Evidence-Based Social Communication Interventions for Children with Autism Spectrum Disorder

Transcription

1 Indian J Pediatr (January 2017) 84(1):68 75 DOI /s REVIEW ARTICLE Evidence-Based Social Communication Interventions for Children with Autism Spectrum Disorder Laci Watkins 1 & Michelle Kuhn 1 & Katherine Ledbetter-Cho 1 & Cindy Gevarter 1 & Mark O Reilly 1 Received: 29 June 2015 /Accepted: 21 October 2015 /Published online: 19 November 2015 # Dr. K C Chaudhuri Foundation 2015 Abstract Impairments in social communication skills are a core feature of autism spectrum disorder (ASD) and include deficits in social-emotional reciprocity, non-verbal communicative behaviors used for social interaction, and developing, maintaining, and understanding relationships. In order to improve outcomes for children with ASD, much research has been focused on developing effective interventions to treat these social communication deficits. The purpose of this paper is to highlight the evidence-based practices found within the intervention literature that specifically targets social communication impairments and provide an overview of these strategies. Four relevant themes regarding evidence-based social communication interventions are considered and discussed: (a) social communication outcomes and practices relevant to different stages of development, (b) practices that both reduce interfering behaviors and improve social communication skills, (c) practices that utilize an eclectic combination of intervention strategies, and (d) considerations for practice and research. Keywords Autism spectrum disorder. Social communication skills. Evidence-based practice Introduction The earliest descriptions of autism spectrum disorder (ASD) included impairments in social and communication skills [1, * Laci Watkins lbwatkins@gmail.com; lbwatkins@utexas.edu 1 Department of Special Education, The University of Texas at Austin, 1912 Speedway, D5300, Austin, TX 78712, USA 2] and deficits in these skills remain central to the diagnostic definition of the disorder. With the advent of the fifth edition of The Diagnostic and Statistical Manual of Mental Disorders, social and communication impairments were combined into one domain in recognition that socialization is inherently linked to the development of communication skills. According to the diagnostic criteria, social communication difficulties become apparent in early childhood and consist of deficits in social-emotional reciprocity, non-verbal communicative behaviors used for social interaction, and developing, maintaining, and understanding relationships [3]. Social communication impairments can encompass a variety of skills. Deficits in social-emotional reciprocity may include abnormal social approach and failure of normal backand-forth conversation; reduced sharing of interests, emotions, or affect; and/or failure to initiate or respond to social interactions [3]. Deficits in nonverbal communicative behaviors used for social interaction can include poorly integrated verbal and nonverbal communication, abnormalities in eye contact and body language, deficits in understanding and use of gestures, and/or a total lack of facial expressions and nonverbal communication [3]. Deficits in social relationships can range from difficulties in adjusting behavior to suit various social contexts, to difficulties in sharing imaginative play or in making friends, to absence of interest in peers [3]. Intervening early to treat these impairments is vital, and social communication skills are often cited as top treatment concerns for children with ASD [4, 5]. Successfully treating these impairments may lead to better short and long-term outcomes as well as contribute to an overall improved quality of life. Fortunately, many interventions for children with ASD can be found in the literature. As the prevalence of ASD has increased, so too has research on the development of effective interventions for individuals with ASD [6].

