Social skills interventions for children and adolescents with high-functioning autism spectrum disorder: a narrative review

Introduction

Autism spectrum disorder (ASD) is a neurodevelopmental condition with an early onset in infancy, characterized by impairments in social communication and the presence of repetitive, stereotypical behaviors and interests (1) V体育官网入口. According to a 2023 report by the Centers for Disease Control and Prevention (CDC) in the United States, the prevalence of ASD among 8-year-old children is 1 in 36, with a male-to-female ratio of approximately 4:1 (2).

Among individuals with ASD, those with average or above-average language and/or cognitive abilities relative to their counterparts of the same chronological age are generally considered high-functioning individuals (3). A report from CDC (2) found that 38. 6% of individuals with autism who underwent cognitive assessments were diagnosed with high-functioning autism spectrum disorders (HFASD) VSports在线直播.

Despite demonstrating adequate linguistic and cognitive abilities, individuals with HFASD still exhibit pronounced social deficits, such as avoiding eye contact and lacking spontaneously interaction with others, similar to other individuals in the autism spectrum (4,5). These social difficulties usually persist into adulthood (6,7), leading to widespread negative outcomes across one’s lifespan (8) V体育2025版. For example, because individuals with HFASD are often aware of their differences from typically developing (TD) peers, they are more likely to experience lower self-perceived social competence, loneliness, and poorer friendships than TD peers. Consequently, they are more prone to depression and anxiety (9-11). In addition, deficits in social skills may have long-term deleterious effects on occupational functioning and well-being later in life (12,13). Therefore, social skills are critical targets for intervention in individuals with HFASD.

Given that individuals’ cognitive, linguistic, and general functioning levels can influence the effectiveness of interventions (14,15), traditional intervention methods, often developed for the general ASD population, may not be equally beneficial for individuals with HFASD. Recently, several methods have been developed specifically for HFASD, most of which involve sessions targeting social skills VSports. A comprehensive review of the relevant literature can elucidate the progress in this field, with the specific objectives of (I) categorizing and summarizing various intervention types and their characteristics; (II) summarizing the effects of these interventions on social skills; and (III) identifying the challenges and limitations of existing research. Therefore, we conducted this literature review to explore future research directions. In addition, this study aims to provide suggestions for practitioners and caregivers in selecting appropriate intervention methods for the HFASD individual. We present this article in accordance with the Narrative Review reporting checklist (available at https://tp. amegroups. com/article/view/10. 21037/tp-2025-220/rc).

"VSports在线直播" Methods

In accordance with the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (16), Education Resources Information Center, Psychology and Behavioral Sciences Collection, PsycINFO, PubMed, and Web of Science were systematically searched for original peer-reviewed articles published between January 1, 2014 and July 13, 2024 VSports app下载. Searches were carried out by inputting the terms: “Asperger”, “autism”, “ASD”, “intervention”, “practice”, “therapy”, “therapeutic”, “treatment”, “social interaction”, “social skills”, “social”, “high-functioning”, “HF”, and “high function”. The detailed research strategies are summarized in Table 1.

Exclusion criteria

As shown in Figure 1, 1,379 articles were identified. Of these, 1164 articles were excluded because they were duplicates, were published in non-peer-reviewed journals, were not relevant or could not be retrieved. Another 176 reports were excluded because they did not meet the inclusion criteria. Reasons included not being published between 2014–2024 (n=73), being non-English publications (n=2), having no focus on HFASD (n=67), including participants aged >18 years (n=8), or not being related to social skills interventions (n=26). Consequently, a total of 39 articles were included in this review. As shown in https://cdn.amegroups.cn/static/public/tp-2025-220-1.pdf, four categories of interventions emerged after reviewing all 39 articles.

Figure 1 Process of records.

Results

Intervention methods reported in the 39 studies target social skills, which are defined as behaviors performed in a social context involving interpersonal engagement (17,18). These methods can be classified into four categories: based on cognitive behavioral therapy (CBT), based on naturalistic intervention (NI), art therapy, and miscellaneous methods.

