meta-analysis. The Corbett study obtained a ‘high
risk’ rating for the baseline measurements criteria due to a
discrepancy between control and experimental groups on
two outcome measures (theory of mind and delayed faces
memory). As this baseline discrepancy did not affect the
Fig. 2 Forest plot of SRS total
SRS or SSRS scores, the Corbett study was retained for
Social Responsiveness Scale (SRS)
A comparison of the treatment and control groups’
postintervention scores showed GSSI participants obtained
better outcomes than controls, with a substantial reduction in
SRS total scores (SMD = − 0.85, 95% CI [− 1.12,− 0.59],
Z = 6.35, p = 0.000; Fig. 2; Table 4). This is a significant
(p < 0.0001) and large effect size.
GSSI participants also improved on all SRS subscales,
relative to controls (Table 5). The effect sizes for the
social awareness (SMD = − 0.57, 95% CI [− 0.87,− 0.28],
Z = 3.78, p = 0.000), social cognition (SMD = − 0.53, 95%
Laugeson 2015 data is not presented in this table as we were not able to gain access to the primary data
CI [− 0.98,− 0.09], Z = 2.34, p = 0.019) and social
motivation subscales (SMD = − 0.55, 95% CI [− 1.02,− 0.07],
Z = 2.27, p = 0.023) were moderate. The effect sizes
on the social communication (SMD = − 0.89, 95% CI
[− 1.2,− 0.59], Z = 5.71, p = 0.000) and restricted interests
and repetitive behaviours subscales (SMD = − 0.9, 95% CI
[− 1.23,− 0.57], Z = 5.4, p = 0.000) were large. All subscale
effect sizes were significant (p< 0.05).
Koning et al. (2013
; Fig. 3) was the only study not to
report improvement in the social cognition subscale.
Social Skills Rating System (SSRS)
GSSI participants improved relative to controls on the social
skills subscale (SMD = 0.56, 95% CI [0.18,0.95], Z = 2.86,
p = 0.004) and had better outcomes on the problem
behaviours subscale (SMD = − 0.55, 95% CI [− 1.13,0.03],
Z = 1.86, p = 0.06; Fig. 4). The effect size for both subscales
was moderate, but only the social skills subscale effect was
Moderator analyses was conducted on the SRS. There were
insufficient studies to conduct moderator analyses on the
SRS Group Analysis by Intervention
A post-hoc analysis analysed group differences on the total
SRS scores by separating studies according to
intervention type (Fig. 5). There was no statistical difference in the
total SRS scores between the treatment and control group
for the SENSE theatre (p = 0.06) or the CBT social skills
Fig. 3 Forest plot of SRS social
cognition subscale scores.
Schohl et al. 2014
subscales were not included in
the analysis as the source data
was not available
intervention (p = 0.39), but sample size was small so there
was a potential Type II error. The SENSE theatre
intervention obtained a moderate effect size (SMD= − 0.72, 95% CI
[− 1.46,0.03], Z = 1.88); the CBT intervention had a small
effect size (SMD= − 0.45, 95% CI [− 1.48,0.58], Z = 0.86).
summerMAX was used in 3 studies and PEERS
was used in 2 studies. Participants receiving these
interventions obtained better outcomes than controls
(p < 0.0001). Both summerMAX (SMD = − 0.93, 95% CI
[− 1.36,− 0.5], Z = 4.22) and PEERS (SMD = − 0.84, 95%
CI [− 1.32,− 0.37], Z = 3.49) obtained large and significant
SRS Group Analysis by Parent Involvement
A group analysis was conducted on the total SRS score
according to parent involvement. Participants performed
better than controls regardless of whether they took part
in an intervention that delivered concurrent parent groups,
both effect sizes were significant (parent group p< 0.0001;
no parent group p = 0.04). The GSSIs that delivered
parent groups had a large effect size (SMD = − 0.91, 95%
CI [− 1.20,− 0.61], Z = 6.08) whereas the GSSI that did
not deliver parent groups had a moderate effect size
(SMD = − 0.63, 95% CI [− 1.23,− 0.02], Z = 2.03; Fig. 6).
SRS Group Analysis by Intensity and Duration
Group analyses were conducted for the intensity and
duration of GSSIs on total SRS scores (Fig. 6). The effect
sizes in both the intensity and duration group analyses
were significant (p < 0.0001). The more intensive GSSIs
which took a summer camp format had a large effect size
(SMD = − 0.90, 95% CI [− 1.23,− 0.57], Z = 5.3), whereas
Fig. 4 Forest plot of SSRS
social skills and problem
behaviours subscale scores
the GSSI taking place once a week had a moderate effect
size (SMD = − 0.77, 95% CI [− 1.21,− 0.34], Z = 3.35).
