Social Cognition Treatment: A Preliminary Investigation of Social Thinking in an Inpatient Setting

Background: Social communication impairment is a core deficit in individuals with Autism Spectrum Disorder (ASD). Challenges in reading non-verbal cues, inferring the intentions of others and interpersonal flexibility are universally present in the population.  Historically, clinicians have addressed social communication impairments with discrete social skill interventions, such as teaching phrases and mannerisms in scripted social situations. These methods have not led to improvements in the flexible application of social cognition or generalizability to unscripted situations (Bellini, 2007).  One approach to this challenge, “Social Thinking” (Winner, 2008) has been widely adopted in schools and other settings within the United States.  Despite its popularity, there has been minimal research on the efficacy of this approach in improving social communication.  There is also a lack of a manualized curriculum for clinicians to increase fidelity and replicability.

Objectives: The primary objective was to develop and implement a manualized Social Cognition Treatment (SCT) curriculum for children with ASD and/or Intellectual Disability (ID).  Our secondary objective was to measure changes in theory of mind capacities in patients exposed to the SCT curriculum and examine for potential differences in theory of mind scores between patient groups (ASD, ASD+ID, ID).

Methods: Nine children hospitalized in a specialized child psychiatry unit with ASD by DSM IV-TR criteria and/or Mild Intellectual Disability (ID, FSIQ 54-70) participated in the SCT curriculum.  The SCT curriculum was created by a multi-disciplinary team of clinicians and was designed to enhance theory of mind capacity in individuals with autism and/or intellectual disability by increasing perspective taking ability, encouraging more flexible thinking and enhancing coping strategies.  The SCT curriculum requires dedicated participant involvement in 16 forty-five minute sessions delivered over a 4 week period.  Teacher responses on the Theory of Mind Inventory (ToMI;Hutchins, Prelock, & Bonazinga, 2012) were collected after a one-week observation period (baseline), and again at 2 weeks (mid-point) and 4 weeks (end-point) of the SCT sessions.  Repeated Measures Analysis of Variance (RMANOVA) was used to examine changes in ToMI scores over time. 

Results: The sample consisted of 9 males, two with ASD, three with ID, and four with ASD+ID, ages 6-18 (mean = 11.0 years) who completed an average of 14 of 16 SCT sessions. RMANOVA results indicated overall patient improvement in mean TOMI scores from baseline (M=14.90, SD= 3.06) to mid-point (M=15.90, SD=2.64) to end-point (M=16.45, SD=2.72), however this was not statistically significant, F(1.16, 9.31)=3.85, p=0.076.  Examination of TOMI differences by diagnostic group revealed improvement in mean TOMI scores for ASD and ASD+ID patients, whereas ID only patients showed a slight decrease in TOMI scores over time. 

Conclusions: Preliminary investigation of a newly developed group Social Cognition Treatment suggests that it may be related to improvements in a measure of theory of mind for children with ASD.  Though we cannot suggest causality in this uncontrolled, open-label preliminary study, our findings may indicate that the SCT has a different effect for the ASD versus ID populations.  Controlled study of the SCT in an outpatient ASD population would provide initial testing for efficacy.