2 Indian J Pediatr (January 2017) 84(1): Efforts have been made to identify interventions that have sufficient empirical support to be considered evidence-based practices (EBPs). The National Standards Project (NSP) [7] and the National Professional Development Center on Autism Spectrum Disorders (NPDC) [8] each conducted comprehensive reviews of the literature to identify focused intervention strategies (i.e., those that address a specific skill or goal) for individuals with ASD that have adequate support to be considered evidence-based. Wong and colleagues recently extended and broadened the findings of previous reviews by conducting a systematic review of the intervention literature from [9]. In order to qualify as an EBP, an intervention had to be supported by at least two high quality experimental or quasi-experimental group, or at least five high quality single subject, or a combination of at least one high quality experimental or quasiexperimental group design study and at least three high quality single subject [9]. The latter review identified 27 focused intervention strategies that had sufficient evidence to be considered an EBP [9]. Of the practices that Wong and colleagues identified as evidence-based, 24 intervention strategies improved social communication outcomes for children with ASD [9]. From this corpus of research, the authors compiled findings to highlight which EBPs specifically targeted social communication impairments (i.e., deficits in social-emotional reciprocity, nonverbal communicative behaviors used for social interaction, and developing, maintaining, and understanding relationships) as described by the diagnostic criteria in the DSM-5 [3]. The authors offered a concise overview of each intervention strategy, provided the age groups for whom the EBP has been effective, listed the commonly occurring social communication outcomes targeted by each intervention, and provided the number of studies supporting each intervention strategy. From these findings, presented in Table 1, four relevant themes regarding evidence-based social communication interventions are considered and discussed: (a) social communication outcomes and practices relevant to different stages of development, (b) practices that both reduce interfering behaviors and improve social communication skills, (c) practices that utilize an eclectic combination of intervention strategies, and (d) considerations for practice and research. Social Communication Interventions Across Stages of Development SeveralEBPsthathaveimprovedsocialcommunicationskills are recommended for children of all ages. These include antecedent-based interventions, modeling, prompting, reinforcement, video modeling, and visual supports (see Table 1 for descriptions of EBPs). These practices are effective for toddlers (0 2 y), preschoolers (3 5 y),elementaryschool age learners (6 11 y), middle school age learners (12 14 y), and high school age learners (15 18 y). Compared to EBPs for older children, relatively fewer social communication treatments for toddler age children have sufficient support to be considered evidence-based. This finding is unsurprising considering the average age of diagnosis for ASD is 4-y-old, even though a diagnosis as early as age 2 can be reliable, valid, and stable [10]. In addition to those practices effective for children of all ages, naturalistic interventions, parent-implemented interventions, and pivotal response training have all resulted in improvements in social communication skills for this age group. Frequent outcomes for toddlers included nonverbal communicative behaviors such as joint attention skills (i.e., the shared focus of two individuals on an object or event) and functional play skills (i.e., playing with a toy or object according to its intended function). For example, Kasari and colleagues targeted both these skills using a parent-implemented intervention in which caregivers were taught a series of behavioral strategies based on the principles of applied behavior analysis (ABA) to improve joint engagement, which resulted in increases in the children s responsiveness to joint attention and diversity of functional play skills [11]. Twenty EPBs for improving social communication skills exist for preschoolers. Along with improvements in play skills and joint attention skills, social-emotional reciprocity skills were also common targeted outcomes. Frequently employed EBPs for this age group included behavioral, naturalistic, and peer-mediated interventions, often times used in combination. For instance, teachers used naturalistic behavioral strategies to stimulate a child s interest in social activities as well as to facilitate the child s social interaction and communication with classmates [12]. Researchers also frequently used prompting and reinforcement behavioral strategies to teach social interaction to young children with ASD [13, 14]. Instructors often used prompting in the form of expectant waiting, or material placement and environmental arrangements. Researchers used reinforcement both through granting access to desired materials and social reactions. When delivered immediately after a social interaction behavior was exhibited, this strategy helped produce increasing numbers of subsequent social interactions [13, 14]. Twenty-four EBPs targeted social communication skills for elementary school age children, constituting the largest evidence base overall. Behavioral, peer-mediated intervention and instruction, social narratives, visual supports, and video modeling were frequently used for this age group, with socialemotional reciprocity and social relationship skills regularly targeted outcomes. In particular, social behaviors needed for school success (e.g., following rules and complying with teacher requests, demonstrating appropriate classroom conduct, and engaging in prosocial behaviors) were target behaviors for many interventions. For instance, Chan and O Reilly

