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Text Transcript: The Science of Making Friends for Teens and Adults with Autism

- Well, my name is Dr. Elizabeth Laugeson.

And today's, webinar is on "The Science of Making Friends" and Evidence-Based Social Skills Program for Teens with Autism Spectrum Disorder.

And the focus of this presentation will really be on the UCLA PEERS program, which is one of the only empirically supported social skills programs for adolescents and adults with ASD.

In terms of what we're gonna talk about at the webinar today I'll begin with just giving a brief overview of some of the social deficits that you see in teens with autism spectrum disorder.

From there, I'll talk about the importance of friendships because social skills is very broad but the PEERS program is really focused on friendship development and maintenance.

And so I'll talk about the importance of friendships and why we want to target that particular type of social skill.

From there I'll get into the consequences of social good deficits and sort of what happens when kids don't have good social skills.

And what are some of the outcomes there.

From there, I'll discuss just an overview of the PEERS intervention and specifically I'll talk about effective methods for teaching social skills, as well as describing some of the ecologically valid social skills that we teach in PEERS.

In particular I'll talk a little bit about conversational skills how to start individual conversations.

I'll talk about entering group conversations and also focus a little bit on some strategies for handling verbal bullying or teasing.

From there, I'll give a brief summary of some of our research findings.

Talk a little bit about some of the current research that we're doing with PEERS and we'll end with some resources.

So that's a little bit about what we're gonna do over the course of this next 90 minutes webinar.

In terms of what we're talking about with regard to social deficits with teens, with ASD, we know that poor social communication is really a hallmark feature of autism, but what does that actually look like in kids with ASD?

Well, one of the issues that a lot of our kids have is with topic initiation and that's just simply not knowing what to talk about and what do they typically talk about?

Well, I tend to focus a lot on their restricted interests and that means that they tend to have very repetitive types of themes in their conversations.

They tend to have very one-sided conversations.

A lot of people will describe our kids as sort of lecturing or monologuing, sort of talking at the other person and not really sharing and very nice reciprocal conversations.

And so that's one of the areas that we need to target in social skills training.

Another issue that a lot of our kids have relates to poor social awareness.

And that's just essentially understanding the social landscape in which they live.

Just understanding that there's different groups of people.

They tend to congregate around certain common interests and that if they're looking for a source of friends we need to help them to decode that social landscape essentially, another issue that a lot of kids with autism have relates to poor social motivation.

And this is a bit of a misnomer.

I think that really, it probably relates more to a poor social engagement.

Our kids aren't as engaged in social situations as maybe typically developing kids.

Some people relate that to a lack of social motivation and a lack of desire to be social.

However, if you ask a lot of teens with ASD if they wanna have friends, many of them will say that they do wanna have friends they just don't know how to have friends.

And so they end up rather socially isolated.

They tend not to be as socially engaged with others.

They also tend to be less involved in social activities.

Things like extracurricular activities, clubs and sports and the difficulty with this kind of social isolation is then it makes it difficult to make and keep friends or to find a source of friends with common interests.

Another issue that a lot of our kids have relates to their peer entry attempts.

So engaging others that either lack these peer etry attempts, where they don't go up and engage other people in conversations, or some of our kids are actually intrusive when they do that.

And they actually may barge into conversations and be off topic.

And of course this can lead to rejection from peers.

Finally another issue that many of our kids struggle with is poor social cognition.

Again, this is one of those hallmark features of autism.

So what does this actually mean?

Well, poor social cognition relates to what we described a very optimist theory of mind.

It's basically putting yourself in someone else's shoes sort of understanding the perspectives of others.

Being able to anticipate how someone might think or feel or react in a given situation.

A lot of our kids struggle with this course of social cognition and of course, this makes it very difficult for them to make and keep friends.

So why would we wanna target friendship skills in particular?

I mentioned that PEERS is really focused on making and keeping friends and also how to handle peer conflict and peer rejection.

Well, what we've known for decades about friendships is that just having one or two close friends can really predict later adjustment in life and actually impacts how we relate to people actually buffers the impact of stressful life events even.

If you think about who you call when you're having a bad day what's usually call a friend.

Imagine if you didn't have that as an option.

We also know that just having a couple of close friends correlates very positively with things like self-esteem and independence you're more likely to feel better about yourself.

More likely to be independent if you have a couple of close friends.

On the reverse and having very few friends is also very much correlated with anxiety and depression.

So those who have few friends are more likely to be anxious and depressed on the reverse side of this, of the flip side peer rejection, kind of the opposite of having friends is really one of the strongest predictors of later adjustment and in life.

And also how we relate to people how we interact with the world very much relates to things like mental health problems.

So those who are peer rejected those who may be actively seeking out their peers, but are actively getting pushed away are more likely to be anxious depressed.

These kids also are more likely to engage in juvenile delinquent behavior perhaps even have early withdrawal from school or academic performance is also very much related to peer rejection, as well as things like substance abuse and really at its worst, perhaps suicidal ideation and even suicide attempts very strongly related to peer rejection.

And when you look at the kind of kids who present for social skills training whether they have autism or not, there's basically two types of kids that present for these social skills programs.

One type is what we call peer rejected kids.

And the other type is what we call socially neglected in terms of identifying these two groups.

Well, the socially a neglected group is the group that's very isolated.

They're often seen as shy or withdrawn.

They're often ignored by their peers, maybe even go unnoticed and they tend to fall through the cracks.

On the other hand, you have this peer rejected group.

This is the group that's often teased and bullied.

They're actively seeking out their peers, but they're actively getting pushed away for a number of reasons.

They may even have bad reputations with their peers and the types of behaviors that they tend to engage in are things like hogging conversations kind of a not realizing conversations maybe barging in to conversations.

I'm trying to be funny all the talent time telling jokes things of that nature.

But again, these are kids who are actively trying to seek out their peers, but they're getting pushed away.

If you wanna predict which category a kid falls into, whether or not they have autism think about the kind of co-occurring diagnosis that you'll see in autism.

Well, we know that a lot of our kids have ADHD.

They'll often have anxiety disorder depression.

Well, the kids who are more likely to barge into conversations, gonna be off topic maybe intrusive during their peer entry attempts.

These are the kids who are more likely to be peer rejected.

And they're probably more likely to have a co-occurring diagnosis of ADHD maybe even some impulse control disorders or mood disorders.

On the other hand, the kids who aren't even trying to seek out the peers they're socially neglected.

There may be isolated in some way.

These are kids who are more likely to be anxious or depressed.

So if you're trying to determine where a kid falls in terms of their acceptance of their peer, by their peers, in terms of whether they're peer rejected or socially neglected thinking about those co-occurring diagnoses.

And then I'll give you a pretty strong hint of maybe what might be happening with them in their social media either way, though, both of these kids whether they're peer rejected or socially neglected they both lack closed reciprocal friendships.

And so again, this is an area that we need to target in social skills training.

This graph actually is from "The Science of Making Friends".

It's our parents look for people who are kind of struggling socially and it's basically, it's summarizing sociometric data taken in research from North America.

And this is sort of an aggregate.

And what they do in these studies is they'll go into a typical middle school or high school.

And they'll have kids identify who their friends are who they like.

Who they don't like.

And what they find is very similar in many many settings in North America, probably about 50% or half of kids in the typical middle school or high school would be in the average range of peer acceptance.

They have some friends they're not particularly popular but they're kind of in good social standing.

