**6. Social skills training**

Social skills have a significant place in diagnosis of autism. Children with autism experience difficulties in using non-verbal behavioural social skills such as eye-to-eye gaze, facial expression, body postures and gestures to regulate social interaction; failure interaction with peers, problems on sharing enjoyment, interests or achievements with other people and problems in social–emotional reciprocity and may require support as of early ages. Individuals with autism have difficulty in understanding nuances and informal rules, which are sponta‐ neously used during communication. Such social interaction problems may lead to indiffer‐ ence, teasing or bullying. Social interaction efforts of many individuals with autism result in negative experiences as the individual is over stimulated or confused and negatively effects the social engagement of individual. Studies report that negative reactions against individuals with autism from their environment are more challenging that their communication problems [130]. Difficulties in social skill behaviours observed in individuals with autism are defined with neuropsychological models such as the theory of mind [131, 132], executive functions [133, 134] and weak central coherence [135, 136].

**5.1. Assessment**

176 Autism Spectrum Disorder - Recent Advances

their interventions.

**5.2. Intervention**

[129].

**6. Social skills training**

Play is what children to do and they expend considerable social, cognitive and motor resources while playing, therefore play assessment may provide very meaningful insights about a child's interests, functional abilities and behaviours [113-115]. The selection of a play assessment will vary depending upon the developmental status of the child, the purpose of the assessment and the intervention plan. Test of Playfulness [114], Knox Preschool Play Scale [115], Play History [116-118] and Trans-disciplinary Play-based Assessment [119], My Child's Play [120, 121] tests are among the common standardized tests used to plan occupational therapy interventions for the improvement of play skills [117]. Furthermore, occupational therapists frequently refer to Observations of Factors Influencing Playfulness Form [121, 122] to plan

Occupational therapists frequently use sensory integration framework where sensory differ‐ ences of individuals are taken into account in improving play skills of children with autism. Developmental approaches like Dr. Stanley Greenspan's "Floor Time" method which aims to turn the relation between children and their families into a play with mutual interaction that contains trust and pleasure and philosophy of "Follow the child's lead" [123-126]. Addition‐ ally, virtual reality studies are also included under play interventions [127]. During occupa‐ tional therapy interventions, in addition to therapeutic use of play, occupational therapists play an effective role in the organization of play environment and parent education with the

It's important for the occupational therapists to implement therapy programs designed according to sensory integration framework, under the leadership of child in structured environments for the improvement of motor skill, social-emotional well-being, cognitive process, praxis, attention, intimacy, interaction expression, use of feelings/ideas and logical thinking development of child with autism in play based occupational therapy interventions

Social skills have a significant place in diagnosis of autism. Children with autism experience difficulties in using non-verbal behavioural social skills such as eye-to-eye gaze, facial expression, body postures and gestures to regulate social interaction; failure interaction with peers, problems on sharing enjoyment, interests or achievements with other people and problems in social–emotional reciprocity and may require support as of early ages. Individuals with autism have difficulty in understanding nuances and informal rules, which are sponta‐ neously used during communication. Such social interaction problems may lead to indiffer‐ ence, teasing or bullying. Social interaction efforts of many individuals with autism result in negative experiences as the individual is over stimulated or confused and negatively effects the social engagement of individual. Studies report that negative reactions against individuals

consideration of developmental level, challenges and strengths of child [128].

Theory of mind is defined as the capacity of interpreting, deducing and explaining the underlying mental situations in other's behaviours. Preschool children are expected to have developed their theory of mind skills. Insufficient development of theory of mind are reported to lead to difficulties in interpreting emotional status from voice tone and facial expression and in social skills and negatively affects empathy skill of individual [131, 132]. Theory of mind is used to describe the major deficits in social functionality and communication in autism [132].