V体育ios版 - Based on CBT

Methods in the first category were developed based on CBT. Although methods in this category vary in implementation format (such as individual, group, or family interventions) and target different age groups (children or adolescents) (19,20), they share common therapeutic elements derived from CBT.

The Program for the Education and Enrichment of Relational Skills (PEERS) is a manualized social intervention project specifically tailored for high-functioning adolescents. PEERS aims to help teens develop and maintain friendships and is designed to teach specific social skills applicable to their daily lives, such as conversation skills and choosing appropriate friends. The classic PEERS curriculum comprises 14 sessions, each lasting 90 minutes and conducted once a week with the peers involved (21). Parents meet in groups and attend weekly classes. Research with a randomized controlled trial (RCT) design has validated the effectiveness of PEERS in adolescents with HFASD, showing significant improvements in their knowledge, communication, and expressive abilities of social skills (22-24). Similar results have been observed in populations outside the United States, such as Poland, Japan, and China, with most effects sustained until follow-up (25-27). Moreover, an accelerated version of the program that lasts 7 weeks, with two sessions per week, has also demonstrated efficacy in enhancing social skills among adolescents with HFASD (28).

The Summer Comprehensive Intervention (summerMAX) is also a CBT intervention. It aims at enhancing social-cognitive abilities, social-communication skills, and reducing ASD-related symptoms in children with HFASD (29). Both parents and peers were typically involved in the intervention. Several programs have been developed from summerMAX, tailored to address specific concerns and needs of different practitioners (15,30). A typical summerMAX intervention lasts 5 weeks, with sessions occurring 3–5 days per week, each lasting 1 hour. Evidence has shown that the participants’ social communication skills improved by the end of the intervention and were maintained throughout the follow-up period (31,32). In addition to PEERS and summerMAX, other CBT-based intervention methods have also been demonstrated to effectively enhance the social competencies in children and adolescents with HFASD. For example, the Social Competence Group Intervention (SOCO) trains children and adolescents with autism through a multilevel rehabilitation approach, incorporating cognitive training, psychological knowledge education, and psychosocial support (33). Research results showed significant improvements in social awareness and social motivation of children with HFASD after a 9-month intervention, and these improvements were maintained during the follow-up period (34).

Social Skills Groups (SSGs) is a structured program whose 9-step teaching protocol has been explicitly outlined in “Skillstreaming”, including defining skills, modeling, role-playing, and other activities (35). An RCT study with 83 participants showed significant improvements in the social communication skills among children with HFASD after following an 18-week parent-involved SSGs intervention (36).

Wood et al. (37) conducted a 32-week program with parental involvement based on the Building Confidence CBT program, which facilitated increased positive and appropriate social interactions between children with HFASD and their peers.

An online prosocial game, “Poki-Poki”, has been developed based on CBT. Adolescent players in this game demonstrated significant improvements in their social communication skills as well as in the recognition of emotional words and facial expressions (38).

Based on NI

The second category, NI, stems from behavioral and/or developmental approaches to learning. These methods typically comprise a set of practices, such as environmental arrangements and interaction techniques, which can be integrated into daily routines, in either classroom or home settings (39).

The pivotal response treatment (PRT) is a representative method within this category. The aims of PRT include fostering the development of communication and language skills, enhancing positive social behaviors, and reducing disruptive self-stimulatory behaviors (40). The PRT facilitates learning by providing opportunities for appropriate responses in the natural environments (41). A multiple baseline design study showed that after 9 months of PRT training, conducted 4 times per week, children with HFASD demonstrated a significant increase in the number of questions asked as well as improvements in expressive and receptive language abilities (42). In a recent study, robots were used in PRT training to assist with interventions, resulting in an enhanced training effect (43).

Capitalizing on the strong interest of individuals with HFASD in LEGO, LEGO therapy is designed to enhance both verbal and nonverbal social skills by encouraging collaboration during group activities involving LEGO model construction (44). Studies employing multi-baseline and multi-probe designs have shown that LEGO therapy increases the frequency of social initiation, social response, and duration of interactions among children and adolescents with HFASD (45,46).

