Beyond Social Skills: Supporting Peer

Relationships and Friendships for

School-Aged Children with Autism
Spectrum Disorder
Amy Rodda, Ph.D., CCC-SLP1 and Annette Estes, Ph.D.1,2

ABSTRACT

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Social impairments are the sine qua non of autism spectrum
disorder (ASD). However, children with ASD are capable of forming
reciprocal friendships and many people with ASD have a strong desire
for friends. Developing and maintaining friendships is associated with
many important outcomes, including improved quality of life, mental
health, and academic achievement. Children with ASD often attend
groups to improve social skills, but strategies for building and main-
taining friendships are not consistently addressed or measured following
intervention. In this article, our objective is to build an understanding of
peer relationships and friendships in school-aged children with ASD
and how to best support them. In this article, we describe characteristics
of peer relationships and friendships for children with ASD. We discuss
current research findings on intervention to improve social skills, peer
relationships, and friendships in school-aged children with ASD.
Finally, we give suggestions for clinical practice and future research.

KEYWORDS: Autism, peer, relationship, social skills, friendship

Learning Outcomes: As a result of this activity, the reader will be able to (1) discuss what is currently known
about peer relationships in children with autism spectrum disorder; (2) evaluate the quality of social skills
interventions and one’s own adherence to recommendations for evidence-based practices; and (3) expand
current clinical practices to include establishing and maintaining friendships as an intervention goal.

1
Center on Human Development and Disability, University
of Washington Autism Center; 2Department of Speech
and Hearing Sciences, University of Washington, Seattle,
Washington.
Address for correspondence: Amy Rodda, Ph.D., CCC-
SLP, University of Washington Autism Center, Box 357920,
Seattle, WA 98195-7920 (e-mail: amyp78@uw.edu).
Enhancing Communication and Social Interaction
Skills of Children with Autism Spectrum Disorders and
178
Their Communication Partners; Guest Editor, Amy
Donaldson, Ph.D., CCC-SLP.
Semin Speech Lang 2018;39:178–194. Copyright
# 2018 by Thieme Medical Publishers, Inc., 333 Seventh
Avenue, New York, NY 10001, USA. Tel: +1(212) 584-
4662.
DOI: https://doi.org/10.1055/s-0038-1628369.
ISSN 0734-0478.