GSSIs groups to examine the effect of duration of
intervention as a co-variate were created with a median
split. The GSSIs which required over 40 h of contact time
also had a large effect size (SMD> 40 h = − 0.93, 95% CI
[− 1.36,− 0.50], Z = 4.22), whereas those requiring 40 h
and under had a moderate effect size (SMD< 40 h = − 0.76,
95% CI [− 1.13,− 0.39], Z = 4.00; Fig. 6).
Heterogeneity was assessed using the I2 statistic. The
heterogeneity in the data was low to moderate, ranging from
0 to 58.2%. However, results did not differ across random
and fixed effect models.
Egger’s regression test and the trim and fill method showed
that there was no evidence of substantial publication bias.
Our systematic review of RCTs using multi-modal GSSIs
has shown that studies use a variety of social skills
measures, assessment types and informants. There was
a predominant reliance on parent-report and self-report
assessments of effectiveness, both prone to expectancy
bias. Even when evidence of outcome was obtained
from external observers such as support staff or
teachers, these observers were seldom blind to treatment group.
In future, evaluations of GSSI should employ blind-rated
Fig. 5 Group analyses forest
plot by intervention programme
for the SRS total scores
observer-reports (of performance). There is currently a
lack of validated participant self-reports (of increase in
social skills knowledge), yet previous meta-analyses of
social knowledge improvement indicate this may be one
of the main gains from group social skills interventions
(Gates et al. 2017)
Evidence of the effectiveness of interventions from the
meta-analysis of the SRS indicated treatments do bring
about a significant reduction in autistic traits as measured
by total and subscale scores, by parental report. Large effect
sizes were found in terms of improved Social
Communication, and reduced Restricted Interests and Repetitive
Behaviour (RRB). The Social Communication scale of the SRS is
intended to capture ‘expressive social communication [and]
“motoric” aspects of reciprocal social behaviour’
(Constantino and Gruber 2012)
. Both subscales were derived from
clinical definitions, rather than factor analysis, and reflect the
main components of DSM-5 diagnostic criteria for Autism
Moderate effect sizes for improvement following
intervention, explicitly in terms of social skills, were found for
the Social Skills subscale of the SSRS, which measures
cooperation, empathy, assertion, self-control and
responsibility. Unfortunately, there were insufficient data available
to enable further analysis of the Social Skills subscale, as it
would have been interesting to see which items contributed
the most to the significant changes in behaviour. The
Problem Behaviours subscale of the SSRS measures internalising
and externalising behaviours, and hyperactivity; no
significant change was found in these behaviours.
Despite the differences in the social skills domains taught
in GSSIs, the syllabuses did overlap in some key areas. For
instance, they all aimed to improve social communication
skills, and evidence from this review that Social
Communication does improve significantly could have been
anticipated. However, improvements on the RRB subscale of the
SRS were unexpected; no teaching materials reviewed here
explicitly target RRB. Perhaps the cognitive and emotional
skills taught during GSSIs, such as cognitive flexibility,
problem solving or controlling emotional impulses are
mediating this change. Consequently, participants become more
confident and less anxious in social situations, which in turn
reduces their anxiety-related restrictive and repetitive
(Rodgers et al. 2012)
. Also, participants may learn that
restrictive and repetitive behaviours are socially
inappropriate, and consequently they conceal them, a hypothesis that
is consistent with the moderate effect size obtained on the
Social Awareness subscale. Evidence from previous
metaanalyses of GSSI shows increases in social knowledge drive
effect sizes in self-report measures of social skills
et al. 2017)
Moderator analysis was only possible for studies in which
the SRS was the outcome measure. A group analysis
compared interventions that delivered concurrent parent groups,
with those that did not. We found that GSSIs that included
parent groups were more effective, associated with a large
Fig. 6 Group analyses forest
plot for parent involvement
(parent group vs no parent
group), intervention intensity
(summer school vs weekly) and
intervention duration (over 40
vs 40 h and under) for the SRS
(compared with a moderate) effect size. Parents who attend
GSSIs might display positive response biases
Lerner et al., 2013)
, but parent involvement in treatment can
nevertheless consolidate the social behaviours and
knowledge acquired by their child, and help support the formation
of appropriate peer networks
(Laugeson and Frankel 2011)
Not all GSSI programmes reduced autistic traits (as
measured by SRS total scores). The PEERS and
summerMAX programmes obtained significant and large effect
sizes compared to the SENSE Theatre and CBT social
skills interventions (though associated with less power to
detect benefit) which obtained small to moderate and
nonsignificant effects effect sizes.