Then you have about another 15% of kids who fall into the popular range of peer acceptance.

So these are kids who have a lot of friends.

They're not always well-liked but they're certainly well-known.

And you have about another 15% of kids who fall in the peer rejected category.

Now, remember these are the kids who are perhaps teased or bullied.

They might have a bad reputation.

It might be doing something that other people don't like and these are kids who are seeking out their peers but they're getting pushed away for some reason.

Then you have about another 15% of kids who fall on the socially neglected range of peer acceptance.

So these are the kids who are not even trying to engage their peers.

Again they often seem withdrawn or shy that go unnoticed unfortunately, but they're still struggling with friendships.

And what this research tells us is that in any typical middle school or high school in North America about one third of kids are struggling socially.

And sadly, I don't think we do enough for these kids.

These are not even just kids with autism spectrum disorder.

These is just in any typical middle school or high school that one third of kids are struggling socially.

This is really what led us to develop the UCLA PEERS program.

Now, PEERS is again in a social skills program.

It's developed originally for teens with autism spectrum deserve their research goes back to 2004.

When we started to develop the program.

And shockingly at that time in 2004, over a decade ago although there were many, many social skills programs for adults or for young children with autism there were very, very few programs for adolescents with ASD.

And certainly also the same was true for young adults.

And this is really what led us to develop this program is that we want it to not only full service gap but also a research gap in developing an evidence-based social skills program.

And this is a manualized treatment.

There's two different published manuals at this time, both for adolescents, with autism spectrum disorders.

They are used for kids who are not on the autism spectrum as well.

But originally the research has focused on that population of kids.

Now the manuals is a parent-assisted program.

And so this manual is typically used in outpatient medical settings in community-based mental health settings.

But it essentially is a weekly program where parents and teens come to learn how to make and keep friends and parents are included in the intervention to act as social coaches, to their kids outside of the group.

And really this ensures that number one, we're not working at cross purposes with parents because adults often give advice about social situations.

But what we found in our research is that adults don't always give the right advice.

We wanna make sure that we're all teaching the same thing.

And we also know that parents are there the vast majority of the time.

So we wanna teach parents to be good social coaches to their kids.

When we, as mental health professionals are not there which again is the majority of the time.

So the way that this works is it's a weekly format.

The sessions are 90 minutes in length and both parents and teens meet in separate rooms concurrently to learn about making and keeping friends.

We also have a teacher facilitated program.

Now that's a school-based program and it's a little bit different in its format and this program, the interventionists or the teachers.

So his social skills are taught in the classroom using the daily lesson format.

So we're teaching social skills much like we would teach any course like math or science, the daily course, anywhere from 30 to 50 minutes, focusing again on making and keeping friends.

And in this case, the teachers are the social coaches providing that additional coaching in this natural social setting which is the classroom because we know that including parents is so critical in teaching social skills.

We also have weekly parent hands that are meant to be sent home to parents.

Of course, some schools do opt to have a weekly parent groups, but because this isn't always feasible for most schools we have these very comprehensive hearing handouts to keep parents in the loop without what we're teaching their kids.

Now, both of these programs are evidence-based social skills programs.

They're evidence-based for teens in middle school and high school with autism spectrum disorder.

We also have some additional research pilot data using the program with those, with ADHD with intellectual disabilities and even fetal alcohol spectrum disorders.

I should also mention too, that we have a young adult program for those on the autism spectrum.

It's been researched for the last probably seven years now.

And we'll just be coming out with the young adult manual and later in 2015.

So that's something to look forward to in terms of how we teach social skills.

I think what you teach us is really critical but how you teach social skills is also quite important.

And we use evidence-based methods for social skills and instruction.

The first kind of method that we use essentially is that we use the small group format and a small group format is important when teaching social skills, not because you're hoping that the group members make friends with one another.

I mean, that's lovely if that happens, but that really shouldn't be the intention.

The intention should be to help them to make friends outside of the group.

But it's very helpful to actually teach these social skills in a small group format so that the teams can actually practice the social skills with one another.

Another important, effective method of social skills instruction is didactic lessons.

That means that from week to week, we have some kind of a lesson that we're teaching.

These are ecologically valid social skills that we're teaching I should mention.

What that means is that we're not teaching.

What we think is as adults that kids should do in social situations.

We're actually teaching what we know works through research.

And that's how it PEERS is not only an evidence based program and that we have a lot of research to support the effectiveness of the program as a whole, but also the program was developed out of research and that went to the research literature to figure out what two socially successful kids do in social situations and let's teach that.

It's also evidence-based in that we looked at the research literature to see what are the common social errors that kids with autism make and once teach them not to do that.

So it was very concrete lessons each week, but are focusing on skills related to making them keep keeping friends.

And the way that we teach these lessons is we sort of get into the mind of kids with autism.

And we know that kids with autism think very concretely and very literally.

And so we teach all of the skills in PEERS using concrete rules and steps of social behavior.

Essentially we break everything down into concrete parts.

From there, we actually demonstrate what these skills should look like.

And in some cases what they should not look like and that's the role-play demonstrations.

So we'll by demonstrations are intended to model certain social behaviors.

Now certainly you wanna model what to do in social situations ecologically valid social skills, but in many cases it's also quite helpful to model what not to do to kind of show them the common social error that a person might make in a social situation.

And not only establish a rule about that and what not to do in these situations, but also just the perspective taking in both cases, a perspective taking questions are also an important component of teaching effective social skills.

What that involves is essentially enhancing or helping to develop social cognitive theory of mind helping kids to put themselves in someone else's shoes and understand the perspectives of others.

And so they might include doing a role play demonstration move, maybe something not to do timing out on that asking what the person did wrong, establishing a rule around that.

And then doing perspective, taking by asking questions like well, what do you think that was like for that person?

Or what do you think they thought of me?

Do you think they're gonna wanna talk to me again?

And this again, helps to enhance and develop social cognition.

From there, it's not just enough to have a lesson with a role play demonstration, but our kids have to have an opportunity to practice these newly learned skills and practicing the good skills, not the bad ones.

These are what we call behavioral rehearsal exercises.

Now this is where the teens are practicing the newly learned skills.

And because we know that they're not gonna get it perfect.

The first time we're gonna have some kind of performance feedback through coaching.

So we're gonna coach them in the moment to try to improve upon that skill.

In order to generalize those skills into other settings, it's really critical that we also include homework assignments.

Now, surprisingly, the vast majority of social skills programs do not include homework assignments.

And that really actually is not quite intuitive because if you think about it, the skills that our kids are learning they may be able to improve upon in the group setting.

But in order to ensure that they use them outside of the group setting, it's actually quite important that they practice in other settings.

That's where homework assignments become really critical.

One of the biggest criticisms of social skills programs is that the skills don't generalize to other settings, but by including homework assignments we're actually gonna enhance the and promote the use of the skills and other settings.

Now it's not only important to assign homework, but you actually have to follow up with these homework assignments.

And that homework review is also very critical.

This is also rehabbing an opportunity to individualize the treatment for each adolescent.

Most of the skills will take right away.

Others may need to be kind of troubling.

We needed to troubleshoot or kind of tweak to actually help to improve upon.

This is also where parent or caregiver coaching or teacher coaching comes into play because these skills are often taught outside of the group or practiced rather outside of the group that often needs to be some kind of social coaching that accompanies that in order to improve upon skills.

So this is another argument for why we wanna include the parents caregivers and teachers in the intervention in terms of the skills that we actually teach in peers.