P eer relationships contribute to social and
cognitive development,1 enhance school per-
formance,2,3 create a positive school environ-
ment,4 decrease victimization,5 and help
children refine their prosocial behaviors.6
Children with autism spectrum disorder
(ASD) frequently struggle to establish and
maintain positive peer relationships. Although
conceptually related, peer relationships and
friendships are different. Peer relationships
include a child’s daily interactions with same-
aged peers. Friendships are relationships bet-
ween specific children requiring reciprocity and
shared interests. ASD is characterized by early
emerging and persistent deficits in social com-
munication and social interaction as well as
repetitive behavior and restricted interests.
One criterion for the diagnosis of ASD is
difficulty developing, maintaining, and under-
standing relationships and difficulty making
friends.7 Deficits in social-emotional recipro-
city, such as difficulty with back-and-forth
conversation, and in nonverbal communication
(e.g., abnormal eye contact and body language)
can directly impact peer relationships and
friendships for people with ASD.
We provide an overview of what is known
about peer relationships and friendships in
children with ASD. We review interventions
for school-aged children with ASD that aim to
improve their social skills and present research
evaluating the efficacy of these approaches. We
discuss the need to ensure that social skills
interventions target increasing and improving
friendships for children with ASD. Finally, we
recommend five evidence-based strategies to
incorporate into clinical practice for improving
peer relationships and friendships for children
with ASD.
PEER RELATIONSHIPS AND
FRIENDSHIPS IN CHILDREN WITH
AUTISM SPECTRUM DISORDER
Despite social communication challenges, child-
ren with ASD can and do make friends. Even as
early as preschool age, parents report that their
children with ASD have playmates and share
many of the necessary precursors to forming
school-aged friendships.8 Many school-aged
children and adolescents with ASD have friends
BEYOND SOCIAL SKILLS/RODDA, ESTES 179
with whom they share interests and activities
according to a variety of sources: parent report,
self-report, and teacher report.9–12 In adoles-
cence, children with ASD and typically develo-
ping (TD) peers note intimacy and security as
important qualities of friendships.13 Children
with ASD and TD children report similar levels
of conflict in their friendships.13–17 In summary,
research has demonstrated children with ASD
have several positive abilities with regard to
friendships.13
However, children with ASD have signifi-
cant challenges with peer relationships and
friendships. Children with ASD tend to have
smaller networks of friends than TD peers and
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rate their own friendships as having less com-
panionship and security, receiving less help
from their friends, and being less close than
TD children.18–23 Children with ASD on the
whole have fewer friends than children with
typical development and fewer friends than
children with other disabilities.24–27 The
friendships of children with ASD are less likely
to be reciprocal. For example, when using peer
ratings, children with ASD often nominate a
child as a friend, but that child does not
nominate the child with ASD in return.15,16
Children with ASD who have friends spend less
time with their friends than same-aged TD
peers.13,14,16,28 Children with ASD are more
likely to be “peripheral” in peer networks,
meaning they are less connected to the children
in their school environments and they are more
likely to be rejected by their peers.13,29 Alt-
hough some children with ASD have reported
less motivation to form friendships,30 children
with ASD who report strong motivation still
experience challenges making and keeping
friends.15
INTERVENTIONS TO IMPROVE
PEER RELATIONSHIPS AND
FRIENDSHIPS IN SCHOOL-AGED
CHILDREN WITH AUTISM
SPECTRUM DISORDER
Social skills are specific behaviors that comprise
the building blocks of successful, fluid social inter-
actions. Social skills are related to successful peer
relationships and are thought to aid in establishing
and maintaining friendships. Examples of social
180 SEMINARS IN SPEECH AND LANGUAGE/VOLUME 39, NUMBER 2
skills are entering peer groups, maintaining play
with peers, and resolving conflict.31
Skills can be broken down into small,