More intensive and longer-lasting interventions had
slightly larger effect sizes. The cost-benefit comparison
between programmes is hard to interpret. For instance,
whereas the PEERS intervention is demanding in terms of
participant and interventionist time, it may nevertheless be
a more cost-effective choice as it is easier to implement with
less resources than the summerMAX programme. Only one
out of the six interventions employed a performance-based
teaching strategy, therefore a comparison between didactic
and performance based interventions was not possible.
A recent increase in methodological rigour in GSSI RCTs,
and the use of common instruments to assess outcomes, has
presented an opportunity to examine the effectiveness of
social-skills interventions in a multi-dimensional context.
Understanding what works for whom will be key to the
future personalisation of GSSIs, improving the efficacy of
GSSI programmes. Examining which social performance
and social knowledge characteristics are responsive to
specific GSSI design features is critical to unlocking our
understanding of the active ingredients of social skills instruction.
We need to develop more sensitive tools in order
comprehensively to capture how treatments impact on the
multidimensional nature of social skills.
Acknowledgments Thank you to the Child Health Research CIO for
supporting this research.
Author Contributions JW, WM and DS designed and directed the
study. JW and EK conducted the systematic review screening. JW and
LR conducted the statistical analysis. JW and DS wrote the manuscript.
JW, SR, WM and DS contributed to critical revisions.
Funding This study was funded by the Child Health Research
Charitable Incorporated Organisation.
Compliance with Ethical Standards
Conflict of interest The authors have no conflict of interest to declare.
Ethical Approval This article does not contain any studies with human
participants or animals performed by any of the authors.
Open Access This article is distributed under the terms of the
Creative Commons Attribution 4.0 International License (http://creativeco
mmons.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.
American Psychiatric Association. ( 2013 ). Diagnostic and statistical manual of mental disorders (DSM-5 ®): American Psychiatric Pub.
Beelmann , A. , Pfingsten , U. , & Lösel , F. ( 1994 ). Effects of training social competence in children: A meta-analysis of recent evaluation studies . Journal of Clinical Child Psychology , 23 ( 3 ), 260 - 271 .
Cappadocia , M. C. , & Weiss , J. A. ( 2011 ). Review of social skills training groups for youth with Asperger syndrome and high functioning autism . Research in Autism Spectrum Disorders , 5 ( 1 ), 70 - 78 .
Cohen , J. ( 1988 ). Statistical power analysis for the behavioral sciences Lawrence Earlbaum Associates . Hillsdale, NJ, pp. 20 - 26 .
Coie , J. , Terry , R. , Lenox , K. , Lochman , J. , & Hyman , C. ( 1995 ). Childhood peer rejection and aggression as predictors of stable patterns of adolescent disorder . Development and Psychopathology , 7 ( 04 ), 697 - 713 .
Constantino , J. , & Gruber , C. ( 2012 ). Social Responsiveness Scale, (SRS-2) (Western Psychological Services , Torrance, CA).
Corbett , B. A. , Key , A. P. , Qualls , L. , Fecteau , S. , Newsom , C. , Coke , C. , et al. ( 2016 ). Improvement in social competence using a randomized trial of a theatre intervention for children with autism spectrum disorder . Journal of Autism and Developmental Disorders , 46 ( 2 ), 658 - 672 .
Cordier , R. , Speyer , R. , Chen , Y.-W. , Wilkes-Gillan , S. , Brown , T., Bourke-Taylor , H., et al. ( 2015 ). Evaluating the psychometric quality of social skills measures: a systematic review . PLoS ONE , 10 ( 7 ), e0132299 .
Crowe , L. , Beauchamp , M. , Catroppa , C. , & Anderson , V. ( 2011 ). Social function assessment tools for children and adolescents: A systematic review from 1988 to 2010 . Clinical Psychology Review, 31 ( 5 ), 767 - 785 .
Egger , M. , Smith , G. D. , Schneider , M. , & Minder , C. ( 1997 ). Bias in meta-analysis detected by a simple, graphical test . BMJ , 315 ( 7109 ), 629 - 634 .
Elliott , S. N. , & Gresham , F. M. ( 1987 ). Children's social skills: Assessment and classification practices . Journal of Counseling & Development , 66 ( 2 ), 96 - 99 .
Elliott , S. N. , Malecki , C. K. , & Demaray , M. K. ( 2001 ). New directions in social skills assessment and intervention for elementary and middle school students . Exceptionality , 9 ( 1-2 ), 19 - 32 .