We sort of break things down into two general areas.

One relates to making and keeping friends and the other relates to handling peer conflict and peer rejection.

So with regard to making and keeping friends, we talk about things like finding and choosing appropriate friends finding a source of friends.

We talk about conversational skills because that's really a critical element to adolescent social interactions as you know, being able to talk with someone.

And then we talk about starting and entering group conversations.

We talk about exiting conversations when necessary.

We talk about things like electronic communication which is really critical once you hit adolescence and as well as things like good sportsmanship and also having successful get-togethers with peers this is how close meaningful friendships develop is by having get togethers hanging out outside of school in terms of handling peer conflict and peer rejection.

We talk about things like how to handle arguments and disagreements.

We know that arguments are not that uncommon in adolescence but if they're not too explosive and they're not to end a friendship.

We also talk about different types of bullying.

Research essentially tells us that there's four types of bullying.

One type is verbal language.

We often refer to as teasing.

There's also physical bullying that could involve hitting, kicking, pushing more aggressive types of a behavior there's also electronic bullying or what we often refer to as cyber bullying.

And then finally, there's relational bullying which includes rumors and gossip and even social exclusion.

And these are four very different types of behavior.

So obviously the strategies for handling these types of behavior are gonna be completely different.

And so we have sessions on each type of bullying and strategies for handling these situations.

Finally, we also have a session on changing bad reputations, and unfortunately for a lot of our kids, particularly the peer rejected kids they struggle with having a bad reputation and it's never easy or quick to change a bad reputation.

However, there's a lot of research that shows us how people are able to successfully change their bad reputations.

and so we teach the strategies for doing that.

In terms of how the skills are actually developed.

We basically have a series of do's and don'ts in PEERS.

The dues are the things we wanna do.

These would be ecologically, valid social skills.

The strategies that socially successful teams are using to make and keep friends.

So we teach those.

We also teach the don'ts and the don'ts are based on what the research tells us are the common social errors committed by people on the autism spectrum.

So it's a series of do's and don'ts, but everything is basically broken down into concrete parts and focused on the simplest way for kids to, to learn these skills which is basically by breaking everything down into again, rules and steps of social behavior.

Wanted to give you some examples of how we actually teach these social skills.

And in thinking about the do's and the don'ts, the next a couple of examples they relate to the don'ts, the common social errors that kids with autism makes.

I want you to first think about what are some of the common social areas by teens with ASD when they're talking to other people.

So then gonna go ahead and show you a video demonstration in person here on the left is Alex, the person on the right is Ben.

I want you to watch this role play demonstration and think about what Alex is doing wrong in this conversation.

- Hey, Ben.

How's it going?

- Good.

How are you?

- I'm good.

I just got back from the Comic Book Convention.

Yeah, it was unbelievable.

It was downtown and everyone was there.

We all dressed up.

Yeah.

We're the coolest outfit I met all the famous authors.

It was awesome.

Yeah.

It was really cool, everyone was dressing up and I think I'm gonna go next week also but I'm not sure what I'm gonna wear.

Cause I don't wanna wear the same thing but maybe I'll get a new one or something to buy that.

But everyone was wearing the coolest costumes.

I got a ton of pictures.

So maybe I'll get some good ideas there.

I think there's one also the weekend after I'm gonna try and go to that to just get a bunch of autographs or maybe a bunch of people.

So we'll say yeah, a lot of my friends wanna go.

So I figured I'll just go with them.

It's a bit of a drive, but you know, it's so worth it.

Cause it's a really big Comic Book Convention.

Yeah.

So it'll be fun.

I really can't wait for it.

- Timeout on that.

So what did Alex do wrong?

Well, when we ask kids with autism, what Alex was doing wrong after that situation, they'll often tell us that he was basically monopolizing the conversation not letting Ben talk.

He was basically being what we call a conversation hog.

And this is a very common social error in autism.

A lot of our lessons have these very one-sided conversations where they talk at the other person, maybe monologue or lecture.

And the problem is that they tend to fail.

They fail to identify common interests in this process.

If they're just focusing on what they're interested in and never really giving the other person a chance to talk this is gonna be very one-sided.

Now the problem with being a conversation hog and failing to identify common interest is that friendships are based on common interests.

And so by virtue of having this very one-sided conversation not finding common interest it's going to make it very difficult to make and keep friends.

Moreover, you have to think about what that was like for the other person.

So this is where the perspective taking questions come into play.

So you have Alex here on the left, we have been here on the right.

Alex was being a conversation hog.

The first perspective taking question we need to ask ourselves is what was that like for men?

Well a lot of kids will say that it was probably kind of boring for men kind of annoying.

Maybe frustrating.

Next question we ask is what does Ben think of Alex?

Well, a lot of kids will say that Alex seems kind of self kind of self-absorbed maybe of noxious, maybe annoying.

And the final perspective taking questions you would ask would be will Ben wanna talk to Alex again.

And of course the answer is probably not.

So that's one example of how we teach rules about conversational skills.

Here's another example.

Watch this next roleplay and think about what Alex is doing wrong with this time.

- Hey Ben, how's it going?

- I'm doing good.

- It's actually, you're doing well.

Well as an adverb and goods and adjective and in this situation, you actually wanna use an adverb "well".

- Okay, well, sorry.

I'm doing well.

- Lemme know it's for your it's for you.

So what what'd you do this weekend?

- I went and played some basketball.

- Okay.

So a little time out on that.

So what Alex do wrong this time?

Well, a lot of people will say, well, he just corrected Ben's grammar.

We call it policing.

It appears we have a rule that you wanna try to make and keep friends.

You can't be policing other people but it's a very common social era that a lot of our kids make.

So why do they do that?

Why do they correct people or people's grammar?

Or why did they point out mistakes that people make?

Well, we know that a lot of kids with autism they struggle with poor social cognition, which means that they have difficulty kind of predicting the social world.

They also engage in a lot of what we call dichotomous thinking.

It's sort of black and white thinking, putting things into categories because of this way of thinking and perceiving the world.

Many of our kids are very rule driven.

They love rules.

In fact, it's one of the reasons I think that they gravitate towards things like math and science.

It's very, very predictable.

There's always you can always know what to expect with the social world.

Not very predictable.

And yet they still try to impose these rules on the social world.

And how do they feel when they notice that someone has committed a rule violation and they feel compelled to point out this rule violation.

Now that's fine if your goal is to be the grammar police and, and point out that these grammatical inconsistency is your errors.

However, if your goal is to make and keep friends the rule needs to be that you don't police others.

So let's do some perspective taking around that.

So again, we have Alex here who is police event.

So we have to think about, well, what was that like for men?

Well, a lot of kids will say that it was probably kind of embarrassing.

Maybe a little bit annoying, maybe a little bit frustrating.

The next question we need to ask ourselves is what does Ben think of Alex?

Well, a lot of kids will say that Ben thinks that Alex is really bossy.

He's probably really controlling, kind of annoying and will Ben wanna talk to Alex again, probably not.

In fact, a lot of kids who do these things like policing and conversation hogging, they get bad reputations among their peers group doing these things.

And people will actually avoid being around them because it makes them uncomfortable.

All right, let's watch this next role play.

And let's think about what Alex is doing wrong this time.

- Hey, Ben, what are you doing this weekend?

- I'm gonna my mom and stepdad's, they're having a party.

- Your stepdad, are your parents divorced?

- Yeah.

- When did that happen?