decontextualized, behaviors to facilitate tea-
ching and learning. For example, making a
verbal request of a same-aged peer is a social
skill that might need to be taught to a child with
ASD.32
Peer relationships, friendships, and social
skills are distinct concepts that are theoretically
related to one another. We will argue that the
distinctions between these concepts are critical
to keep in mind when designing and imple-
menting interventions for children with ASD.
Because social skills are theoretically related to
peer relationships and friendships, we examined
seven systematic reviews of social skills inter-
ventions for school-aged children with ASD.
All reviews were focused primarily on inter-
ventions to improve social skills and only one
included an explicit focus on friendships.18 All
reviews were conducted over the past 10 years
(January 1, 2007, to September 1, 2017), focu-
sed on children, measured at least one social
skill outcome, used experimental, quasi-expe-
rimental, and single subject designs, and were
published in English in a peer-reviewed jour-
nal.19–21,33–36 Collectively, the reviews included
104 unique studies published between 1984 and
2016. These studies comprise the literature
used in our evaluation and review that follows.
Evidence-based practices (EBPs) must
meet a priori quality standards. According to
one widely accepted framework, to be consi-
dered established, an EBP must have either two
independent randomized controlled trials of
“strong” methodological rigor or at least five
single subject studies of “strong” methodologi-
cal rigor.37 Per this framework, strong metho-
dological rigor in group research was indicated
primarily by a well-defined sample (e.g., age and
gender, explicit inclusion criteria, specific diag-
nostic characteristics), replicable treatment
approach (e.g., using a treatment manual),
clearly described outcome measures that were
related to the treatment targets, direct relation-
ship between research questions and data ana-
lyses, and adequate sample size for the statistical
analyses. Secondary indicators of methodologi-
cal rigor included interventions that randomi-
zed participants to treatment groups, collected
2018
interobserver agreement on outcome data, had
blind raters of outcome behaviors, implemented
a fidelity measure for treatment, had similar
attrition rates between groups, examined gene-
ralization and/or maintenance data, reported
effect sizes for outcomes, and measured socially
important outcomes.22 Single subject indicators
of methodological rigor were similar to group
research, and included stable, multipoint base-
line data, visual analysis of data, and multiple
instances of the treatment effect.22 Two reviews
evaluated whether interventions met standards
for EBP.33,34 These reviews reported that
several social skills interventions for children
with ASD met the criteria for EBP. All were
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school-based, two investigated social skills
groups,38,39 and three investigated peer-media-
ted interventions.35,40,41
We independently evaluated 104 studies
from the previously mentioned reviews. To
identify the approaches that have the most
promise for improving peer relationships and
friendships in children with ASD, we evaluated
whether each study contained the following: (1)
outcome measures related to peer relationships
and friendships, (2) manualized treatment pro-
tocols, (3) treatment fidelity assessment, (4)
support for generalization to settings with peers,
and (5) children with cognitive impairment.
Outcome Measures Related to Peer
Relationships and Friendships
The implicit target of most social skills inter-
ventions is to increase participants’ interac-
tions with peers and to facilitate friendships.
However, the large majority of social skills
interventions did not target a friendship out-
come (73 of 104; 70%). Some of studies of
social skills intervention discussed friendships
but did not measure friendships or peer rela-
tionships after treatment.19,20,36 However,
nearly one third (31 of 104) of the studies
included in the systematic reviews assessed
friendships or peer relationships following
treatment (see Table 1). These studies asses-
sed direct friendship outcomes such as number
of friends, inclusion in peer networks, friend-
ship quality, or having friends over for play
dates. For the purposes of our review, peer-
related social skills such as increasing social
 BEYOND SOCIAL SKILLS/RODDA, ESTES 181