Ferraioli , S. J. , & Harris , S. L. ( 2011 ). Treatments to increase social awareness and social skills. Evidence-based practices and treatments for children with autism (pp . 171 - 196 ). Springer, New York.
Gantman , A. , Kapp , S. K. , Orenski , K. , & Laugeson , E. A. ( 2012 ). Social skills training for young adults with high-functioning autism spectrum disorders: A randomized controlled pilot study . Journal of Autism and Developmental Disorders , 42 ( 6 ), 1094 - 1103 .
Gates , J. A. , Kang , E. , & Lerner , M. D. ( 2017 ). Efficacy of group social skills interventions for youth with autism spectrum disorder: A systematic review and meta-analysis . Clinical Psychology Review.
Gresham , F. M. ( 1986 ). Conceptual issues in the assessment of social competence. In Children's social behavior: Development, assessment, and modification (pp. 143 - 179 ). Elsevier, New York.
Gresham , F. M. ( 1997 ). Social competence and students with behavior disorders: Where we've been, where we are, and where we should go . Education and Treatment of Children , 233 - 249 .
Gresham , F. M. , & Elliott , S. N. ( 1990 ). Social skills rating system: Manual: American Guidance Service .
Higgins , J. ( 2016 ). Green S. Cochrane handbook for systematic reviews of interventions . The Cochrane Collaboration . 2011 . Version.
Higgins , J. P. , Thompson , S. G. , Deeks , J. J. , & Altman , D. G. ( 2003 ). Measuring inconsistency in meta-analyses . BMJ: British Medical Journal , 327 ( 7414 ), 557 .
Kaat , A. J. , & Lecavalier , L. ( 2014 ). Group-based social skills treatment: a methodological review . Research in Autism Spectrum Disorders , 8 ( 1 ), 15 - 24 .
Kasari , C. , Rotheram-Fuller , E. , Locke , J. , & Gulsrud , A. ( 2012 ). Making the connection: Randomized controlled trial of social skills at school for children with autism spectrum disorders . Journal of Child Psychology and Psychiatry , 53 ( 4 ), 431 - 439 .
Koenig , K. , De Los Reyes, A. , Cicchetti , D. , Scahill , L. , & Klin , A. ( 2009 ). Group intervention to promote social skills in school-age children with pervasive developmental disorders: Reconsidering efficacy . Journal of Autism and Developmental Disorders , 39 ( 8 ), 1163 - 1172 .
Koning , C. , Magill-Evans , J. , Volden , J. , & Dick , B. ( 2013 ). Efficacy of cognitive behavior therapy-based social skills intervention for school-aged boys with autism spectrum disorders . Research in Autism Spectrum Disorders , 7 ( 10 ), 1282 - 1290 .
Laugeson , E. A. , & Frankel , F. ( 2011 ). Social skills for teenagers with developmental and autism spectrum disorders: The PEERS treatment manual . Routledge.
Laugeson , E. A. , Frankel , F. , Mogil , C. , & Dillon , A. R. ( 2009 ). Parentassisted social skills training to improve friendships in teens with autism spectrum disorders . Journal of Autism and Developmental Disorders , 39 ( 4 ), 596 - 606 .
Laugeson , E. A. , Gantman , A. , Kapp , S. K. , Orenski , K. , & Ellingsen , R. ( 2015 ). A randomized controlled trial to improve social skills in young adults with autism spectrum disorder: The UCLA PEERS® Program . Journal of Autism and Developmental Disorders , 45 ( 12 ), 3978 - 3989 .
Lerner , M. D. , & Mikami , A. Y. ( 2012 ). A preliminary randomized controlled trial of two social skills interventions for youth with high-functioning autism spectrum disorders . Focus on Autism and Other Developmental Disabilities , 27 ( 3 ), 147 - 157 .
Lerner , M. D. , & White , S. W. ( 2015 ). Moderators and mediators of treatments for youth with autism spectrum disorders. Moderators and mediators of youth treatment outcomes , 146 .
Lerner , M. D. , White , S. W. , & McPartland , J. C. ( 2012 ). Mechanisms of change in psychosocial interventions for autism spectrum disorders . Dialogues in Clinical Neuroscience , 14 ( 3 ), 307 .
Lopata , C. , Thomeer , M. L. , Volker , M. A. , Toomey , J. A. , Nida , R. E. , Lee , G. K. , et al. ( 2010 ). RCT of a manualized social treatment for high-functioning autism spectrum disorders . Journal of Autism and Developmental Disorders , 40 ( 11 ), 1297 - 1310 .
Matson , J. L. , Matson , M. L. , & Rivet , T. T. ( 2007 ). Social-skills treatments for children with autism spectrum disorders an overview . Behavior Modification , 31 ( 5 ), 682 - 707 .