- When I was 12.

- Why?

- I don't know.

Can we talk about something else?

- You're 12 was that hard on you?

- Yeah.

Yeah.

- Did they tell you why or you still don't know?

- Can we talk about something else?

- I'm just, I'm just curious it is a weird like going to your mom's a down, just curious?

- Yeah.

- What do you like, see one of them more than the other or did they like get jealous?

Is it weird?

- I'm I dunno.

- Like did they fight over you still, is it awkward there?

- Okay.

So let's time out on that.

What did Alex do wrong this time?

Well, obviously he was getting really, really personal and this is again, another common social error that people on the autism spectrum might make is that they get to personal at first.

So why did they do that?

Well again, when you know that poor social cognition is sort of a driving force here they often have difficulty taking on the perspectives of others.

They also have difficulty picking up on social cues.

So not only may they have difficulty understanding that really personal questions may make the other person feel uncomfortable.

But when that person is actually experiencing that discomfort it's difficult for our kids to actually read the social cues and know that they're actually feeling uncomfortable.

So the issue here is that they'll often ask a lot of personal questions that the other person or they might even share too much personal information.

And so the rule is that we don't wanna get too personal at first, as we get to know someone a little bit better then it's okay to get more personal but we still need to pick up on the social cues.

So now let's do some perspective taking.

What do we think that was like for Ben?

Many people would say it's really uncomfortable for Ben but really, really awkward, very, very uncomfortable.

And what does Ben think of Alex, as he's asking all these really personal questions and many people say that Alex seems really insensitive.

He seems like he doesn't really have any empathy.

He started nosy too at the same time, but really not very caring her considerate of Ben's feelings.

And the final question of course, is Ben going to wanna talk to Alex again?

And many people will say no, he probably won't wanna talk to him again.

So another role for having a good conversation is that we don't wanna get too personal at first.

Now, obviously these are very common social errors that kids with autism make the conversation hog perhaps they might police.

They might get too personal.

There's many, many other issues that they may fall into.

And just because we established a rule about these particular behaviors and just because I do some perspective taking doesn't mean that our kids are gonna stop doing these behaviors right away.

This really highlights the importance of including parents, caregivers, teachers in the intervention, because they're gonna provide that additional social coaching in the real world when these mistakes are made.

And they'll also be able to help to provide some additional perspective taking.

Right now it's actually talking about an ecologically valid social skill how people start individual conversations.

No, again, there's many many different rules around conversation skills, too many for us to actually get into in this very short webinar.

But one of the ways that people start individual conversations is they do this thing called trading information.

Now, before they start trading information they first find some kind of common interest.

So maybe they'll notice that they have a gaming logo on a t-shirt that maybe is that of a video game that they like maybe something has some kind of technology that they're interested in the new iPhone, something like that.

But essentially they find some kind of common interest and then they either make a comment about that common interest.

They'll maybe ask a question about that common interest or they'll even give a compliment about that common interest.

From there they get into this idea of trading information back and forth about this particular common interest.

And we do that by asking the person questions about themselves or what related to the common interest.

We don't wait for them to ask us questions in return.

They may ask us questions but if they don't, we answer our own question.

That's how we start to share information about ourselves and to keep things on topic, we ask follow-up questions so that we're not jumping from topic to topic but the goal here in these individual conversations is that applying common interests.

And again the reason that common interests are so critical is that friendships are based on common interests.

If you think about who you're friends with, or maybe you've been friends with, you probably have things in common with those people.

And those are the things that you talk about, and those are the things that you do together.

So finding common interest is really a critical component to making and keeping friends.

So now that we know sort of the rules for starting individual conversations let's watch another role-play and let's think about what Alex is doing right this time and starting this conversation.

- Yes.

- Was that the game?

- Yeah.

Yeah.

- Wow.

What's the score?

- It's three zero, there's a minute left.

- Oh my! That's crazy.

Has it been an entertaining game?

- It's been awesome.

Did you see the one last night?

- No, I don't.

I was in the library.

I didn't get service.

How do you get on your phone?

- No, I have this app, it's free.

- Oh my gosh! It's so cool.

Does it like take up a lot of batteries?

- Yeah, but I mean it's worth it.

- That's awesome.

Yeah.

I gotta get one of these so I can watch the games.

- You should.

It's awesome.

- Okay.

So it's time out on that.

So what did Alex do right?

Well, this would be an opportunity for repetition of instruction.

We found a common interest.

He asked a question, he traded information about that common interest.

And essentially that's how he started the conversations.

Let's do some perspective taking what was that like for men?

Well, many people will say that it was pretty comfortable.

It was nice.

Interesting.

What did Ben think of Alex?

Well, a lot of people will say Bonnie was nice friendly, sort of interesting.

And then thirdly we'll ask will Ben wanna talk to Alex again?

And usually the answer is yes.

Probably he will.

I wanna give you another example, a clinical example of another very common social error that kids on the autism spectrum make and it relates to entering group conversations.

Now I mentioned before that we wanna be teaching ecologically valid social skills in this type of program.

We don't wanna teach.

We think that kids should do in social situations but what we know actually works in reality.

Well, unfortunately adults, we give advice all the time when it comes to social situations but unfortunately we get really bad advice a lot of times.

Now it's not knowingly that we do this, but unfortunately we don't always get the ecologically valid strategies here.

Peer entry or entering group conversations is a perfect example of this.

So first think about what are most teens told to do when trying to meet new people?

Well, I asked this question to every group of teenagers that I work with and they always gave me the same two replies.

They're often told to go up and say, "Hi", or go up and introduce themselves.

Well, imagine what that would actually look like.

Imagine if I were to walk up to a group of people that I've never met before that I vaguely know.

And I just said, "Hi," or, "Hi, I'm Liz." And introduce myself for no reason at all, interrupting their conversation.

What are they gonna think of me?

Probably gonna think that's kind of strange pretty random.

It's not ecologically valid.

And even the advice that we give kids time and time again, it's not even really what we as adults often do in social situations.

Before we get at the ecologically, let's think about what's the common social error that's made by kids with autism when they're entering their conversations.

We'll go back to thinking about those peer rejects versus socially neglected kids.

So remember the peer rejected kids are the ones who ultimately comorbid diagnoses like ADHD, impulse control disorders.

What are they likely to do in entering conversations?

Well, many people will say that they'll probably barge into the conversation, they'll probably be off topic.

They'll probably hog the conversation maybe monopolize it and really not pick up on the cues that other people aren't gonna be interested.

What about the socially neglected kids?

What are they gonna do?

Or remember, these are the kids that often have co-occurring diagnoses like depression or anxiety.

Well, sadly when it comes to pure entry these are the kids who often don't even try to engage their peers.

They'll stand on the side of the room.

Maybe not really even actively pursuing others to in conversation.

And they'll often be worried or go unnoticed.

All right.

So let's go ahead and watch before we're gonna say ecologically valid strategies.

Let's watch a role play demonstration of what this should not look like.

So this is a group of people that are gonna be talking in a moment.

You're gonna see another person enter the conversation.

Her name is Yasamine.

I want you to think about what Yasamine is doing wrong in entering this group conversation.

- So Alex, you'll never believe it.

I ran into Mary at my piano lesson place.

- I didn't know you played piano.

- I had no idea that she played piano and we ran into each other.

It was the craziest thing.

It really was.

And again-- - Have you've been to the water park?

You wanna just open up.

- Do you play anything else?.

