Using Technology-Based Interventions to Improve the Social-Communication Skills of Adolescents with Autism Spectrum Disorder (ASD)

Dr. Nicole Anthony

Dr. Cynthia Wooten

 

Fayetteville State University

This issue of NASET’s Autism Spectrum Disorder series comes from the Fall 2021 edition of the Journal of the American Academy of Special Education Professionals (JAASEP). It was written by Dr. Nicole Anthony and Dr. Cynthia Wooten from Fayetville State University. For more than two decades, researchers have used technology-based interventions to treat symptoms associated with autism spectrum disorder (ASD). Drawing on a preference for technology-driven devices, many advances have been made in the research and treatment of  ASD; however, the overwhelming majority of the technology-based interventions are used to address the social-communication challenges of children with ASD under the age of 10 years-old. Thus, the literature review aims to: (a) identify and examine studies that have used technology-based interventions over the past 30 years to improve the social-communication abilities of adolescents with ASD; (b) summarize findings of relevant variables (e.g., participant demographics, experimental setting, and technology-based strategies used to deliver the intervention); and (c) based on reported empirical outcomes, it will be determined, if technology-based interventions are effective in improving the social-communication skills of adolescents with ASD. Results of the current review indicated that technology-based are effective when used to address the social-communication skills of adolescents with ASD. Implications for future research are discussed.

Abstract

For more than two decades, researchers have used technology-based interventions to treat symptoms associated with autism spectrum disorder (ASD). Drawing on a preference for technology-driven devices, many advances have been made in the research and treatment of  ASD; however, the overwhelming majority of the technology-based interventions are used to address the social-communication challenges of children with ASD under the age of 10 years-old. Thus, the literature review aims to: (a) identify and examine studies that have used technology-based interventions over the past 30 years to improve the social-communication abilities of adolescents with ASD; (b) summarize findings of relevant variables (e.g., participant demographics, experimental setting, and technology-based strategies used to deliver the intervention); and (c) based on reported empirical outcomes, it will be determined, if technology-based interventions are effective in improving the social-communication skills of adolescents with ASD. Results of the current review indicated that technology-based are effective when used to address the social-communication skills of adolescents with ASD. Implications for future research are discussed.

Keywords: Autism, ASD, adolescents, social-communication, technology

Using Technology-Based Interventions to Improve the Social-Communication Skills of Adolescents with Autism Spectrum Disorder (ASD)

Autism Spectrum Disorder (ASD) impacts how a person behaves, communicates, and socializes (American Psychiatric Association [APA], 2013). The complexities of an ASD diagnosis are unique to each individual, and for the most part, based on the severity of the symptoms and existing co-conditions (Klinger, Dawson, Barnes, & Crisler, 2014). For instance, some children with ASD are nonverbal, and others converse using sophisticated language (Fodstad, Matson, Hess, & Neal, 2009). When faced with joint bids for attention, some children with ASD may engage in self-stimulating behaviors such as hand flapping, rocking back and forth, or spinning while others engage in escape behaviors (Rudy, Betz, Malone, Henry, & Chong, 2014). Although these idiosyncratic behaviors fluctuate from one individual with ASD, social-communication impairment is a defining feature of the disorder (Kennedy & Adolphs, 2012; Reed, Hyman, & Hirst, 2011).

As early as preschool, children with ASD demonstrate social-communication challenges that distinguish them from their typical peers. In comparison to same age preschoolers, children with ASD vocalize less, engage in solitary play more often, and gravitate toward adults instead of playmates (Fodstad et al., 2009).  Once children with ASD enter elementary school, they have an arduous time interacting with their peers due to the inability to capture the subtle nuances of the conversations around them (Rao, Beidel, & Murray, 2008). As the demands for social interaction increase in middle and high school, even for adolescents with ASD who develop strong functional language skills, challenges persist in conversing with others (Kim et al., 2013). For example, common challenges in social-communication skills include issues with initiating  interactions, difficulties with maintaining eye contact, managing turn-taking and topics of discussion, responding to peers in an appropriate manner, and not fully understanding the perspective of others (Daniel & Billingsley, 2010; Kennedy & Adolphs, 2012; Qi et al., 2018). For example, Daniel and Billingsley (2010) found that in a sample of 10-14-year olds with ASD, all participants attributed their lack of peer interactions to not wanting to initiate contact. Ultimately, lack of social interactions can exacerbate the possibility of being socially isolated, rejected by peers, and bullied (Kagohara et al., 2013a). If not remediated, impairments in social-communication skills can negatively impact future outcomes for adults with ASD.