Table 1 Characteristics of Social Skills Interventions

Study Place Friend Manualized Fidelity Cognitive Level
Outcome
Antshel et al (2011)93 School No No No Higher
Banda et al (2010)65 School No No No Higher
Barnhill et al (2002)94 School Yes No No NR (exclusive dx)
Barry et al (2003)45 School Yes No No Higher
Bauminger (2002)46 School No No No Medium & higher
Begeer (2011)95 School No No No Higher
Bock (2007)74 School No No No Higher
Brady et al (1987)68 School No No No Lower
Broderick (2002)96 School Yes No No NR (exclusive dx)
Buggey (2005)97 School No No No NR
Carter et al (2004)149 School Yes No No NR (exclusive dx)
Castorina and Negri (2011)98 School No No No NR (exclusive dx)

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Charlop-Christy and Danesh- School No No No NR
var (2003)99
Corbett et al (2014)41 School No No Yes Medium & higher
Cotter (1998)100 School Yes No No Medium & higher
Cotugno (2009)101 School No No No Medium & higher
Delano and Snell (2006)73 School No No Yes NR (but verbal)
DeRosier et al (2011)38 School No Yes Yes Higher
Feldman and Matos (2013)49 School No No Yes NR
Fisher and Happe (2005)102 School No No No NR
Frankel et al (2010)55 Clinic Yes Yes Yes Higher
Gantman et al (2012)56 School Yes Yes Yes Higher
Ganz and Flores (2008)103 School No No No NR
Gevers et al (2006)104 School No No No NR (inclusion cutoff)
Gonzalez-Lopez and Kamps School No No Yes NR (self-contained class)
(1997)105
Harper et al (2008)106 School No No Yes NR
Hartzell et al (2015)43 School Yes No No NR
Herbrecht et al (2009)57 School No Yes No NR (inclusion cutoff)
Hillier et al (2007)107 School No No No Medium & higher
Hillier et al (2011)108 School No No No Medium & higher
Hillier et al (2012)109 School Yes No No NR
Kalyva and Avramidis (2005)19 School No No No NR (“average IQ”)
Kamps et al (1992)44 School No No No Medium & higher
Kamps et al (2014)35 School Yes Yes Yes Medium & higher
Kamps et al (2015)42 School No Yes No Lower, medium, & higher
Kasari et al (2012)80 School Yes Yes Yes NR (inclusion cutoff)
Kasari et al (2016)39 School Yes Yes Yes Medium & higher
Koegel et al (2005)150 Community No No No NR
Koegel et al (2014)50 School No No Yes NR
Koegel et al (2012)110 School No No Yes NR
Koegel et al (2012)111 School No No No NR (inclusion cutoff)
Koenig et al (2010)58 School No Yes Yes Medium & higher
Koning et al (2013)112 School No Yes Yes Medium & higher
Kretzmann et al (2015)51 School No Yes Yes NR (inclusive class)
Kuhn et al (2008)113 School No No No NR