- It's so awesome.

- Yeah, I play guitar.

- There's this slide at the very top.

And you just go around and around and you can all it.

It's so much fun-- - I play acoustic.

- So fun.

And its really fast down the slide.

- I play in my garage.

- There's also this place where you can kind of like body surf.

How you guys been body surfing before?

- I'm sorry you play in your garage.

- It's so much fun.

And it's so close to.

- Okay.

So timeout on that.

What did Yasamine to do wrong in entering that real conversation?

Well, many people will say she barged into the conversation right?

She barged in, she was off topic for sure.

And she just tried to kind of have the conversation.

Next question I'd like to ask is it seemed like the group wanted to talk to her.

Well, most people say no, absolutely not.

They did not wanna talk to her then I'd like to ask, how could you tell?

Well, the interesting thing about picking up on these social cues during peer entry is that often may think that whether or not we're accepted or unaccepted in sort of the feeling that we get, it's true that there are feelings attached to these behaviors but there's actually concrete behaviors that we're picking up on that go beyond the feelings.

So one thing relates to the verbal cues where they actually talking to her.

No, they weren't.

That's not a good sign.

Next thing relates to eye contact where they looking like Yasamine?

No, they weren't.

If they were looking at her, it was to look at her and kind of make a face or maybe roll their eyes.

And the third thing that we're supposed to be looking for relates to body language, were they facing her?

No.

In fact they weren't facing, they were turning away from her.

They were giving her what we call the cold shoulder.

Often when people talk in groups, they sort of talk in circles.

When they wanna talk to you they basically open the circle when they don't wanna talk to you.

They essentially close the circle.

In this case, the group was the circle.

So that's one of the three key behaviors that we're looking for.

We're always asking yourself were they talking to me?

Are they looking at me?

And were they facing me?

And kids with autism they don't know to naturally look for these behaviors.

But once you teach to look for those behaviors they can actually pick up on these social cues quite well.

So we know that the group wasn't interested in talking to Yasamine, she definitely barged in, she was off topic.

Now we have to do some perspectives taking, what was that like for the group?

Many people will say that it was really obnoxious.

It was really annoying.

It was aggravating.

Next question.

What does the group think of Yasamine?

Well they probably think that she's weird, obnoxious annoying and they wanna talk to her again, probably not.

Instead of actually doing this we wanna actually teach ecologically valid strategy for what we call through your entry.

And this is something that many of us naturally do.

Just don't think about the fact that we're doing this.

The first thing that we do is watch and we listened to the conversation.

So what are we watching and listening for?

Well, the first thing is we're sort of listening for the topic, trying to figure out what they're talking about and making sure that we actually know something about the topic.

So sort of finding a common interest essentially, we're doing this as we're sort of watching from a distance now we're not staring at the group because that would be kind of interested.

We're not staring at, but we're looking over periodically, maybe showing some interest.

And in the process, we're probably using some sort of a prop.

A lot of people will use a phone, a gaming device something of that nature but something to distracted by could be a book could be a comic book, something like that.

But you're basically using a prop to sort of look like your attention is focused on something else as you're actually listening to the conversation.

But basically what you're doing is you're eavesdropping but you don't want us to look like you're eavesdropping.

So let's say you've watched and listened a little bit.

You figured out the topic, you know something about the topic and you've decided that you wanna join.

Next step is that you're gonna have to wait for something.

Well, what are you waiting for?

You're probably waiting for a little pause in the conversation and this is really just so that we don't actually interrupt the conversation too much.

There's never a perfect pause.

It's never gonna be ideal but you're just trying to not interrupt too much.

Best time to join is usually when one person stops talking and another one is about to start talking.

Then the next step is we move a little bit closer.

Usually no closer than an arms length away.

And then we actually joined the topic.

And this is why either making comments asking a question or giving a compliment about that topic.

And that was essentially how we slip into a conversation very naturally as if we were already in that conversation.

So the next step in this process of teaching this particular ecologically valid strategy is to do a role play demonstration.

So I would say, watch this role-play and think about what Yasamine's doing right this time and entering this with conversation.

- So Alex you'll never believe that yesterday I ran into Mary when I was leaving my piano lesson.

You play piano?

- [Mary] Yeah.

I've been playing.

It was the craziest thing.

I've never run into her before.

- I can't believe it.

- That's so funny.

- Do you play an instrument?

- I play guitar.

- I just started to play guitar.

- That's awesome.

Electric or acoustic?

- No.

I'm playing acoustic, how about you?

- I play electric.

- Cool.

- Do you play?

- [Mary] No, but I really wanna learn though.

- It's really fun.

You should definitely take lessons.

- I play the guitar.

Do you play the guitar?

- Yeah, we were just talking about it Alex and I play.

- That's so awesome.

What do you play?

- I play acoustic.

- I play electric.

- Nice.

I play guitar.

Yeah.

I've been playing for like five years now.

- That's awesome.

I just started so… - Yeah, it's really fun.

- Yeah.

I like it a lot.

You should definitely learn.

- I know.

I really want to feel cool.

- We should all jam sometime.

It will be fun.

- I'd love that.

- Okay.

So timeout on that.

So next question is what did Yasamine do right in entering that group conversation?

Well, first she kind of watched and listened to the conversation she was using probably looking at her phone.

She waited a little pause.

She moved a little bit closer and she basically said something on topic.

Next question would be did it seem like the group wanted to talk to her?

And of course the answer is yeah, it actually did seem like they wanted to talk to her.

Next question is how could you tell?

Well, they were looking at her, they were facing her.

They sort of opened the circle and they were actually talking to her.

Next comes the perspective, taking questions.

So what do you think that was like for the group?

Most people would say it was pretty comfortable pretty natural, nice pleasant.

What did the group think of Yasamine?

She seems nice.

She seems friendly, kind of outgoing.

And with the group, I wanna talk to her again probably.

So that's an example of teaching an ecologically valid strategy or what we call peer entry or entering a group conversation.

The last skill I wanna talk to you about relates to peer rejection or bullying teasing.

And we know that teasing is really, really common.

Typically developing teens.

However, the strategies that our kids use for handling teasing, aren't always very effective.

So first I wanna think about what are most teams told to do in response to teasing?

Well, I asked this question, every group of teens that I work with and every group gives me the same three replies.

They're told to either ignore the person, walk away or telling adults.

Then I asked them if it works and guess what they say, no, it doesn't typically work.

That's because this is not actually an ecologically valid strategy to do any of those things walk away or tell them adult think about what that would look like.

Imagine someone were teasing you and you just ignored them.

What would they do?

Well, they would probably keep teasing you.

And in the process you looked sort of weak because you didn't do anything to defend yourself.

And they're probably more likely to get teased again.

Imagine someone is teasing you and you walk away.

What do you think they're gonna do?

Well they're probably gonna follow you and keep teasing you.

And again, you sort of look weak in the process and you're more likely to get teased again.

And if you told an adults, imagine what happened next.

Well that person's probably gonna wanna retaliate against you because you tried to get them into trouble.

So again, you're probably more likely to get teased maybe even get a bad reputation.

These are not ecologically valid strategies.

And yet for generations, we've been telling kids to do these things.

And before we get into the ecologically valid strategy let's think about what are the common social errors made by kids with autism when they're being teased.

Many people will say that they get upset.

They even get mad or angry.

They may be even tease back.

Think about what the teaser is trying to get us to do.

It's very important to get into the mind of the teaser.