3 70 Indian J Pediatr (January 2017) 84(1):68 75 Table 1 Summary of evidence based social communication interventions for children with ASD [9] Evidence-Based Interventions Ages Intervention description Social communication outcomes Evidence base Antecedent-Based Intervention Toddlers, preschool, elementary school, Variety of modifications that are made to the environment or context in an attempt to change or shape a learner s behavior Cognitive Behavioral Intervention Elementary school, high school Learners are taught to examine their own thoughts and emotions, recognize when negative thoughts and emotions are escalating in intensity, and then use strategies to change their thinking and behavior Differential Reinforcement of Alternative, Incompatible, or Other Behavior Preschool, elementary school, Reinforcement is provided for desired behaviors, while inappropriate behaviors are ignored Discrete Trial Training Preschool, elementary school One-to-one instructional approach used to teach skills in a planned, controlled, and systematic manner Functional Communication Training Preschool, elementary school, Modeling Toddlers, preschool, elementary school, Systematic practice to replace inappropriate behavior or subtle communicative acts with more appropriate and effective communicative behaviors or skills Demonstration of a desired target behavior that results in imitation of the behavior by the learner and that leads to the acquisition of the imitated behavior Naturalistic Intervention Toddlers, preschool, elementary school Collection of practices including environmental arrangement, interaction techniques, and strategies based on applied behavior analysis principles designed to encourage specific target behaviors based on learners interests by building more complex skills that are naturally reinforcing and appropriate to the interaction Parent-Implemented Intervention Toddlers, preschool, elementary school Parents directly use individualized intervention practices with their child to increase positive learning opportunities and acquisition of important skills Peer-Mediated Instruction and Intervention Picture Exchange Communication System Preschool, elementary school, middle school, high school Preschool, elementary school, middle school Pivotal Response Training Toddlers, preschool, elementary school, middle school Prompting Toddlers, preschool, elementary school, Reinforcement Toddlers, preschool, elementary school, Response Interruption/ Redirection (RI/R) Preschool, elementary school, Typically developing peers are taught ways to interact with and help learners with ASD acquire new social skills by increasing social opportunities within natural environments Learners are taught to give a picture of a desired item to a communicative partner in exchange for the item Naturalistic intervention based on the principles of applied behavior analysis that uses learner initiative and interests to improve motivation, responding to multiple cues, self-management, and self-initiations of social interactions Verbal, gestural, or physical assistance is given to learners to assist them in acquiring or engaging in a targeted behavior or skill A consequence that increases the probability that a behavior will occur in the future, or at least be maintained, is delivered contingent upon demonstration of a specific learner behavior Introduction of a prompt, comment, or other distractors when an interfering behavior is Reduction of interfering or challenging behaviors and increase in communication, play, initiations, and language skills Reduction of problem behaviors related to specific emotions (e.g., anger or anxiety), and increase in emotion recognition and emotional regulation Reduction of interfering or challenging behaviors and increase in pro social behavior, communication and language skills Increase in joint attention, imitation, symbolic play, perspective-taking, answering questions, responses, requests, labeling emotions, and expressive language Reduction of interfering behaviors and subtle, less-clear communicative forms with clearer language or communicative forms Increase in joint attention, play skills, language, initiations, empathy, and social engagement Increase in joint attention, turn-taking, speech intelligibility, use of gesture, requesting, expressive language, social phrases, and social interaction Increase in joint attention, conversation skills, social interaction, spontaneous language, use of augmentative and alternative communication, and play skills Increase in initiations, responding, conversational reciprocity, empathy, social engagement, and social interaction Increase in requesting, communicative interaction, social functioning, and play skills Increase in joint attention, imitation, verbal communication, social interaction, and symbolic play skills Increase in joint attention, verbal and nonverbal communication, initiations, requesting, asking questions, emotion recognition, and pretend play skills Increase in joint attention, imitation, play skills, seeking assistance, social interaction, initiations, responses, and requesting Reduction of vocal stereotypy and increase in social, communication, and play skills 32 single case 3 group design and 1 single case 26 single case 13 single case 12 single case 1 group design and 4 single case 10 single case 8 group design and 12 single case 15 single case 2 group design and 4 single case 1 group design and 7 single case 1 group design and 32 single case 43 single case 10 single case

4 Indian J Pediatr (January 2017) 84(1): Table 1 (continued) Evidence-Based Interventions Ages Intervention description Social communication outcomes Evidence base Scripting Preschool, elementary school, Self-Management Preschool, elementary school, Social Narratives Preschool, elementary school, Social Skills Training Preschool, elementary school, occurring that is designed to divert the learner s attention away from the interfering behavior and results in its reduction Presenting learners with a verbal and/or written description about a specific skill or situation that serves as a model for the learner Learners are taught to discriminate between appropriate and inappropriate behaviors, accurately monitor and record their own behaviors, and reward themselves for behaving appropriately Stories or narratives that describe social situations in some detail by highlighting relevant cues and offering examples of appropriate responding Group or individual instruction designed to teach learners to appropriately interact with typically developing peers Structured Play Groups Elementary school Small group skill instruction with typically developing peers characterized by occurrences in a defined