In a critical review of empirical studies that examined social outcomes for adults with ASD, Levy and Perry (2011) reported that even in adulthood, parents of individuals with ASD initiated and orchestrated social interactions for their children due to the lack of initiative on their part. This lack of initiative by adults with ASD may affect familial bonds, independent living, and community relationships (Levy & Perry, 2011). While 86% of typical peers live independently in adulthood, only 4% of adults with ASD develop the social-communication skills necessary to accomplish this task (Levy & Perry, 2011). Additionally, after analyzing NLTD-2, Shattuck et al. (2012) found that 50% of young people with ASD who left high school did not participate in employment or postsecondary education more than two years after graduation. Furthermore, young people with an ASD had the lowest rates of participation in employment and the highest rates of no participation compared with youth in other disability categories (Shattuck et al., 2012). These findings suggest there is a need for effective interventions to address the social-communication challenges experienced by adolescents with ASD; however, researchers have focused less on this age group, with research studies predominately including preschool- and elementary-age children as participants (Odom et al., 2015; Wong et al., 2014). The enigmatic nature of ASD produces challenges for professionals in the field to elucidate effective, unobtrusive, socially acceptable strategies that can address social-communication skills. Fortunately, because of the nature of current trends in socialization and communication among adolescents with ASD, technology-based interventions could possibly fill this void.     

Technology and Adolescents with ASD

For more than two decades, technology has taken a more prominent role in research and treatments related to ASD (Mazurek, 2013). With the introduction of computer laptops, iPods, iPads, and iPod Nanos, and virtual reality systems, technology-based interventions are more accessible and socially acceptable than cumbersome traditional intervention methods like book bound social stories or picture exchange communication systems (Kim et al., 2013; Mazurek, 2013). Technology-based interventions have emerged as tools that can potentially lead to more effective evidence-based practices and an improved quality of life for individuals with ASD (Bolte et al, 2010; Ploog, Scharf, Nelson, & Brooks, 2013). Many researchers have suggested potential reasons why technology-based interventions may be particularly effective (Kuo et al., 2014; Mazurek, Shattuck, Wagner, & Cooper, 2012; Odom et al., 2015; Shane & Albert, 2008). For example, Mazurek et al., (2012) found that among a sample of 920 children and adolescents with ASD, 64.2% of the individuals surveyed spent most of their time engaging in screen-based activities (e.g., T.V, videos, and electronic or video games). Moreover, when compared to other disability categories (speech/language impairment, learning disabilities, intellectual disabilities), the rate of nonsocial-media use was higher among the ASD group (Mazurek et al., 2012). In a similar study, Kuo et al. (2014) surveyed 91 adolescents with ASD found that 78% of the adolescents with ASD watched television approximately two hours a day, and 98% used computers approximately five hours on any given day. Shane and Albert (2008) suggested visual presentation of information is a more desirable form of learning and support for many adolescents with ASD.

Purpose of the Study

Due to adolescents’ with ASD preference for technology-based devices and given the need for the development of appropriate social- communication skills, the purpose of this literature review is two-fold. First, the review of the literature will identify and examine studies that have used technology-based strategies from 1990-2020 to improve the social-communication skills of adolescents with ASD. Second, the authors will summarize findings of relevant variables (e.g., participant demographics, experimental setting, and technology-based strategies used to deliver the intervention). Specifically, the review of the literature will answer the question, “Are technology-based interventions effective when used to improve the social-communication skills of adolescents with ASD?”

Method

Search procedures

Studies included in this review of the literature were located by conducting a search of peer reviewed journal articles published between 1990 to 2020 utilizing ERIC, EBSCO Host, and PsyInfo databases. Search terms included autism, autism spectrum disorder, ASD, adolescents, emotional recognition, social skills, social initiations, social responses, social-communication, communication, computer, and technology were used singly and in various combinations to produce articles for the review. Then, using the reference lists of each study located through ERIC, EBSCO Host, and PsyInfo databases, a hand search was conducted to find additional studies in the journals of Focus on Autism, Journal of Autism and Developmental Disabilities, and Autism. Additionally, previous reviews of the literature that examined the efficacy of technology-based interventions for individuals with ASD were reviewed for identification of additional studies (Grynszpan et al., 2014; Odom et al., 2015; Ploog et al., 2013; Ramdoss et al., 2011; Wainer & Ingersoll, 2011). Odom et al. (2015) review of the literature only targeted technology-based interventions for adolescents with ASD and included several studies found in Wong et al. (2014) comprehensive review of technology-based interventions for children and youth with ASD.  In addition, the Wong et al. (2014) review covered literature from 1990 to 2011 while Odom et al. (2015) conducted an additional computer and hand search of the literature for studies published between 2011 and the end of 2013. Odom et al. (2015) identified a total of 30 articles that met the inclusion criteria as technology interventions for adolescents and young adults with ASD; however, only five studies addressed the communication or socialization skills of the identified group.