And what is the teaser trying to get you to do trying to get you to react essentially to get upset, to get mad at you and so to tease back, and that makes it fun for them.

So when we do those things we're actually making it more likely that we're gonna be teased again.

So those are awesome not ecologically valid strategies instead of kids who are socially successful do something rather different.

Now the reality about teasing is that every kid gets teased.

It doesn't matter how popular you are.

Every kid gets teased.

It's how you react to it.

That determines how significantly how chronically you're teased.

And so kids who are socially successful they do this thing where they give a really short comeback that shows that what the person said didn't bother them.

And actually what the person said was kind of stupid or if it was kind of blame.

So they'll say things like whatever on that.

And our enter point is.

Why so insecure.

I also wanted to provide you with a little bit of a research snapshot, a little overview of the types of outcomes that you could expect from this program.

As I mentioned, PEERS is really one of the only evidence-based social skills programs in autism.

The research that I'm about to share right now it relates to our parent assistant program.

And as I mentioned early on we have a number of different programs.

One is parent assistant.

We have a teacher facilitated program we've even combined both programs.

So this research really relates to our parent assistant program for teens with autism.

And typically what we see is is quite similar across clinical trials below here represents the treatment group.

Those who received PEERS rather than magenta represents our wait-list control group.

Those who did not receive any PEERS intervention in this first graph here on the upper left hand side is taken from research on the social skills rating system by Gresham & Elliott.

This is a rating scale that looks at social skills.

Using standard scores in standard scores have a mean or an average of 100 and a standard deviation of 15.

What that means is that 15 points above or below that mean it's pretty significant essentially.

And what we typically see is about a 10 point standard score improvement from pre to post test.

So these are kind of different scores changes from pre to post test with very, very little change in the wait list control group.

We also use another measure called the social responsiveness scale that was developed by John Constantino and the social responsibility scale is an autism screening questionnaire.

So basically what we see here this is a scale that uses T-scores that have a mean or an average of 50 and a standard deviation of 10.

What that means is that 10 points above or below that mean is really significant.

And we typically see again about a 10 or 11.2 T-score improvement in social responsiveness from pre to post test and those receiving PEERS with very little movement in those who did not receive the intervention.

We also look at things like social engagement.

So that would be for example, the number of get-togethers our teens are having at the end of the intervention.

And what we found typically in our program is that our kids are having about four additional get-togethers per month at the end of treatment, compared to those in the wait list of this group that have very little change.

We also look at followup data looking to see how our kids are doing after they've left our program.

So just to explain these graphs T1 here represents the pretest that's before the intervention.

T2 is the post test immediately following the intervention and T3 is a 14 week followup assessment following the PEERS program.

This is again that social skills rating system that has the mean or an average of 100 uses standard scores.

And what we see is that at pretest our kids are kind of in the delayed range of social skills when they leave our program.

And they're in the more average range of social skills, and that maintains very nicely at that 14 week up assessment.

We also want us to look at the social responsiveness scale to see how that maintained over time.

Now remember that this is an autism screening questionnaire.

That means that higher scores represent more autism symptoms are greater in terms of impairment, lower scores represent less impairment in terms of social responsiveness.

So what we see is this very nice improvement in social responsiveness from pre to post test.

And that maintains a very nicely, even 14 weeks later.

We also looked at those to get together top to where our kids having get togethers in the previous month.

And as I mentioned our kids are typically having about four additional get togethers following the intervention per month, when they come back 14 weeks later they're having about two additional get-togethers per month.

And that's a little bit of a decline from the end of the treatment but it is still statistically significant higher than when they first came into the program.

We also found some new followup information or new findings at that 14 week followup assessment.

This relates to things like problem behaviors, according to parent reports.

So one thing is that our kids are coming up and kind of be elevated and range of problem behaviors when they come into our program when they leave, they have a nice little decline in problem behaviors related to social skills.

And then that decline decreases even further actually having greater improvements in decrease problem behaviors 14 weeks after the intervention we also saw some additional findings related to teacher report.

Now, teachers in this particular study were blind to the conditions under investigation.

They didn't know that their kids were participating in a social skills program.

And that's what's really nice about these findings is that they're actually independent ratings of social skills.

And typically find that teachers are reporting that there's a very nice improvement in social skills from the pre to post test among their students.

And that that improvement continues 14 weeks after the intervention.

So very nice additional findings out a 14 week follow up using the parents assisted version of PEERS.

Now this is also sort of a caregiver assistant version of PEERS.

And this is for adults with autism.

And this study was conducted with care-givers who primarily involved parents but it also might've included other family members adult, siblings, job coaches, life coaches, even peer mentors.

But again, there was some form of caregiver assistance outside of the treatment.

And what we found is very similar in this particular study we saw a nice improvement in overall social skills in the treatment group from pre to post test.

For those in the wait-list we actually saw a little bit of a decline according to caregiver reports in the wait-list control group.

We also saw very nice improvements in social responsiveness on the social response on this scale in the treatment group those were seating PEERS with very little change maybe even a slight decline in the wait-list group.

We also send nice improvements and empathy using the empathy quotient in the treatment group and the very little change in the wait list control group.

Additionally, we saw decreased loneliness and those that received the peer intervention with very little change in the wait-list group as well as an increase in hosted and invited get togethers.

So on average, our young adults are having about one additional get together per month in the treatment group, as well as about one additional invited get together at per month in the treatment group.

What this tells us is that our kids or our young adults rather are not only inviting people onto more get-togethers but they're actually experiencing greater social reciprocity.

People are actually seeking them out as well.

So that's the research with young adults.

We've also continued to do our research in the school setting.

And so in this case this study is looking at a teacher facilitated version of the peers intervention.

In this study, we actually compared those who received the PEERS intervention in the classroom in comparison to another social skills program.

And the other social skills program that we used was called "Super Skills" it was a program developed by Coucouvanis, that uses very similar targeted skills.

It looks at fundamental skills like eye contact and voice volume.

It looks at sort of social initiation things like starting a conversation getting along with other people and also social reciprocity.

So it's kind of targeting those friendships skills as well as the manualized treatment.

Essentially the participants in this group were in middle school.

So the average age was around 12.

This was mostly a male sample and somewhat ethically diverse sample.

What we found here on the left are that changes in the scores in the treatment group, those receiving PEERS versus those in the active treatment control those receiving Super Skills.

What we found was those then the peers intervention not only improved in their overall social skills knowledge, they learned the skills we were teaching them but they were also having about two additional get-togethers per month in that group.

Those in Super Skills were actually having fewer get together.

So that three fewer get together as per month, that was rather unexpected.

So we'll have to come back to that and talk about why that might be.

We also saw a nice improvements in social responsiveness and those two went through the PEERS intervention particularly in the areas of overall social responsiveness with regards to things like social awareness, social cognition, social communication even social native motivation, all improved over time.

These negative numbers are actually indicating in social skills because higher scores on the social responsiveness scale indicate more impairment lower scores indicate less impairment.

However there was all these nice improvements in PEERS group we actually saw very little change in the Super Skills close condition.

Finally we also saw a nice improvement in decreased social anxiety in the PEERS group, but actually increased social anxiety in the Super Skills group.

That was also unexpected.

So when you get findings like that, you expected to see improvements in PEERS, but we didn't expect to actually see decreases in things like a social anxiety and social engagement and the Super Skills condition.

So it's difficult to really know why that might be.