area and with a defined activity, clear delineation of theme and roles by adult leading the group, and prompting or scaffolding as needed to support the students performance related to the goals of the activity to appropriately interact with typically developing peers Task Analysis Preschool, elementary school, middle school Technology-Aided Instruction and Intervention Preschool, elementary school, Time Delay Preschool, elementary school, Video Modeling Toddlers, preschool, elementary school, Visual Supports Toddlers, preschool, elementary school, Complex behavioral skills are broken into smaller, more manageable steps in order to teach the skill Electronic devices, such as speech-generating devices, smart phones, tablets, computed-assisted instructional programs, and virtual networks, used to support the goal or outcome of the learner Practice that focuses on fading the use of prompts during instructional activities Mode of teaching that uses video recording and display equipment to provide the learner with a visual model of a targeted behavior or skill Concrete cues presented visually that provide information about an activity, routine, or expectation and/or support skill demonstration Increase in joint attention, play skills, verbal communication, conversational speech, requesting, initiations, and social interaction Reduction of interfering behaviors and increase in social communication skills such as giving compliments, responding, initiating interactions, play skills, and conversing with others Reduction of interfering behaviors and increase in social interaction, social engagement, socially appropriate behaviors, choice-making, expressive language, and play skills Increase in perspective-taking, conversation skills, friendship skills, problem-solving, social competence, emotion recognition, theory of mind, and problem-solving Reduction of interfering behaviors and increase in joint attention, language, collaborative problem-solving, sharing, turn-taking, social interaction, and play skills Increase in responses to joint attention initiations, social interaction, play skills, and social engagement Increase in joint attention, initiations, requesting, expressive language, conversation skills, and emotion recognition Increase in joint attention, imitation, initiations, requesting, verbal communication, manual signs, and social play skills Increase in complimenting behaviors, imitation, play sequences, conversation skills, initiations, responses, requesting, social language, helping behaviors, sharing, and perspective taking Increase in play skills, verbal communication, social interaction, social engagement, and initiations 1 group design and 8 single case 10 single case 17 single case 7 group design and 8 single case 2 group design and 2 single case 8 single case 9 group design and 11 single case 12 single case 1 group design and 31 single case 18 single case

5 72 Indian J Pediatr (January 2017) 84(1):68 75 improved behaviors such as appropriate initiations and hand raising during instructional activities using social narratives and behavioral role-playing strategies [15]. Similarly, a video modeling intervention that also utilized prompting and reinforcement strategies resulted in increases in helping behaviors (e.g., sharing toys, snacks, and other materials) at school for three children with ASD [16]. Researchers increased peer interaction through strategies such as training peers to initiate play with children with ASD [17], using a tactile prompting device (i.e., a vibrating pager) to prompt children with ASD to initiate to peers [18], and employing visual strategies and script training procedures to reduce perseverative speech and increase social statements made to peers [19]. Nineteen EBPs and 16 EBPs exist for adolescents in middle school and high school, respectively. Behavioral, peermediated intervention and instruction, self-management, and visual cue strategies were regularly used to treat social communication impairments, with a focus mostly on socialemotional reciprocity and social relationship skills with peers. This focus on peer interaction in the intervention literature reflects the increased amount of time adolescents typically spend with their peer group during this developmental phase. To both improve social interaction with peers and promote academic engagement, Carter and colleagues trained multiple middle and high school age, typically developing peers to adapt activities to allow students with ASD participate in class, provide feedback to students, and prompt students interaction with other classmates [20]. Similarly, Koegel and Frea demonstrated that teaching social behaviors using behavioral strategies including pivotal response training and selfmanagement produced improvements in social behaviors and social interaction in two adolescents with ASD [21]. Self-management and self-reinforcement procedures also resulted in an increase in the number of relevant statements and questions used during conversation for three adolescents with ASD [22]. Practices that Reduce Interfering Behaviors and Improve Social Communication Skills Children with ASD may use challenging behaviors (e.g., stereotypy, aggression, tantrums, property destruction, self-injury, echolalia) to communicate [23, 24], and research suggests that % of challenging behavior may have a communicative function [25, 26]. For this reason, interventions focused on reducing challenging or interfering behaviors and teaching functionally equivalent replacement behaviors that provide an appropriate means of communication are vital for a significant number of children with ASD. Outcomes for eight of the 24 evidence-based social communication interventions reported both a reduction in challenging or interfering behaviors and produced an increase in appropriate social communication skills. These EBPs include antecedent-based interventions, cognitive behavioral interventions, differential reinforcement of alternative/incompatible/ other behavior, functional communication training, response interruption/redirection, self-management, social narrative, and structured play groups. Before implementation, these interventions are often preceded by strategies such as functional behavior assessments (FBA) or functional analyses (FA) in order to determine the function or purpose of