(Continued)
182 SEMINARS IN SPEECH AND LANGUAGE/VOLUME 39, NUMBER 2 2018

Table 1 (Continued)
Study Place Friend Manualized Fidelity Cognitive Level
Outcome
Laugeson et al (2009)23 School Yes Yes Yes Medium & higher
Laugeson et al (2012)59 School Yes Yes Yes Medium & higher
Laushey and Heflin (2000)114 School No No Yes NR
Laushey et al (2009)66 School Yes No Yes Medium & higher
Leaf et al (2009)115 Clinic & Yes No No Medium & higher
School
LeBlanc et al (2003)116 School No No No NR
Lee et al (2002)117 School No No No NR
Lee et al (2007)47 School No No Yes NR
Lee and Sturmey (2006)118 Community No No No NR
LeGoff and Sherman School No No No Medium & higher
(2006)119

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LeGoff (2004)120 School No No No Medium & higher
Lerner and Mikami (2012)60 School Yes Yes Yes NR (exclusive dx)
Lerner et al (2011)121 School No Yes Yes NR
Lerner et al (2012)151 School No No No NR
Liber et al (2008)122 School No No No NR
Loftin et al (2008)72 School Yes No Yes NR (“average IQ”)
Lopata et al (2006)123 School No No Yes NR
Lopata et al (2008)61 School No Yes Yes Medium & higher
Lopata et al (2010)62 School Yes Yes Yes Medium & higher
MacKay et al (2007)124 School Yes No No NR
Marriage et al (1995)125 School No No No NR (exclusive dx)
Mason et al (2014)67 School No No Yes Higher
McDonald and Hemmes Community No No No NR
(2003)48
Mesibov (1984)126 School No No No NR
Mishna and Muskat (1998)127 School No No No NR (exclusive dx)
Morrison et al (2001)128 School No No No NR
Mundschenk and Sasso School No No No Lower, medium, & higher
(1995)69
Nikopoulos and Keenan NR No No No NR
(2004)
Nikopoulos and Keenan School No No No Medium
(2007)152
Owen-DeSchryver et al School No No No Medium & higher
(2008)20
Owens et al (2008)63 School No Yes No Medium & higher
Ozonoff and Miller (1995)129 School No No No Medium & higher
Provencal (2003)130 School Yes No No Medium & higher
Radley et al (2014)131 School Yes Yes No Medium & higher
Roeyers (1996)70 School No No No Lower, medium, & higher
Rose and Anketell (2009)132 School Yes No No NR
Rosenberg et al (2015)133 School No Yes No NR
Ruble et al (2008)134 School No No No Medium & higher
 BEYOND SOCIAL SKILLS/RODDA, ESTES 183

Table 1 (Continued)
Study Place Friend Manualized Fidelity Cognitive Level
Outcome
Sansosti and Powell-Smith School No No Yes Higher
(2008)32
Sarokoff et al (2001)135 School No No No NR
Scattone (2008)153 School No No No Higher
Shabani et al (2002)136 School No No No NR
Shafer et al (1984)137 School No No No NR
Sherer et al (2001)138 School No No No NR
Solomon et al (2004)139 School No No No Higher
Soorya et al (2015)64 Clinic No Yes Yes Medium & higher
Stichter et al (2010)140 School No No No Higher
Stichter et al (2012)141 School No No No Medium & higher
Thiemann and Goldstein School Yes No Yes Lower & medium

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(2001)142
Thiemann and Goldstein School Yes No Yes Lower, medium & higher
(2004)71
Trimarchi (2004)143 Clinic Yes Yes Yes NR
Tse et al (2007)144 School Yes No No NR (exclusive dx)
Tyminski and Moore (2008)145 School No No No NR
Webb et al (2004)40 School Yes Yes No Medium & higher
Weidle et al (2006)146 School Yes No No Medium & higher
White et al (2010)147 School Yes No Yes Medium & higher
Williams (1989)54 School Yes No No Lower, medium & higher
Wood et al (2014)36 Clinic No Yes Yes NR (inclusion cutoff)
Yang et al (2003)148 School No No No Medium & higher

“Exclusive dx” mean only participants with certain diagnoses included (e.g., Asperger syndrome). “Inclusion cutoff”
means participants had above set cutoff score on IQ test. NR, not reported.