Matson , J. L. , & Wilkins , J. ( 2009 ). Psychometric testing methods for children's social skills . Research in Developmental Disabilities, 30 ( 2 ), 249 - 274 .
McFall , R. M. ( 1982 ). A review and reformulation of the concept of social skills . Behavioral Assessment.
McMahon , C. M. , Lerner , M. D. , & Britton , N. ( 2013 ). Group-based social skills interventions for adolescents with higher-functioning autism spectrum disorder: a review and looking to the future . Adolescent Health, Medicine and Therapeutics , 4 ( 23 ), 9 .
Merrell , K. W. , & Gimpel , G. ( 2014 ). Social skills of children and adolescents: Conceptualization, assessment , treatment: Psychology Press, Hove.
Nangle , D. W. , Grover , R. L. , Holleb , L. J. , Cassano , M. , & Fales , J. ( 2010 ). Defining competence and identifying target skills. Practitioner's Guide to Empirically Based Measures of Social Skills (pp . 3 - 19 ). Springer, New York.
Rao , P. A. , Beidel , D. C. , & Murray , M. J. ( 2008 ). Social skills interventions for children with Asperger's syndrome or high-functioning autism: A review and recommendations . Journal of Autism and Developmental Disorders , 38 ( 2 ), 353 - 361 .
Reichow , B. , Steiner , A. M. , & Volkmar , F. ( 2012 ). Social skills groups for people aged 6 to 21 with autism spectrum disorders (ASD) . Evidence-Based Child Health: A Cochrane Review Journal , 7 , 266 - 315 .
Reichow , B. , & Volkmar , F. R. ( 2010 ). Social skills interventions for individuals with autism: Evaluation for evidence-based practices within a best evidence synthesis framework . Journal of Autism and Developmental Disorders , 40 ( 2 ), 149 - 166 .
Rodgers , J. , Glod , M. , Connolly , B. , & McConachie , H. ( 2012 ). The relationship between anxiety and repetitive behaviours in autism spectrum disorder . Journal of Autism and Developmental Disorders , 42 ( 11 ), 2404 - 2409 .
Schneider , B. H. ( 1992 ). Didactic methods for enhancing children's peer relations: A quantitative review . Clinical Psychology Review , 12 ( 3 ), 363 - 382 .
Schneider , B. H. , & Byrne , B. M. ( 1989 ). Parents rating children's social behavior: How focused the lens ? Journal of Clinical Child Psychology , 18 ( 3 ), 237 - 241 .
Schohl , K. A. , Van Hecke , A. V. , Carson , A. M. , Dolan , B. , Karst , J. , & Stevens , S. ( 2014 ). A replication and extension of the PEERS intervention: Examining effects on social skills and social anxiety in adolescents with autism spectrum disorders . Journal of Autism and Developmental Disorders , 44 ( 3 ), 532 - 545 .
Spence , S. H. ( 1995 ). Social skills training: Enhancing social competence with children and adolescents: Nfer- Nelson , Windsor.
Thomeer , M. L. , Lopata , C. , Donnelly , J. P. , Booth , A. , Shanahan , A. , Federiconi , V. , et al. ( 2016 ). Community effectiveness RCT of a comprehensive psychosocial treatment for high-functioning children with ASD . Journal of Clinical Child & Adolescent Psychology , 1 - 12 .
Thomeer , M. L. , Lopata , C. , Volker , M. A. , Toomey , J. A. , Lee , G. K. , Smerbeck , A. M. , et al. ( 2012 ). Randomized clinical trial replication of a psychosocial treatment for children with high-functioning autism spectrum disorders . Psychology in the Schools , 49 ( 10 ), 942 - 954 .
Thompson , S. G. , & Higgins , J. ( 2002 ). How should meta-regression analyses be undertaken and interpreted? Statistics in Medicine, 21 ( 11 ), 1559 - 1573 .
Volkmar , F. R. , Lord , C. , Bailey , A. , Schultz , R. T. , & Klin , A. ( 2004 ). Autism and pervasive developmental disorders . Journal of Child Psychology and Psychiatry , 45 ( 1 ), 135 - 170 .
Waugh , C. , & Peskin , J. ( 2015 ). Improving the social skills of children with HFASD: An intervention study . Journal of Autism and Developmental Disorders , 45 ( 9 ), 2961 - 2980 .
White , S. W. , Keonig , K. , & Scahill , L. ( 2007 ). Social skills development in children with autism spectrum disorders: A review of the intervention research . Journal of Autism and Developmental Disorders , 37 ( 10 ), 1858 - 1868 .