 After the electronic and hand searches were completed, the abstract for each identified article was examined. The search produced 42 articles which were screened against the inclusionary and exclusionary criteria.

Inclusionary and Exclusionary Criteria

There were six inclusionary criteria utilized to determine whether an article was included in this literature review. First, participants must have been identified as having ASD. Second, the study must have contained independent variables that targeted social-communication skills such as verbally initiating or responding during a conversation or emotion recognition (selected skills determine the quality of social interactions for individuals with ASD). Third, studies must have assessed the effectiveness of a technology-based intervention for only adolescents with ASD. The World Health Organization (2016) defines adolescents as those people between 10 and 19 years of age. Fourth, the study must have employed a rigorous experimental design (e.g., multiple baseline, alternating treatment, or a group design). Fifth, all studies must have been published in peer reviewed journals between 1990 and 2020. Sixth, only studies conducted in the United States were included. Excluded from the review were: (a) studies that did not include adolescents with ASD; (b) studies that did not use a technology-based strategy to deliver an intervention; (c) studies that consisted of findings that were reported in an anecdotal form; (d) studies that solely addressed the enhancement of life skills.  After applying the inclusionary and exclusionary criteria, this search generated seven studies. Table 1 below provides a description of reviewed studies.

Table 1. Reviewed studies

Results

Description of Studies

Seven articles address the social-communication skills of adolescents with ASD. Table 1 contains summarized information from the identified research studies. The following information can be found in Table 1: (a) participant characteristics; (b) social-communication skill targeted; (c) setting; (d) type of technology-based intervention; and (e) reported intervention outcomes.

Participant characteristics

A total of 33 adolescents with ASD participated in the identified research studies. The age range for participants was 10-19 years old. Participants attended elementary, middle, and high school and their primary diagnosis was ASD.

Targeted Social-Communication Skills

All seven articles addressed multiple social-communication skills. Researchers targeted interactional skills like asking questions (Plavnick & Duenas, 2018), making comments during play activities (Macpherson et al., 2015), requesting information ( Plavnick et al.,2015; Wendt et al., 2019), and simple and complex verbal greetings made towards teachers and research staff (Kagohara et al.2013). Nonverbal communication skills and conversational reciprocity (Hurwitz et al., 2020) were also addressed using a technology-based strategy. One research study utilized Theory of Mind activities (Ozonoff, & Miller, 1995).

Setting

Some research studies (Hurwitz et al., 2020; Macpherson et al., 2015; Wendt et al., 2019) took place in clinical settings, while three studies (Kagohara et al.2013; Plavnick & Duenas, 2018; Plavnick et al.,2015) occurred in school. One study occurred in a school and a clinical setting (Ozonoff, & Miller, 1995).

Technology-based Instructional Strategies

Several of the studies (Kagohara et al.2013; Macpherson et al. 2015; Plavnick & Duenas, 2018) used video models as a form of intervention. Video modeling is an evidence-based practice defined as the presentation of a model demonstrating a targeted skill using videotape, DVD, or computer presentation (Kagohara et al, 2013; Sansosti & Powell-Smith, 2008). In the past, video modeling has been used to promote the acquisition of new skills such as imitation, joint attention, mathematical concepts, academic responding, and initiating contact with peers (Kagohara et al., 2013). Video modeling has evolved from using videotapes and televisions to a readily accessible intervention for individuals with ASD (Sansosti & Powell-Smith, 2008). Studies under current review also used video-based group instruction (Plavnick et al., 2015), iPad-based speech generating device (Wendt et al., 2019), dual-first person video recording glasses (Hurwitz et al., 2020), and videotaped performance feedback (Ozonoff, & Miller,1995).     

Reported Intervention Outcomes

Results from Hurwitz et al., (2020) study indicated that all four adolescents modified their nonverbal communicative behaviors during subsequent conversations. Kagohara et al., (2013) found that both students increased the number of verbal greetings made towards teachers and research staff above baseline levels. After the introduction of the video model intervention, Macpherson et al., (2015) results indicated that study participants increased verbal compliments to peers. Ozonoff, and Miller (1995) study participants increased performance on Theory of Mind task. Plavnick et al., (2015) results revealed that three out of four participants demonstrated improvement of targeted skills, with mixed outcomes for the fourth participant. Plavnick and Duenas (2018) results indicated all participants increased social interaction skills. Finally, Wendt et al., (2019) found that all three participants significantly improved requesting behaviors during the intervention phase.