The Social Initiation and Motivation Intervention (SIMI) is also a peer-involved group course consisting of eight sessions with one 75-min session per week. During the intervention, group leaders explicitly instructed children with HFASD in behavioral regulation of initiations, following strategies of naturally occurring behavioral interventions proposed by Fredeen (47). An RCT showed that SIMI improved joint attention and social initiation in children with HFASD (48).

Digital interventions based on NI appear to have effects comparable to those of traditional NI interventions. In a recent study, children with HFASD participated in both typical LEGO-based social interventions and mixed reality interventions. There were no significant differences in the number of social initiatives and anxiety levels among children with HFASD under these two conditions (49).

Art therapy

The third category is art therapy, which provides participants with sensory stimulation through creative art activities. Art therapy can provide personalized interventions, encouraging participants to experience and express themselves during the creation process (50). Although art therapy is still in its early stages, supporting evidence has been obtained regarding its effectiveness in treating children with ASD (51). Among the literature on art-based intervention approaches, three out of five studies focus on SENSE Theater. In these studies, participants were guided to interact with their peers in games, role-playing exercises, and improvisation during 10 four-hour sessions or a 2-week summer camp (52). Observational coding of target behaviors according to the peer interaction paradigm before and after the intervention showed an increase in proactive cooperative behavior during play and verbal interactions, along with overall improvements in social functioning (53,54).

The other two studies in this category were single case studies. The first was rhythm-mediated music therapy in which participants were guided to lead their peers, mimic peer behaviors, and adjust themselves through drumming games. Following eight 30-minute sessions, children with HFASD showed improved synchronization with their peers and a significant increase in co-engagement behaviors during dyadic drumming (55). In another case study, an Individual Therapeutic Education Plan (ITEP) was developed for a child with HFASD to facilitate art self-expression using various art materials. Her parents received counseling services as part of the intervention. This intervention enhanced the child’s ability to share and express herself, and enabled her to engage more in play with other children (56).

"V体育官网入口" Miscellaneous methods

In addition to the three main categories of interventions discussed above, several other approaches have been explored that do not fit into these classifications. The Social Tools and Rules for Teens (START) Program is a comprehensive social skills intervention. START encourages young people with autism to engage in individual and group social activities, providing guidance in a total of 20 sessions, with one session per week. Parents were invited to collaborate with practitioners to monitor changes in their children. At the end of the intervention, most adolescents with HFASD showed an improvement in their social skills and social responses as well as increased self-rated and parent-rated social motivation (57,58).

The social skills training (SST) was developed to promote the socialization of children with autism (59). Typically delivered in a group setting, SST provides individuals with ASD opportunities to interact with their peers (60). SST organizes activities such as learning social skills and role-playing exercises for children with autism in 10–12 group sessions. Additionally, it includes guidance for parents, offering advice and instructional manuals to help them support their children in applying new skills in daily life. An analysis of coded social interactions among children and adolescents with HFASD revealed an increase in the number of adaptive social behaviors after the intervention compared to baseline (61). Social skills improved more in the SST group than in the control group, although the difference was not statistically significant (62).

The performance-based social skills interventions do not involve explicit teaching. Instead, they promote the development of social skills by providing opportunities for social engagement. These interventions have been found to be effective in enhancing the social knowledge of adolescents with HFASD (63).

The immediate video feedback, as an extension of video self-modeling, enables participants to reevaluate conversations between themselves and other people from a first-person perspective by viewing videos captured with recording glasses. This technique is especially helpful for adolescents with ASD in identifying their strengths and abnormalities in social interactions. A multi-baseline study found that immediate video feedback improved nonverbal communication behaviors and reciprocal conversations among adolescents with HFASD (64).