But one hypothesis is that we're still kind of expecting these teams to engage in the similar behaviors to have these homework assignments to practice these skills outside of the classroom setting.

But perhaps they felt a little bit less socially competent than those in PEERS.

Perhaps we weren't really teaching them the ecologically valid social skills.

And as a result, their social anxiety may have increased which is what appears to have happened.

And of course, when people are socially anxious they tend to withdraw meaning that they're gonna have you or get togethers ultimately normally real way of knowing why this might be but that's one hypothesis for this particular findings.

And this study, what we want it to look at was the component of adding the teacher facilitated program with an actual parent assisted study.

So essentially what we did was we had all of the teams in this particular sample 146 kids with ASD received PEERS in the classroom as facilitated by their teachers.

The big difference here was whether or not their parents participated in this program.

So of those 146 adolescents with ASD 49 of them have parents who actually attended weekly parent social coaching groups to learn about how to be good social coaches to their kids.

And the other 97 did not have parent participation.

And we essentially wanted to look at what was the difference between those two groups.

Now, in terms of the demographics, this was a study that took place in a middle school and high school.

So average age was about 15, mostly male sample not surprisingly and pretty ethnically diverse sample in terms of looking at the overall treatment outcome.

So this was looking at how kids did in the program, regardless of whether or not their parents actually participated in the treatment.

What we found was that teens not only improved from pre to post test in their social responsiveness but they also improved in their overall social skills.

They decreased in their social anxiety that we're having about three additional get-togethers per month.

And they were also experiencing greater self-esteem and improved social skills knowledge, regardless of whether or not their parents participated in treatment.

The next thing we wanted to look at well what was the impact of parent participation in treatment?

What we have here on the left is the parent assisted program at pretest and posttest, and just adjacent to that is the no parents assisted pre and post assessments.

And what you'll notice is that when kids had parents who participated in treatment, they were definitely having better outcomes.

Not only did they have greater social responsiveness in the areas of social awareness, social cognition and social communication but they actually were experiencing greater friendship quality, particularly in the area of companionship and even in the areas of helpfulness and decrease conflict at a trend level.

But I wanna point out is that it's not just that kids whose parents participated in treatment did better than those who did not participate in treatment.

There's actually something qualitatively different about those adolescents whose parents actually agree to participate in treatment.

And that is that the parents, if you look at the pretest for parent assisted versus no parents assistant what you'll notice is that the kids in the parent assistant program were actually more impaired to begin with.

In other words, these were parents who agreed to come to a parent social coaching group once a week for 90 minutes because their kids were probably more impaired and needed a little bit more assistance.

And so what the bottom line here is that everyone's gonna benefit potentially from this treatment, but the kids who actually are, have greater social impairment to begin with might need that additional social coaching.

The last thing that we wanted to look at in this study was how parent assistance and parent attendance in these social coaching groups actually impacted treatment outcome.

We noticed very quickly that even though we invited all parents to come to the groups every week to learn about how to socially coach their kids not every parent came consistently and regularly.

So we wanted to look at how that parent attendance impact change outcome.

What we found was that the more regularly the parents attended those social coaching groups the better outcomes that their kids had particularly as related to the number of get togethers they were having kids whose parents came more frequently had more get togethers where they actually invited other people and get togethers but also were invited to get togethers by their peers which also says it shows a very nice social reciprocity.

We also found that things like internalizing was lessened or decreased as well, hyper activity decreased.

And those whose parents came more regularly to treatment as did problem behaviors.

Those also decreased more frequently when parents came more regularly to do social coaching groups.

And then this next study, we actually wanted to look at the long-term treatment outcomes of individuals who had gone through our parents assisted program.

Now, this is one of my favorite studies because I think it not only shows that the durability of these treatment gains can be maintained very nice they over time, but I think it highlights the importance of parents assistance in social skills training.

And what happened in this study was we were actually collecting data one to five years after treatment.

And we have potential pool of 82 participants who could actually participate in this study one to five years after treatment.

They all had to be under the age of 18.

And that was because we wanted to keep the sample kind of clean.

There's a lot of issues that come up as adolescents transitioning into adulthood.

So these were all a still adolescents under the age of 18, about potential pool of 82 participants 53, actually, to participate in the treatment.

So the 64% response rate that's pretty high when it comes to long-term followup assessment.

So the first thing we wanted to look at was, were there any significant differences between those who agreed to participate in this study and those who did not agree to participate in the study?

And what we found was there was no significant difference in terms of the treatment outcome from brief to posttest.

So that was good news.

The average age to follow up was about 17 and a half.

So these kids were roughly juniors in high school.

And the means to follow-up was about two and a half years after treatment.

Now in terms of the testing we had three testing time points test one was the pretest.

Test two was the post test immediately following treatment.

And test three was the one to five year followup.

And this is what we found.

And this is the social skills rating system by Gresham & Elliott, it's sort of considered to be the gold standard for assessing social skills.

Now, this is a scale that uses standard scores meaning that it has a mean of 100 and a standard deviation of 15 T1 here represents the pretest.

T2 is the posttest T3 is the followup.

What you'll notice is that when teens come into our program, they're sort of in a decreased range of social skills when they leave our program they're in the more average range of social skills.

And that maintains very nicely one to five years later if you look at the problem behaviors scale of the social skills rating system you'll see something similar high scores in this case are bad.

They actually indicate greater problem behaviors lower scores are better.

Fewer problem behaviors.

When our kids come to our program, they're at nearly the elevated stage or range of problem behaviors.

When they leave our program they experienced a little decrease they're in the more average range of problem behaviors.

And that decreases even further at one to five years following treatments.

If you look at the subscales of the same measure, the social skills rating system blue here represents the pretest.

Red is the posttest and green is the one to five after follow-up what you'll wanna notice is that everything is moving in the right direction.

Cooperation, assertion, empathy, self-control all going up and there's statistically significant internalizing externalizing all going down again statistically significance.

If you look at the scale, the social responsiveness scale which is again, an autism screening questionnaire higher scores represent greater social impairment and more autism symptoms lower scores show less impairment, fewer autism symptoms.

When our kids come into our program they're in the severe range of autism symptoms.

Now these are adolescents with autism without intellectual disabilities.

They have average to above average IQs, adequate language skills but they're still in the severe range of autism symptoms.

When they leave our program they're in the more mild moderate range.

And that maintains beautifully one to five years following the treatment.

If you look at the sub on the social responsiveness scale again, blue represents pretest, red is the posttest green is the follow-up.

Everything's moving in the right direction.

Social awareness, social cognition, social communication, social motivation even autistic mannerisms symptoms are going down over time.

And they're statistically significant.

If you look at the level of social engagement this isn't measured by the number of hosts to get together kids are having, blue here represents the parent report team represents the team report.

On average, when our kids come into our program they're having about to get together as a month and just think about what the typical developing team has in terms of number of get togethers in a weekend, it's probably gonna be closer to something like three or four get-togethers in a week.

Our kids aren't typically having about two get togethers in a month when they leave our program they're typically having anywhere from four to six get-togethers per month.

And that maintains very nicely one to five years later, all of these data are really not the normal social trajectory that you see for kids with autism.

How do we actually make sense of these findings?

I think this study truly highlights the importance of parents assistance.

The fact that parents are learning to be social coaches to their kids.

They're essentially continuing the program on long after they left the PEERS group.

And I think this really, again highlights the importance of putting parents in treatment.

What's so great about this last finding here is that when our families leave our program we actually give them suggestions about where to go from here or how to kind of move ahead.

