Potential study children were referred from two sources: parents calling the UCLA outpatient clinic inquiring about the social skills program for their child, or parents evaluated by UCLA CART, Assessment and Evaluation Core whose child met diagnostic criteria for an Autism Spectrum Disorder with significant social problems. Parents were sent a packet of questionnaires to complete which included the ASSQ, SSRS and QPQ. Upon meeting preliminary screening criteria, and after obtaining parent consent and child assent, clinic referred children were given a diagnostic evaluation by CART, which included the ADOS-G, ADI-R, VABS and the WISC-III.
Upon meeting inclusion criteria, children were randomly assigned to receive 12 weeks of CFT immediately or after a 12 week delay (DTC). Study children were randomized as the screening was completed, using an online random number generator from Random.org. After an evaluation to determine if they met study criteria a random number between 1 and 2 was generated for each participant. If the value was 1 the participant was assigned to the CFT group and if the value was 2 the participant was assigned to the DTC group.
A 2-group CFT vs. DTC longitudinal design was used. Children and their parents in the CFT Group completed outcome measures just prior to receiving the intervention (T1), the last night of the intervention (T2), and 12 weeks after the conclusion of the intervention (T3), while DTC children and their parents completed outcome measures upon entering the study (T1), 12 weeks after T1 just prior to starting the intervention (T2), and the last night of the intervention (T3). Children and parents completed assessment measures in the presence of the research team, while teachers were mailed assessment measures at each of the testing periods.
Treatment Content
The CFT manual was developed for the mixed clinical sample seen through the UCLA Children’s Friendship Program which, throughout its 18 year history, has included high functioning children with ASD. The treatment manual lists children with ASD as one of the common categories of children showing up for social skills training. Screening criteria 1–3 above were specifically developed to screen children with ASD who were likely to benefit from CFT.
The CFT manual is based upon research that has demonstrated that child and parent behaviors within certain critical situations discriminate socially accepted from rejected children. These critical situations are: (1) social network formation with the aid of the parent (Parke et al.
1994); (2) informational exchange which explores mutual interests with peers leading to common-ground activities (Black and Hazen
1990); (3) entry into a group of children already at play (Frankel
2005); (4) in-home play dates (Frankel
2010); and (5) conflict avoidance and negotiation (Rose and Asher
1999). The key features of CFT were taught through instruction on simple rules of social behavior; modeling, rehearsal, and performance feedback during treatment sessions; rehearsal at home; homework assignments; and coaching by parents during play with a peer (Elliot and Gresham
1993). The CFT manual has been successfully implemented for children between the ages of 6 and 12 years in multiple clinical contexts (Frankel and Myatt
2007; Frankel et al.
1997b; Frankel et al.
1999; O’Connor et al.
2006) and by clinicians with no connection to the present authors (Sim et al.
2006).
The CFT manual format (Frankel and Myatt
2003) reviewed the research base for the development of each module. It gave a step by step outline of how to run screening, intake, each treatment session and homework assignment of the intervention. It provided all necessary parent handouts and child session plans. It gave short vignettes of the effects of typical session components as well as many vignettes on common problematic encounters and suggested how group leaders should respond to these challenges. Two intake and 19 session vignettes presented in the manual specifically pertain to children with ASD.
CFT (and DTC children after T2) were integrated into classes being conducted by the UCLA Children’s Friendship Program, with no more than 4 children with ASD admitted to any class (class size was usually 10). The non-ASD children were seeking clinical treatment on a fee for service basis and also met the inclusion criteria 2 through 9. Chart diagnoses for these children were Adjustment Disorder (18.6%), ADHD (46.0%), ADHD and Oppositional Defiant Disorder (ODD, 2.7%), ODD alone (0.5%), Fetal Alcohol Spectrum Disorder (0.7%), anxiety disorder (4.9%), mood disorder (1.3%), learning disability (1.3%) and 25.2% had no diagnosis. The mixing of children with and without ASD was done to provide peers who were more typically developing and could offer realistic practice for the skills being taught, as the aim of the program was to integrate children with ASD into groups of typically developing peers. Each CFT class was composed of children separated by no more than one grade level. Study children were not identified in any way to other class participants.
Treatment was composed of 12 weekly sessions, of 60 min in length. Children and their parents were seen concurrently in separate locations (except for the finalization of the child’s homework assignment). Each child session (except for the first and last) was composed of four segments. During the first segment (10 min) children reported the results of the homework assignment given in the previous session. The second segment (20 min) consisted of a didactic presentation and brief, coached behavioral rehearsal between children. The third segment (25 min) consisted of coached play in which children practiced newly learned skills. In the fourth segment (5 min), parents and children were reunited and contracts for homework were finalized.