Additionally, some other studies, although with small sample sizes and lacking control groups, have reported methods that offer valuable insights for the fields, and thus, are summarized here. Most of these studies employed observational behavior coding to compare participants’ social behaviors before and after the intervention. For example, Rodríguez-Medina et al. (65) conducted the Recess Pals program to help school-aged children with HFASD improve their social behaviors during school recesses. After four weeks, participants showed a slight increase in social initiations and responses and a significant decrease in challenging behaviors. Similarly, Kalyvezam et al. (66) and Rashed et al. (67) introduced TD peers into their programs to help children with HFASD practice social skills through group games, providing opportunities to communicate across various domains. These programs improved the participants’ performance in terms of the length of social interaction, social initiation, and social response (67). These effects may generalize to unstructured contexts such as playgrounds (66). Au et al. (68) taught preschoolers to correctly identify appropriate or inappropriate social behaviors, initiate games, and comment through modeling, demonstration, and role-playing. By the end of the program, participants had mastered some social skills and were able to use them in interactions with new peers. Henning et al. (69) developed a game intervention combining group sessions and family games to guide children with HFASD in peer interactions. They found an improvement in social play skills after the intervention.

Discussion

This paper examines studies published in peer-reviewed journals over the past decade concerning social skills interventions for children and adolescents with HFASD. The 21 methods reported in the literature are categorized into four groups. Among these, methods based on CBT and NI have obtained sufficient empirical support.

According to the principles of CBT, maladaptive cognitions are central to the maintenance of emotional and behavioral difficulties, and modifying these thought patterns can lead to positive changes in behavioral functioning (70). Although understanding the major concepts of CBT and applying them in real life may seem difficult for most individuals on the autism spectrum, individuals with HFASD do not have cognitive deficits except for emotional cognition (71). Hence, the intervention methods in the first category improve social skills by adjusting social cognition and providing structured strategies for HFASD individuals to address real-life social challenges (21,31,37). Because cognitive levels vary across different age groups, it is essential to tailor these programs according to the children’s developmental stages. As we know, the PEERS team is dedicated to developing different curricula tailored to individuals of various age groups.

NI emphasizes following the child’s interests and integrating instruction into natural routines and social interactions. Accordingly, intervention methods based on NI enhance social skill development in children and adolescents with HFASD by embedding teaching contexts into real-life contexts. The greatest advantage of this approach is the ability to promote motivation and engagement, as well as facilitate the generalization of learned skills. Empirical evidence has shown that NI contributes not only to improvements in the social domain but also to enhancements in adaptive behavior, language, and play (72,73). However, the effectiveness of NI relies heavily on the flexibility and creativity of the practitioner, who must continually tailor strategies to meet each child’s unique needs.

Art therapy provides a non-verbal, emotionally expressive modality through which individuals can explore feelings, build relationships, and practice social interaction in a more engaging environment (50,74). As an emerging type, art therapy is very appealing to children and adolescents with HFASD, particularly for those who are drawn to creative expression. Although promising, the empirical evidence supporting the effectiveness of art therapy remains limited.

Although miscellaneous methods have demonstrated some effects, they lack sufficient empirical support, which limits their adoption as mainstream intervention approaches (67-69).

The implications of this review for scientific research include the need for larger sample sizes, more female and younger participants, and more rigorous designs in future studies in order to test the efficacy and generalizability of existing intervention methods. In developing new intervention methods, combining multiple approaches holds great promise. For example, applying CBT techniques in art therapy may produce greater efficacy than using either approach alone. Informed by the results of this review, we advise practitioners and caregivers to give priority to the first two categories (i.e., methods based on CBT and NI) when selecting intervention methods for children and adolescents with HFASD, due to their greater maturity and more substantial empirical support.

Conclusions (V体育平台登录)

This review focuses on social skills intervention methods developed over the past decade for children and adolescents with HFASD. Empirical research has confirmed the effectiveness of interventions based on CBT and NI. Art therapy and other emerging interventions, though promising, remain underexplored and lack rigorous evaluation. Future studies should adopt more robust methodologies and include larger, more diverse samples.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors completed the Narrative Review reporting checklist. Available at https://tp.amegroups.com/article/view/10.21037/tp-2025-220/rc

Peer Review File: Available at https://tp.amegroups.com/article/view/10.21037/tp-2025-220/prf

Funding: This work was supported by the National Natural Science Foundation of China (No. 32130045), and the Golden Resources Love Fund (Overseas Chinese Charity Foundation of China).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tp.amegroups.com/article/view/10.21037/tp-2025-220/coif). X.L. serves as an unpaid editorial board member of Translational Pediatrics from March 2024 to February 2026. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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