the challenging behavior. Although an FBA or FA does not intervene directly on behavior, the use of such procedures is oftentimes a necessary precursor in order to develop effective social communication interventions. Antecedent-based interventions, differential reinforcement, functional communication training, response interruption, and self-management have the most overall evidence of efficacy in reducing challenging behaviors and improving appropriate social communicative behaviors. Several studies have sought to decrease socially inappropriate behaviors and replace them with more socially acceptable alternative behaviors. For example, Carter utilized an antecedent-based intervention in which children exhibiting disruptive behaviors, a lack of engagement in social play, and a lack of expressive language were offered a choice in which game to play during therapy sessions [27]. When choice was offered prior to the therapy session, disruptive behaviors reduced considerably and social play and pragmatic language skills increased [27]. Using differential reinforcement and corrective feedback procedures, Hagopian and colleagues reduced the attention-maintained inappropriate behaviors (e.g., inappropriate comments, social withdrawal, and inappropriate touching of others) of an adolescent by providing edible reinforcers when problem behaviors were not exhibited as well as corrective feedback when inappropriate behaviors were present [28]. These procedures resulted in a decrease in inappropriate behaviors and an increase in appropriate solicitations of attention and interactions with others [28]. Similarly, Koegel and colleagues demonstrated that teaching children to self-monitor their responsivity to social initiations from others in school, home, and community settings resulted in a concomitant reduction of disruptive behaviors [29]. Severe challenging behavior and stereotypic behavior can be resistant to treatment. Functional communication training (FCT) [30] and response interruption/redirection interventions have been especially effective in treating these behaviors and teaching appropriate communication skills [31]. For example, after conducting an FBA and FA to determine the function of challenging behaviors (e.g., elopement, screaming, hitting, and biting) exhibited by a child with ASD, Olive and colleagues examined the effects of using FCT procedures to teach the child to use an augmentative and alternative communication device to request her mother s attention[32]. Implementation of FCT resulted in a decrease in challenging behavior,

6 Indian J Pediatr (January 2017) 84(1): an increase in requesting communicative behaviors, and an increase in correct pronoun use when speaking [32]. Ahearn and colleagues used response redirection/interruption to reduce vocal stereotypy in students with ASD [33]. When vocal stereotypy was present, a teacher verbally directed a previously mastered demand to the student, thus redirecting the behavior and resulting in a reduction of vocal stereotypy as well as an increase in appropriate communication [33]. From the literature, it is evident that children with ASD can be taught communication skills that are more efficient and effective than challenging behaviors. Using these EBPs to replace challenging or interfering behaviors with appropriate forms of social communication can potentially aid in behavior management across school, home, and community settings, as well improve outcomes in academic achievement, relationship development, and vocational prospects [23]. Combined Intervention Approaches Interventions based on the principles of applied behavior analysis have by far the most support among the studies identified by Wong and colleagues as evidence-based [9]. Specifically, studies using the behavioral strategies of prompting and reinforcement have considerable support in the literature. Whether used in isolation or in combination with another EBP, prompting, reinforcement, and other foundational behavioral strategies should be considered important components of social communication interventions for children with ASD. Regardless of intervention type, however, almost all of the strategies identified as evidence-based were used in combination with other practices. For example, Beaumont and Sofronoff improved the emotion-regulation and social competency of children with ASD through a social skills training intervention that utilized behavioral principles such as role-play, verbal prompting, and tangible reinforcement, as well as technology-aided instruction and parent training components [34]. Similarly, Leaf and colleagues improved the conversation, play, and emotional skills of children with ASD through a social skills group that utilized priming and a teaching interaction procedure with behavioral components (e.g., prompting, modeling, role-play, and reinforcement) [35]. While both these studies utilized a social skills training intervention, they employed unique combinations of EBPs not found in other interventions. This unique combination of treatment components is representative of many interventions in the evidence base. Odom and colleagues have described this systematic use of multiple focused intervention strategies as a Btechnical eclectic^ approach, meaning that a combination of interventions were used to target a specific outcome [36]. Experts in the field have suggested that combining and systematically applying focused evidence-based interventions may be an optimal approach to designing treatment programs that are individualized based upon the needs of the child [9, 36, 37]. Given the variation of characteristics that exist in children with ASD, this approach seems to be a promising way to target individual social communication needs and produce potentially robust clinical effects. The multi-component nature of these interventions potentially makes it difficult to distinguish precisely which treatments or combinations of treatments result in favorable outcomes, and future research that refines interventions by identifying the active components and eliminating superfluous ones would seem warranted [23]. In order for the technical eclectic approach to be most effective, programming should be planned around individual needs, informed by the use of EBPs, focused on program quality, and appropriately implemented