Discussion

The purpose of this review of the literature was to identify studies that used technology-based interventions to increase the social-communication skills of adolescents with ASD. In addition, the question was asked, “Are technology-based interventions effective when used to improve the social-communication skills of adolescents with ASD?” Based on the reported results of each study included in the current review of the literature, technology-based strategies are effective when used to improve the social-communication skills of adolescents with ASD. Results of the current review are unsurprising as previous reviews of the literature found that interventions using technology as a delivery model were promising practices. For instance, Ramdoss et al. (2011) evaluated 14 studies that used computer assisted technology (CAT) to teach social-communication skills to individuals with ASD. Researchers indicated that while CAT appeared to be a burgeoning practice, it cannot be considered an efficacious intervention tool. In a similar review, Ploog et al. (2013) reviewed 45 studies that used CAT to improve the social, communicative, and language development of children, adolescents, and adults with ASD. Ploog et al. (2013) divided the research studies into four main categories: language, emotion recognition, theory of mind, and social skills. Like Ramdoss et al. (2011), Ploog et al. (2013) found that strategies utilizing CAT were very promising; however, most studies lack rigorous, scientific assessment of efficacy in relation to more traditional intervention methods. In a more recent review of a technology-based intervention, Qi et al., (2018) synthesized 24 research studies that used single case research designs (SCRD) to examine the effects of video model on the social-communication skills of individuals with ASD. Qi et al., (2018) applied the What Works Clearinghouse (WWC) SCRD design standards to the studies identified during the review. Findings from the synthesis concluded that video model intervention is an evidence-based practice according to the WWC standards for increasing social-communication skills of individuals with ASD.

Studies from the current review illustrated how technology-based strategies can be effective when implemented at school and a clinical setting. With the number of computer applications and programs available for computers, iPads, iPod, iPhones, and now virtual reality, practitioners in the field have a myriad of intervention delivery options available in multiple settings. However, the task of empirically validating each intervention must be done. The current review indicates that technology-based interventions are effective when used to improve the social-communication skills of adolescents with ASD. Future research using technology-based interventions should be conducted to add to the social-communication literature for adolescents with ASD.

Conclusion

Adolescents with ASD display social-communication challenges that may include the inability to initiate or respond to peers in an appropriate manner. Adolescents with ASD may also be unable to decipher the perspectives of others. Social-communication challenges have the potential to impact friendships, familial bonds, and post-secondary opportunities. Practitioners in the field realize the importance of remediating these skills, so for more than twenty years they have employed technology-based strategies as intervention tools. Drawing on a preference for technology-driven devices, many advances have been made in the research and treatment of ASD. Technology-based strategies are effective; however, research studies still need to be empirically validated and many of these studies focus on remediating the social-communication challenges of children under the age of 10 years-old. Understanding the life-long impact of social-communication challenges faced by individuals with ASD, researchers must now turn their focus to addressing the needs adolescents with the disorder.

                                                           

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About the Authors

Dr. Nicole A. Anthony serves as the assistant chair of the Early Childhood, Elementary, Middle Grades, Reading, and Special Education department in the College of Education. Her research interests include adolescents with autism spectrum disorder (ASD) social-communication development, transition outcomes for African American students with ASD, and postsecondary opportunities for children with disabilities. With more than 20 years of experience as an educator, she has remained committed to creating equitable and inclusive spaces for students with disabilities. Dr. Anthony spearheaded the Autism Advisory Council at FSU, which is dedicated to meeting the needs of children with ASD in Cumberland County. The council is composed of faculty, students, parents, and autism-related community organizations. The Autism Advisory Council is believed to be the first of its kind on the campus of an HBCU.

Dr. Cynthia Brooks Wooten is an Assistant Professor of Elementary Education, in the College of Education at Fayetteville State University. She received her Ph.D. from the University of North Carolina Greensboro. Her dissertation titled, Multiple Case Studies of Literacy Practices Utilized by Intermediate Grade Teachers Which Enable African American Males to Become Literate Individuals-What’s Going On?, focused on accomplished teachers of African American males. Research interests relate to preservice teacher preparation, experiential learning, literacy education, literacy instruction for Black males, multicultural education, and beginning teacher support. Dissemination of research is accomplished via presentations at state, national, and international level conferences.