initiations or duration of contact with peers
were not counted as a friendship outcome.
One example of a study that targeted
friendships and assessed whether friendships
increased was a peer-mediated intervention
for school-aged children.21 This randomized-
controlled trial increased participants’ friendship
nominations (i.e., more classmates nominated
the children with ASD as friends) by the end of
the intervention. In this intervention, classmates
learned to include children who were socially
isolated. Participants with ASD received
more friendship nominations following treat-
ment, suggesting that their peers’ attempts
to bring them into the social milieu were suc-
cessful. However, the authors noted persistent
difficulties for the children with ASD in
forming reciprocal friendships, positing that
more intensive work on developing reciprocal
friendships was needed, even though the inter-
vention was effective in improving peer
relationships.
Future research is needed to evaluate whe-
ther social skills interventions lead to improved
friendship outcomes. (A discussion of potential
operational definitions of friendship is presen-
ted later.) Specific skills, such as initiating
interactions or entering groups, are important,
but these skills are ultimately of interest in part,
if not in whole, because these skills are thought
to improve friendships and peer relationships.
Promising intervention targets for improving
friendships include increasing social motiva-
tion, increasing initiation and responding in
peer groups, and reducing interfering problem
behaviors.22 Future clinical and research efforts
184 SEMINARS IN SPEECH AND LANGUAGE/VOLUME 39, NUMBER 2
are needed to identify the specific skills that may
be most effective in promoting peer relations-
hips and friendships.
Manualized Treatment Protocols
Twenty-four studies included treatment manuals
to define the structure and content of the inter-
vention being studied. Manuals included estab-
lished, ASD-specific curricula (e.g., PEERS) and
programs that were developed for other clinical
populations (e.g., the SCORE program).23,40
Manuals described methods for teaching skills
to children with ASD, such as making activities
and structure predictable for participants,38 desc-
riptions of order of intervention activities,39 and
specific lessons for teaching skills.23
Intervention Fidelity Assessment
Thirty-five studies reported using fidelity mea-
sures. Fidelity includes clinician adherence to a
treatment technique, such as following behavi-
oral approaches,41 competence in a technique
following training by independent observers,42
or completing a self-report fidelity check during
intervention (e.g., checklist indicating aspects
of the treatment that occurred).32
Generalization of Skills Learned in
Intervention
Peer relationships typically develop in everyday
settings including the classroom, playground,
lunchroom, and community, and with many
people. The goal of treatment should be to
teach skills that are generalized, meaning they
are used outside of treatment, across a variety of
settings, with many different people. We orga-
nized interventions by setting to indicate the
potential for generalization of skills from treat-
ment to other settings and people: (1) profes-
sionally led group based, (2) peer mediated, (3)
combined (group based and peer mediated), (4)
individual based, and (5) paraprofessional
implemented. We describe these interventions
in terms of setting (e.g., school or clinic).
Group-based interventions were the most com-
mon type of social skill intervention (n ¼ 56
studies), with 51 taking place in school, 3
occurring in a clinic, one occurring in both
2018
clinic and school, and 1 in the community.
Groups consisted of two or more children and
an adult leader. The leaders included teachers
and specialists (e.g., special education teacher or
speech-language pathologist) who directly
intervened with the children. In addition, we
included two interventions in the group-based
category because the intervention included the
entire class.43,44
Peer-mediated interventions were second
most prevalent, with 26 studies. Peer-mediated
interventions specified that children of similar
age to the participants with ASD received
training in some aspect of social skills such as
skills in helping children who are isolated from
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the group, conversational skills, and play skills.
All peer-mediated interventions took place in
school. Two interventions combined group-
based and peer-mediated approaches, in which
children with ASD learned in a social skills
group and peers were trained to help children
with ASD generalize their newly learned
skills.45,46 Both interventions were school
based. Sixteen studies were individual-based
(i.e., taught individuals with ASD one-on-
one with a therapist). Interventions took place
mostly in school (n ¼ 12), one in a clinic,36 and
two in the community.47,48 Paraprofessional-
implemented interventions were examined in
three studies, all of which took place in
schools.49–51
Including Children with Lower
Cognitive Functioning
Seventy-one studies described the cognitive
functioning level of participants. Some studies
did not report cognitive functioning, some
described categorical functioning level without
including participants’ scores, and some inclu-
ding scores of participants on IQ or related
tests. We counted studies as having a measure of
cognitive functioning if they included measures
of IQ (e.g., Wechsler Intelligence Scale for
Children) or measures highly correlated with
IQ (e.g., receptive vocabulary measures).52,53
Our characterization is adapted from one
review’s system of describing lower functioning
as IQ scores < 55, medium functioning as
scores of 55 to 85, and higher functioning as
scores > 85.34 We used standardized scores