Formal parent sessions were held concurrently for the entire hour of all child sessions. Session 1 was devoted to parent orientation (with an accompanying handout) and arrangements for calling other class members to practice conversational skills. Sessions 2–11 were broken into four segments. During the first segment (15 min), the group leader reviewed parent and child performance on the previous socialization homework assignment. During the next segment (30 min), a parent handout was reviewed with the parents and relevant questions were answered. In the third segment (10 min), the next socialization homework assignment was presented and specific problems anticipated by the parent were discussed. During the last segment (5 min), parents and children were reunited and verbal contracts were made for completion of the next socialization homework assignment.
Children were taught conversational techniques (voice volume, smile, physical closeness) and were instructed on how to “play detective” as an information sharing and query technique with other class members in order to plan future play. They also rehearsed calling up another class member on the telephone. Children were instructed on good and bad times and places to make friends, how to watch a group of children in play in order to understand what the group was doing, and what the rules were to participate. They were also coached to make relevant comments or praise the children who were playing (e.g., “good shot”), and to join the play by “helping them play their game”. Children were cautioned not to ask questions, mention themselves or their feelings, disagree with, or criticize the children playing the game. Children were told to expect 50% rejection in their attempts to enter the playing groups. Reasons for rejection were discussed as well as what to do in each case. They were instructed on how to avoid criticizing others and to let others have fun (i.e., let them catch the ball too). Emphasis was placed on “helping others play” rather than “winning at all costs”. Techniques of persuasion and negotiation were taught to allow subjects to change activities when they lost interest.
The “rules for a good host”, were presented in order for children to avoid conflict on play dates: (a) The guest is always right (s/he gets to pick the games, take turns, etc.); (b) Praise the guest’s behavior (e.g., “nice try”, “great shot”); (c) No criticism of the guest; (d) If you’re bored, make a deal with the guest to change the game; and (e) Be loyal to your guest (play dates were to be with only one guest at a time, who was not to be left alone). Children were paired together to practice being a good host during pretend play dates (i.e., one was the “host” and one was the “guest” in each pair).
Children were taught to respond neutrally or humorously to teasing in the following manner: The group leader modeled how to “make fun of the teasing” so that the perpetrator was teased about their inability to tease well (e.g., “I’ve heard that one before”, “Tell me when you get to the funny part”). Subjects practiced “making fun of the teasing” in response to a structured teasing exercise from the group leader using benign teasing comments.
Socialization homework assignments were key to obtaining generalization. No assignment was made until its contents were practiced in the child sessions and presented within a handout to parents. The first segment of each parent session was especially critical as parents were asked to recount the events of the homework assignment for the previous week. Thus, after a play date homework assignment, parents described the major events of the play date. Any barriers to organizing a successful play date were discussed and suggestions were made to overcome these barriers.
Socialization homework assignments were as follows: (a) Children were to call another member of the class (at first, and in later sessions another child in their community with whom they wanted to be friends) in order to practice information sharing and query. During a CFT session, parents were to arrange the day and time of the call and at the appointed time, were to listen in on the call. (b) Children were instructed to bring a nonviolent, interactive toy from home to all sessions to be used during play activities. Group leaders inspected these toys for appropriateness prior to allowing them into the child session. (c) Children were to practice joining a group of children at play in their local community. In order to increase their chances of gaining entry, they were encouraged to approach slightly younger children with whom they were unfamiliar. Parents were to help their child decide where and when this would be attempted. The parent was instructed to let the child try this by him/herself as unobtrusively as possible. (d) Parents were provided with a handout listing the specific steps to organizing and implementing a play date (Frankel and Myatt
2003, p.132). The first step was to agree on a potential play mate they would like to invite over to their home for 1–2 h. Social contacts with class members outside the class were prohibited, so that this potential play mate had to be a child who was not a member of the CFT intervention. The study child was to call this child and “play detective” in order to generate a list of possible games to play. The parent was to check with the invited child’s parent to arrange the date, time and length of the play date. During the play date, the parent was to listen for violations of any good host rule and to step in and remind their child of these rules when they were broken. (e) Children were to practice “making fun of the teasing” with a child who was teasing them. (f) The final session included a handout on maintenance of treatment gains which focused upon maintaining weekly one-on-one play dates with other children.