Dynamic and complicated nature of information process in brain reveals definition of highlevel cognitive functions and concept of executive functions. This theory covers skills such as self-regulation of behaviour sequence, flexibility, response inhibition, planning and organiza‐ tion of behaviour. Executive functions where prefrontal cortex play a central role provides that an individual thinks about himself/ herself and defines what can happen in future and how they can be affected [133]. Executive functioning in autism is an approach studied fort he last 20 years. Studies on executive functioning and frontal lobe functions report that performances of children with autism in executive functions are lower than expected [133, 134]. Social skill deficits, namely executive function disorders or stereotypical behaviours, which are consid‐ ered to be caused by their deficits, are observed in individuals on the spectrum and in their relatives [132-134].

According to weak central coherence model, information received from different sources cannot be integrated in autism [135]. Meaningful and consistent meronymy relation cannot be established from stimulus perceived due to information processing deficit. Weak central coherence can be associated with disadvantages experienced by individuals with autism in areas such as learning, social, language and cognitive skills etc. and it's reported to be the reason for behavioural deviations in these areas [136].

Different disciplines commonly agree that autism is centrally a social skill deficit and therefore this area should be the first area to be targeted in training [137]. In social skill studies for children with autism, attainment of basic skills such as eye contact, using expressions like hello, thank you which are the basics for social communication, answering questions like how are you, playing with peers and getting in line in plays etc. are targeted with priority [137, 138].

There are many advanced social skills that should be attained by a child with autism after the attainment of basic social skills. These social skills can be classified under four main groups; communication skills: self introduction, asking proper questions to meet someone new, starting a conversation, involving in a conversation, not deviating from topic of the conversation, listening in a proper position, not keeping the talk too long, changing the topic properly, using voice tone, facial expression and body posture according to the topic of the conversation [139-141].

Social interaction skills (friendship): These are the skills like touching properly, ringing, answering a call, helping a friend properly, asking for help, spending time together, acting at a proper distance depending on the type of relation, respecting ideas of others, not feeling uncomfortable with changes in rules etc. [140].

Social interaction skills (playing): These are the skills like engagement in play, sharing toys, playing games with rules, getting into a line during play, coping with winning and defeat [140, 141].

Emotion recognition and management skills: They include skills like awareness on emotions, consoling a sad person, anger control and expressing anger properly, accepting criticisms, coping with mocking, sharing happiness, coping with making mistakes, not feeling uncom‐ fortable when trying new things. [140, 142].

Social skill training is not a routine part of occupational therapy interventions for individuals with autism. Occupational therapy interventions play an important role in designing inter‐ vention programs for the assessment and improvement of insufficient social initiations and responses against any occupational performance of the individual with autism at home, school or in society, and in enhancing social participation of individual [130].

In social skill studies with children with autism, skills are tried to be taught face to face or in groups or some skills are taught during playtime with parents or peers [140, 141]. It's reported that a shift can be made from individual works to group works for the development of empathy skill [139]. These working principles are also taken into consideration in occupational therapy interventions [16].

Among the studies on improvement of social skills in children with autism, there are research‐ ers who think that "theory of mind" is the problem [133, 142, 143], and studies, which refer to, structured training programs [140, 144] or developmental approaches [145]. More than one technique is used in some studies. For instance various techniques like scenarios, social skill groups, self-control, class interventions, video modelling, social plays, peer training, peer mediation and circle of friends are used together [146-148]. There are also studies where a single technique is used like social stories [149], peer mediation etc. [150]. It's reported that social skill training of children with autism is more effective in communication with other children in a natural group setting [151].

In a study where 79 studies on children with autism under the age of 12 were reviewed, it was noted that modeling and reinforcement, approach, peer training, scenarios and social stories were used [138]. It's further noted that programs designed with techniques of approaches to learn social skills in groups or socially are more effective in children with autism [138, 152].

#### **6.1. Assessment**

In occupational therapy, social skills of individuals with autism are assessed with observatio‐ nal standardized tests and checklists [153]. Standardized tests helps assessment of social skills and daily living skills of an individual with autism. Vineland Adaptive Behaviour Scale [83] and Social Skills Rating System [154] can be given as an example of such tests.