from the measures previously mentioned to
categorize the functioning level of research
participants in each study (see Table 1).
Group-based interventions consisted mostly
of children with standardized scores in the
medium and higher range (n ¼ 31). Two
group-based interventions included children
with lower functioning.42,54 Twelve group-
based interventions did not report individual
cognitive functioning data, but reported that all
participants had average or above-average cog-
nitive functioning.23,38,55–64 Twelve additional
group-based interventions did not report IQ
measures. Peer-mediated interventions inclu-
ded seven studies with participants with IQs
suggesting medium to high cognitive functio-
ning.20,35,39,41,65–67 There were more children
with lower cognitive functioning in peer-
mediated interventions than group-based inter-
ventions (n ¼ 5).68–71 Twelve peer-mediated
interventions did not report cognitive functio-
ning scores, although several of these described
children as having “average” cognitive functio-
ning.19,72,73 The majority of individual-based
interventions did not report cognitive functio-
ning scores (n ¼ 12), but four reported scores,
all of which were in the medium and high range
of cognitive functioning.32,74,152,153 None of
the three paraprofessional-implemented inter-
ventions included IQ scores, but one study
described all participants as being in inclusion
classrooms.51
In summary, there has been extensive work
to develop and validate social skills interven-
tions for children with ASD. Limitations to
this literature are mostly related to the quality of
the evidence to date. Two recommendations for
ensuring high-quality interventions include
using treatment manuals and describing sample
populations so findings are reproducible.37
Our review of 104 studies found that only
24 used a treatment manual. Using treatment
manuals in intervention research and practice
can support consistent treatment implementa-
tion, which is crucial for understanding and
replicating treatment studies. Second, many
studies do not use reliable, validated measures
to describe sample populations and define
ascertainment criteria. When a study popula-
tion is not well defined it limits understanding
of the generalizability of findings and the ability
BEYOND SOCIAL SKILLS/RODDA, ESTES 185
to determine for whom a specific treatment
works.75 In studies of participants with ASD,
measures of cognitive and/or linguistic functio-
ning are particularly important. This supports
increased understanding of whether a treatment
is effective for children with varying cognitive
and/or linguistic abilities.
CLINICAL RECOMMENDATIONS
Recommendation 1: Interventions for
School-Aged Children with Autism
Spectrum Disorder Should Directly
Target Improving Friendships and Peer
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Relationships
Establishing and maintaining friendships is one
of the most important goals of social skills
interventions. Making friends is both a deve-
lopmental milestone and a foundational expe-
rience of the school-aged child.1,6 Making
friends is a critical factor for improved quality
of life for individuals with ASD across the
lifespan.76–78 Building friendships is usually
an implicit goal of social skills interventions,
but friendships are often not an explicit target.18
Directly targeting friendships can increase peer
connections and decrease loneliness.55
A testimony to the importance of friends-
hips, in one of the studies we reviewed, is that
receiving more friendship nominations and
making more connections with peers predicted
socially successful behaviors such as having
better engagement during recess.79 Few studies
have described specific approaches for impro-
ving children’s friendships. One notable excep-
tion is Children’s Friendship Training,55 which
includes lessons on having better conversations
with peers and being a good sport during play.
This approach includes a parent group, so that
parents can support their children in using the
skills they are learning in the group and at
home. Interventions must go beyond teaching
social skills to focus on whether these skills
improve friendship outcomes.18,39,80 Before prac-
ticing skills with friends, many children with
ASD will need to gain an understanding of
what a friend is. Because reciprocity is often an
issue, children with ASD should be provided
concrete descriptions such as “a friend is
someone who you like and who likes you
186 SEMINARS IN SPEECH AND LANGUAGE/VOLUME 39, NUMBER 2
back” and “a friend is someone who enjoys
doing some of the same things with you.” If
children are having difficulty picking up on bids
from potential friends, they need direct instru-
ction on detecting others’ social attempts (e.g.,
responding to another child’s attempt to start a
game or sit by them at lunch). To determine the
impact of social skills training on friendships,
clinicians should use pre- and postmeasures that
focus on friendships such as the Friendship
Qualities Scale,81 friendship nominations,79
and qualitative measures describing frequency
of meetings and shared activities with friends.32
We developed the Friend Information Inter-
view (FII),82 in part, to define the number of
friends in a child’s life (see Fig. 1). The FII
assesses six core characteristics of friendships in
school-aged children. Namely, a friend is
someone who (1) the child knows outside of
structured group settings, (2) reciprocates the
friendship, (3) has seen the child within
Figure 1 Friend Information Interview.
2018
6 months, (4) has at least one shared interest,
(5) is not a first-degree relative, and (6) lives in a
different house, as well as several other relevant
characteristics of a friend. Data gathered from
the FII could be used as pre- or postmeasure to
quantify the number of friends a child might
have or it could be used to identify teaching
targets. For example, before treatment, a child
with ASD might identify a potential friend, but
may not currently share interests with the child.
Friendship training could help the child with
ASD determine shared interests, help the child
initiate interactions around those interests, and
then measure whether the child with ASD and
the target friend engage in activities around
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those interests following treatment.
Children with ASD, even those with age-
appropriate intellectual ability and who are able
to function in mainstream classrooms, may have
significant challenges if left to build friendships
on their own. Most children with ASD will