One of the recommendations we give them is that they should have at least one get together a week moving forward and look at that one to five years later that's where they're essentially having, four get together a month, which essentially is one get together a week.

Finally, we also wanted to look at social skills knowledge and how that maintained over time.

This is essentially a showing us free tests social skills, knowledge to those tests.

And what it tells us is that the kids are learning the skills that we're actually teaching them in peers.

And even one to five years later they still remember at significant amounts of frequencies of the skills that we're actually teaching them.

So I think this again, highlights the importance of including parents in the intervention that continuing to use all the buzzwords of the buzz phrases, all the language that we develop in PEERS, and they're remembering these skills one to five years later.

So that's a little overview of some of the outcomes that you could expect using the PEERS program.

I also wanted to highlight some of the current research that we're doing.

We've actually partnered with a number of people around the world.

These are just a few of the research collaborators that we have one study that's of interest to many as a cross-cultural adaptation study using PEERS in South Korea.

And this was a study that was conducted at Seoul National University by Dr. Hee-Jeong Yoo.

And Dr. Yoo is actually not only translated the manual into Korean, but she actually conducted a beautiful randomized control trial with the Korean version of the peers manual and found very similar results.

I'm using this Korean version.

That's been cross-culturally addict adapted to a Korean population.

That paper was published in 2013 again, with various similar findings to what we see in American samples.

We also have partners at Caltech Dr. Ralph Adolphs is actually looking at pre comparisons of outcome following PEERS but using biomarkers of treatment outcome.

And so typically what he does in these studies is looks at things like eye tracking, as well as app MRI imaging studies looking at how the brain changes as a result of treatment, how neuro pathways are changed.

He's also looking at predictors of treatment outcome and seeing who's most likely to benefit from this this particular treatment again using biomarkers.

Our colleagues, Angela Scarpa and Susan White at Virginia Tech are also using the PEERS program quite a bit in their clinic there.

Not only for teens and adults with autism but also those with ADHD and traumatic brain injury.

We have our colleague Dr. Ofer Golan at Bar Ilan University in Israel is also conducting a cross-cultural validation trial using PEERS.

And this is where he's translated the manual into Hebrew and is conducting a randomized control trial with teens of ASD, and also doing some research with adults with autism, as well as preschoolers with autism using some different math programs that we've developed.

My colleague Dr. Amy Van Hecke at Marquette University has probably gone the furthest in replicating this research at Marquette.

She's not only published at several studies replicating the findings that we've achieved at UCLA where she's also actually found additional treatment gains in the areas of decreased social anxiety also decreased parenting stress.

And she's also established the very first biomarker treatment outcome using EEG technology where she actually saw changes in the social brain as a result of treatment.

So that's very exciting research that's being conducted really all across the globe.

And in terms of the current research we just completed a study looking at using PEERS with a virtual coach.

So we have a parent assistant model.

We have a teacher facilitated model but not all kids have a parent or a teacher that's around all the time to provide social coaching.

And it also may not be developmentally appropriate for these adults to be around all the time but most kids have an iPhone or a smartphone with them.

So the idea behind this study was to actually develop what is called a virtual coach essentially to provide coaching during real life social situations, where it's not possible for adults to be there to provide that coaching.

And this is involved the development of a mobile app called FriendMaker.

It's available to anyone in the App Store and it essentially provides the entire PEERS curriculum and an outline format with role play embedded videos in this FriendMaker app.

So imagine you have a kid who wants to go and join a conversation.

Can't really remember the steps for how to do that.

They can pull up their FriendMaker app, which acts as a virtual coach.

They can again be reminded of the steps that they're supposed to follow in that situation and actually enter that conversation.

So we just completed a study looking at the spiritual coach model.

And what we found was that in comparison to a delayed treatment control group and also a parent assisted program that was sort of treatment as usual, those adolescents who receive as additional virtual coaching actually had better outcomes than those who were just receiving treatment as usual for those who were not receiving treatment at all.

So that's kind of exciting.

Another research study that we're currently under actually investigating is PEERS for preschoolers.

So we just completed our first randomized control trial using this intervention.

Now this is a program that was designed for very young children from four to six years of age with autism.

And the idea behind this program is again to help our kids learn how to make and keep friends.

And we know early intervention is very, very important in autism, but unfortunately there's not a lot of social skills programs specifically targeting social skills for preschoolers with autism.

It's just an area that's unfortunately neglected.

And so we wanted to again, feel about all this service gap at research gap by developing this program that this is a 16 week manualized social skills intervention like all of our programs, we involve as additional social component, a coaching component.

So in this case it's a parent assisted program where parents are taught to be social coaches to their kids and essentially helped to expand their social world by getting kids involved in social groups organizing play dates for their kids and finding essentially playmates for their children.

The way that this works is there are concurrent parent and child sessions about making and keeping friends.

But the last 30 minutes of every group involves parent coach play.

This is where we actually bring parents into the treatment room with the kids.

And we organize sort of mock get togethers by setting kids up into little dyads.

And while these kids are having their little mock play dates we're actually having the parents coach their kids around their play skills.

And we as the treatment team are actually coaching the parents.

So this is PEERS for preschoolers.

In terms of resources, things that are actually accessible to anyone at this point we do have a couple of manuals treatment mails available to anyone wherever books are sold Amazon wherever this first manual was published in 2010, and this is our parents' assistance manual.

So this is a 14 week curriculum that includes weekly 90 minute teen and parent sessions.

It also includes parent handouts that are distributed and it's again focused on skills related to making and keeping friends and also handling peer rejection or peer conflict.

We have a similar program but this one was actually developed in the school setting.

So this is a teacher facilitated manual.

The curriculum was developed or published in 2014.

It's a 16 week curriculum with daily lesson plans.

So we're teaching social skills in the classroom, much like we would teach math or science or any other particular subject if teacher facilitated.

And so that teachers are actually providing the intervention rather than mental health professionals.

Again, we're focusing on skills related to making them keeping friends and also handling peer conflict and peer rejection.

Finally, we also have a parent book called "The Science of Making Friends" and "The Science of Making Friends" was written for parents or caregivers, even for adolescents and adults wanting to learn more about the skills related to making and keeping friends and also handling peer rejection and conflict.

So all of the skills that we teach in PEERS are actually in this book "The Science of Making Friends" everything's broken down into concrete parts again but ecologically valid skills and strategies.

What makes this program kind of nice is there's not only a parent narrative section that provides a social coaching tips but there's also teen and young adult chapter summaries that are intended to be read by the young person who is wanting to learn more about making and keeping friends.

But it's sort of in kid-friendly terms essentially.

At the end of every chapter there's chapter exercises these are essentially homework assignments to practice the newly learned skills.

And there's also a DVD companion that's intended to, to actually show role with my demonstrations of the skills that are being targeted.

So there's that only good examples of what to do, but also that examples of what not to do.

And the idea behind this DVD companion is that it's one thing to just, read about social skills.

It's a whole nother thing to actually see what it looks like in action.

This book also is used in companion with the FriendMaker app.

So that can also be another use of the virtual coach tool.

So this was some of the resources that we have related to the PEERS program with that.

I'll go ahead and wrap up and just leave with our contact information.

If you'd like more information about the PEERS program about the resources that we have available.

This is our contact information.

I'd also like to thank Shelley McLean and Autism in Education Partnership for hosting this webinar.

And I thank you all so much for your attention.