Occupational therapists may make structured interviews with parents and caregivers in addition to the standardized tests, and make observations in the natural settings and structured play settings of the child. During the assessment, informal rating scales can be used in the observation of social skills of the child such as spontaneously engaging in communication, imitation, socially responding, eye contact, game playing, asking for help/ helping, adjusting voice tone, using body language, expressing emotions verbally and non-verbally, giving proper responses, distance with others during communication and interaction [16, 128, 155].

#### **6.2. Intervention**

a proper distance depending on the type of relation, respecting ideas of others, not feeling

Social interaction skills (playing): These are the skills like engagement in play, sharing toys, playing games with rules, getting into a line during play, coping with winning and defeat

Emotion recognition and management skills: They include skills like awareness on emotions, consoling a sad person, anger control and expressing anger properly, accepting criticisms, coping with mocking, sharing happiness, coping with making mistakes, not feeling uncom‐

Social skill training is not a routine part of occupational therapy interventions for individuals with autism. Occupational therapy interventions play an important role in designing inter‐ vention programs for the assessment and improvement of insufficient social initiations and responses against any occupational performance of the individual with autism at home, school

In social skill studies with children with autism, skills are tried to be taught face to face or in groups or some skills are taught during playtime with parents or peers [140, 141]. It's reported that a shift can be made from individual works to group works for the development of empathy skill [139]. These working principles are also taken into consideration in occupational therapy

Among the studies on improvement of social skills in children with autism, there are research‐ ers who think that "theory of mind" is the problem [133, 142, 143], and studies, which refer to, structured training programs [140, 144] or developmental approaches [145]. More than one technique is used in some studies. For instance various techniques like scenarios, social skill groups, self-control, class interventions, video modelling, social plays, peer training, peer mediation and circle of friends are used together [146-148]. There are also studies where a single technique is used like social stories [149], peer mediation etc. [150]. It's reported that social skill training of children with autism is more effective in communication with other

In a study where 79 studies on children with autism under the age of 12 were reviewed, it was noted that modeling and reinforcement, approach, peer training, scenarios and social stories were used [138]. It's further noted that programs designed with techniques of approaches to learn social skills in groups or socially are more effective in children with autism [138, 152].

In occupational therapy, social skills of individuals with autism are assessed with observatio‐ nal standardized tests and checklists [153]. Standardized tests helps assessment of social skills and daily living skills of an individual with autism. Vineland Adaptive Behaviour Scale [83]

Occupational therapists may make structured interviews with parents and caregivers in addition to the standardized tests, and make observations in the natural settings and structured

and Social Skills Rating System [154] can be given as an example of such tests.

or in society, and in enhancing social participation of individual [130].

uncomfortable with changes in rules etc. [140].

178 Autism Spectrum Disorder - Recent Advances

fortable when trying new things. [140, 142].

children in a natural group setting [151].

[140, 141].

interventions [16].

**6.1. Assessment**

Occupational therapy interventions for improvement of social skills in individuals with autism should be client-centred, with concrete narrations, supporting active engagement in coopera‐ tion with family and teachers in the natural settings of the individual and should consider emotional differences. Individuals with autism may experience significant difficulties in implementing the social rules despite having memory skills that facilitate repeating and memorizing these rules. Occupational therapists can give social skills training with creatively referring to the routine daily activities of the individual with autism during the sessions. A therapy program which starts with individual works of 30-90 minutes where necessary considerations and modifications are made over an activity related with the occupations of the individual with autism in his/her life and progresses with group works is considered as an ideal occupational therapy intervention. Adult-mediated or peer-mediated activities can be used in intervention. Teaching that the same response would not be proper in every social situation with the consideration of social hierarchy and group work principles during the intervention is an important detail of the intervention [16, 128, 155].

Social Stories and Social Autopsies, Social Skills Lessons and Activities, Jump Starters, Social Skills Activities for Special Needs, and Walker Social Skills Curriculum: The Accepts Pro‐ gramme, Do-Watch-Listen-Say" Framework, Video Modeling methods are frequently used in occupational therapy interventions [156-158].

Occupational therapy interventions designed to improve occupational performance in line with the basic principles given above may help in the development of social skills in individ‐ uals with autism and can increase their social engagement levels.