need direct intervention to learn specific skills
to interact with others and develop and main-
tain friendships. Numerous studies have been
conducted to describe friendships in children
with ASD and over 100 studies have been
conducted to evaluate social skills interventions
with children with ASD. Thus, there is an
excellent research base on which to build.
One future direction could be adapting
widely used tools to support friendships for
children with ASD. First, Social Stories help
children with ASD increase game playing with
peers.83,84 Children with ASD could be taught
other friendship-related skills such as entering
peer groups, talking about shared interests, and
inviting friends over for play dates using Social
Stories. Video modeling also may help children
with ASD with perspective taking, play skills,
and conversation.85,86 Neither of these tools are
core features of existing social skills or friendship
curricula. However, many clinicians already are
using these tools and could use them to illustrate
target skills and enhance learning.
Another avenue that shows promise is to
have paraprofessionals facilitate interactions
between children with ASD and peers on
the playground or throughout the school
day. Although not yet reported in the litera-
ture, paraprofessionals could also support peer
interactions in community settings, sports
teams, churches, or day camps. Paraprofessio-
nal-delivered intervention has demonstrated the
ability to increase peer interaction for children
with ASD.15,50,51 Paraprofessional interventions
have the advantage of being implemented by an
adult who is available on a regular basis when
children are interacting with each other (such as
during recess), unlike pullout models that often
rely on clinicians who are not readily available to
offer support outside of intervention time. Alt-
hough paraprofessional-delivered interventions
have not yet met the criteria for EBP, creative
and informed clinicians have several avenues
available to support friendships for children
with ASD.
Recommendation 2: Use Manualized
Interventions
Treatment manuals provide information to
allow clinicians to standardize and structure
BEYOND SOCIAL SKILLS/RODDA, ESTES 187
treatment, suggest clearer intervention targets,
enable long-term planning for sessions, and
provide a framework for pre- and postassess-
ment.12 Using a manual to structure and stan-
dardize treatment is recommended frequently,
but is much less frequently implemented.87 A
manual describes the length and number of
sessions, content of the intervention, and provi-
der training.88
Clinicians can refer to two research-based,
manualized treatments as examples: Children’s
Friendship Training and the PEERS treat-
ment,59,89 which each include a clear descrip-
tion of the treatment. Clinicians may also
develop manuals of successful intervention stra-
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tegies for more consistent implementation
among team members.
Recommendation 3: Assess and
Monitor Treatment Fidelity
It is recommended that clinicians develop fide-
lity measures to ensure clinicians understand
treatment principles, implement the specific
techniques associated with the intervention,
and get additional training and support when
fidelity criteria are not met. Many social skills
interventions reviewed previously did not mea-
sure treatment fidelity, but practitioners can use
fidelity measures to reflect on their own practice
and maintain high-quality intervention. Clini-
cians or supervisors can assess new interven-
tionists’ learning during training with pre- and
post-tests.41 After training, clinicians can use
fidelity checklists, Likert scales, observation,
self-report, and feedback from participants to
monitor treatment implementation and provide
additional coaching to interventionists when
needed.41,42,88 Tools to assess treatment fidelity
can be developed and customized to fit the
needs of an intervention team.
Recommendation 4: Target
Generalization
Generalization of skills to new settings or
related therapy targets should be part of all
intervention approaches with children with
ASD.9,15 A real strength of the reviewed inter-
ventions was that many of them took place in
schools, providing access to peers and a variety
188 SEMINARS IN SPEECH AND LANGUAGE/VOLUME 39, NUMBER 2
of peer interaction settings (structured group,
quiet individual work, playground, lunch).
Children who received classroom and play-
ground interventions increased social skills,
maintained skills over time, and generalized
skills to new contexts.18,90 However, the nature
of many social skills groups is to teach children a
set of skills in a setting such as a clinic. In these
settings, extra attention needs to be paid to
generalization to the school and home setting.
Individual, one-on-one social skills interven-
tions face an even greater challenge. Not only is
the setting different from the setting in which
actual peer interactions and friendships are
built, but also the child needs to practice the
skills with peers. Although a didactic approach
can be effective,39 interventions without gene-
ralization as a direct focus seldom achieve the
desired outcomes.18,33 Clinicians can write
generalization into goals (e.g., play with five
different peers), promote generalization by tea-
ching parents to work on goals at home, and
expand deployment of skills by holding sessions
in different settings.9
Recommendation 5: Include Children
with Cognitive Impairments
Most social skills intervention studies have inclu-
ded only children without cognitive impairments.
However, 30 to 70% of children with ASD have
coexisting intellectual disability. Children with
cognitive impairments can form reciprocal, stable
friendships, with some notable differences from
children without cognitive impairments. Parents
of children with cognitive impairments report
that their children engage more in parallel play,
rely more on play than conversation to build
relationships, and require more parent support
to maintain the friendship.32 The unique challen-
ges of making friends for children with cognitive
impairments require additional research, espe-
cially with regard to interventions to improve and
support friendship and peer relationship develop-
ment in school-based social skills groups. An
emerging research literature on peer-mediated
interventions with children with cognitive
impairments is a positive step toward filling this
gap in our understanding.33,34
One of the most salient barriers for child-
ren with cognitive impairments making friends
2018
is effective communication. It is critical to
understand that it is possible for children
with ASD and low communication skills to
form reciprocal, stable friendships,82 but navi-
gating peer communication requires additional
and specialized support. Some of these children
may use augmentative and alternative commu-
nication (AAC), and emerging evidence supp-
orts using AAC systems to enhance peer
interactions.55,56 Clinicians with AAC expe-
rience can guide treatment by aiding in device
programming, identifying barriers for effective
communication with peers, and teaching peers
and other educators how to facilitate commu-
nication. To make interactions successful, peers
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should be taught strategies to interact with
children who have different communication
styles and modalities, respond to unexpected
or distracting behaviors, and address logistical
challenges of AAC.91,92
SUMMARY
There have been great strides in knowledge and
understanding of the social challenges children
with ASD face. Researchers and clinicians have
developed many tools to address these challen-
ges. Over 100 different studies of social skills
interventions have evaluated and built an evi-
dence base regarding the approaches that can
increase social skills for children with ASD.
However, most interventions have not yet been
evaluated in terms of increasing friendships.
Social skills groups, interventions implemented
by peers, and interventions by paraeducators in
schools appear promising for increasing peer
interactions, expanding social networks, and
improving peer-directed social communication
for children with ASD. It is not yet known
whether friendships are also increased. The
“active ingredients” of these interventions that
contribute most to improved peer relationships
and friendships is also not yet known. Future
studies of social skills interventions are needed
to investigate whether these interventions inc-
rease the number of friendships or improve the
quality of friendships. With momentum toward
developing a range of EBP, and with ingenuity
in both clinical practice and research, children
with ASD can and will develop greater social
skills and meaningful friendships.

DISCLOSURES
Financial: Dr. Rodda has no relevant finan-
cial relationships to disclose. Dr. Estes con-
ducts research supported by grants from
NIH: 1R01 MH100887; R01 HD055741–
11; R01ES026961; MH 100030–01.
Nonfinancial: No relevant nonfinancial rela-
tionships exist for either author.
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