with fidelity [36]. When correctly and systematically applied, this approach allows researchers and practitioners to design comprehensive treatments utilizing focused evidencebased strategies that meet the varied needs of children with ASD. Considerations for Practice and Research As is evident from the results of Wong and colleague s comprehensive review of the literature [9], there are a number of evidence-based interventions available that teachers, parents, and other service providers can use to inform their practice. However, no single intervention has been identified as effective in improving social communication skills for every child with ASD, and practitioners must use their clinical expertise when designing a treatment plan. As demonstrated by studies in the evidence base, the most beneficial treatment may involve the combination of several empirically validated approaches. Regardless of the EBPs employed, it is essential that interventions are individualized according to the child s need and marked by ongoing assessment of goals and outcomes in order to determine the success of the treatment [38]. Instructors should consider the particular characteristics (e.g., developmental stage, interfering behaviors, existing skills, preferences, etc.) of the child when selecting which EBPs to implement. In addition, instructors also need to consider their ability to utilize a certain approach and the feasibility of implementing the intervention in the instructional setting before developing a comprehensive treatment plan [9]. Identifying for whom a certain intervention approach is effective has been an ongoing concern for future research because children with different levels of functioning may require different intervention goals, procedures, and outcomes. To exemplify, social skills research has typically included a majority of participants with medium and high cognitive functioning levels (i.e., aniqof55 85 and rudimentary

7 74 Indian J Pediatr (January 2017) 84(1):68 75 communication skills, and an IQ>85 and well developed verbal communication, respectively), and it is unknown if the positive outcomes reported in the literature will be effectively replicated with lower functioning participants [39]. Therefore, future studies should examine the potential of using different EBPs based upon a particular participant profile in order to better determine for whom certain strategies will be most efficient and effective in improving social communication outcomes [40]. Similarly, it also apparent from the literature that future research concerning social communication interventions should include participants with a wider range of ages. There is considerable support for a variety of EBPs for elementary school age learners, and research involving this population can provide valuable guidance in developing social skill interventions for other age groups. However, as the social communication skills and outcomes targeted may vary according to the child s developmental stage, research is needed to determine if other EBPs can be successfully applied to younger and older children. The expansion of the age ranges included in interventions has been consistently identified as a need for future research [9, 39]. Finally, future research that examines the effectiveness of applying evidence based interventions to more complex social communication skills and skill sequences seems warranted. Outcomes of the studies included in the evidence base often focus on more simplistic or foundational behaviors such as requesting, initiating, responding, and maintaining social engagement. While these are certainly important skills, research that also focuses on interventions targeting more complex behaviors seems a logical next step. Similarly, future research should also address whether these interventions bring about the sort of overarching and long-term changes that are important in the lives of children with ASD. For example, results that indicate an EBP has improved a child s social reciprocity skills do not necessarily indicate that the child s peer relationships have also improved. Thus, closer examination of how the application of EBPs to treat social communication deficits in children with ASD may also influence these kinds of important collateral outcomes is needed. Conclusions As social communication deficits represent a core feature of ASD (APA, 2013), it is imperative that appropriate interventions are identified to target improvement of these skills. Although the evidence base of EBPs supporting increases in social communication skills is substantial, it is important to note that effective intervention strategies are selected based on a variety of factors including the child s age and desired outcome, and treatment success is dependent on fidelity of implementation and ongoing monitoring of progress. Of the EBPs identified by Wong and colleagues [9], no independent strategy was found to be successful across all measures, highlighting the importance of matching appropriate strategies or combinations of strategies to the individual. Moreover, the most effective approach for improving social communication skills and reducing interfering behaviors may be the systematic application of multiple EBPs based upon individual characteristics [9, 36]. Additionally, with different stages of development requiring various social communication needs (e.g., play in early childhood, peer relationships in middle and high school, etc.) an awareness of developmentally-appropriate targeted outcomes is essential. The increasing empirical evidence for various interventions, however, provides both a strong knowledge base and confidence in the ability to assist individuals with ASD in meeting goals created to improve these skills. Acknowledgments The authors would like to thank their colleagues at the University of Texas at Austin for their careful reading and insightful feedback of this work. Contributions LW, MK, and KLC wrote the initial draft. CG and MOR revised and reviewed the draft. LW will act as guarantor for this paper. Conflict of Interest Source of Funding References None. None. 1. Kanner L. Autistic disturbances of affective contact. Washington: Winston; Asperger H. Autistic psychopathy in childhood. In: Frith U, editor. 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