Parent-Child Reciprocity and the Effectiveness of PEERS (ISR-PEERS)

Entering adolescence is a significant milestone in the development of socialization. Same-sex friendships and "best friends", developed during childhood, become more intensive, reciprocal, and intimate. In addition, social networks evolve and become more central for adolescents. Social interaction moves in adolescence from focusing on game playing to conversation focused interaction. Teens begin to exhibit dialogical skills, including the capacity to acknowledge others' opinions and emotions; view oneself in someone else's position; discuss disagreements with empathy while maintaining positive affect; and engage in a give-and-take, fluent, and non-constricted exchange while maintaining an autonomous stance. The consolidation of close friendships requires for teens to learn to dialogue joint positive plans as well as interpersonal conflicts within the relationship. Parents, through their relationships with their teens, can provide them with opportunities to learn, experience, and practice the dialogical skills needed for social functioning. Parental contribution to teens' dialogical skills is possible despite the differences between parent-teen and teen-peers interactions, since interaction in both kinds of relationships requires reciprocity .

Reciprocity is defined as the capacity to engage in social exchange that integrates inputs from multiple partners into a unified social event. It involves an ongoing process of awareness to- and interpretation of- the emotional and interpersonal cues of others, followed by an appropriate response that enables a smooth continuation of the social interaction. Parent-child reciprocity is a key element of early social relationships, which sets the foundation for social collaboration, empathy, and pro-social behavior. Developmental studies have demonstrated how early parent-child reciprocity predicts social adaptive functioning in adolescence, whereas intrusive, controlling parenting is associated with poorer social outcomes, such as affiliations with deviant friends. Adolescents gain from productive reciprocity with the parent, as it gives them an opportunity to express their individuation vis-a-vis the parental stance, and to practice important perspective taking, exchanging information, negotiation, and conflict resolution skills in a secure, enabling environment. The proposed study aims to examine the effect parent-teen reciprocity has on adolescents with an Autism Spectrum Disorder. Autism Spectrum Disorder (ASD) is a neuro-developmental condition, characterized by social communication deficits and restricted and repetitive behavior patterns. ASD symptoms vary in severity (e.g. from total lack of social initiative and extreme difficulty tolerating change, to an awkward social approach and difficulties adapting behavior do the social context), which may be related to different levels of functioning. In addition, ASD can involve intellectual impairment and comorbid psychopathology, that may further hamper independent functioning . Despite positive effects of early intervention social deficits in ASD persist throughout the lifespan even for higher functioning individuals .

For many individuals with ASD, adolescence is a particularly troubling period, characterized by enhanced motivation for social relationships, but at the same time, by increased realization of the difficulties they encounter when interacting with peers and their lack of knowledge and experience in friend-making . As they attempt to integrate socially, adolescents with ASD experience more negative social outcomes (e.g., fewer friends, little support from classmates, limited involvement in social activities, and increased peer rejection) compared to adolescents with other developmental disabilities or typically developing teens. Due to their social-communication deficits as well as their social naivety, adolescents with ASD are also more exposed to bullying, reflected in high rates of victimization and perpetration.

Parents play a pivotal role in caring for their child with ASD. Due to the developmental delays and social isolation of individuals with ASD, parents continue to care for their children into adolescence and adulthood, often as the only carers . Because of their central supportive role in their children's lives, research has attempted to highlight parental factors that may predict the quality of parent-child relationships as well as child outcomes. Most studies observing such parental factors have focused on parents of toddlers and preschoolers, associating parental resolution of the child's diagnosis, parental insightfulness into the experience of the child, and parental sensitivity, with child's secure attachment. Studies of parents' relationship with their older offspring linked maternal pessimism to poorer relationships with sons/daughters with ASD , and maternal warmth and praise with lower levels of internalizing and externalizing symptoms in adolescents and adults with ASD. However, these studies are based on self and parental report rather than on behavioral observation, and did not examine parent-teen reciprocity.

Examinations of the effects of parent-child reciprocity on children with ASD have mostly focused on young children. Our own work showed parent-child reciprocity is associated with improved emotion regulation and lower negative emotionality as well as with increased levels of oxytocin in children with ASD. On the other hand, controlling, intrusive parenting was associated with externalizing behavior problems in children and adolescents with ASD. Parent-child reciprocity has also been shown to predict higher social skills of children with ASD and to mediate the relation between child's level of functioning and social skills. The contribution of parent-child reciprocity to the child's intervention related progress has been addressed in some intervention studies for toddlers and pre-schoolers with ASD , revealing parent-child reciprocity mediates the effect of social communication interventions in this young age group. However, an examination of parentadolescent reciprocity in ASD, as a predictor of teen outcome is still needed.

The complexity of the parental role in adolescence is greater and more stressful when parenting teens with ASD . The need for greater parental input into the nature of social interaction, the new themes of intimacy and sexuality brought upon by puberty, and the parental wish to protect their teens from exclusion and bullying may bring parents to be more controlling, and even intrusive in their interaction with their teens . However, as described above, parent-teen reciprocity is important in developing teens' appropriate social reciprocity with peers. Hence, the ability of parents to be more reciprocal and less intrusive in their interaction with their teens is expected to predict teens' social skills and reciprocity with peers. Furthermore, parent-teen reciprocity is expected to play a part in the ability of teens and parents to gain from interventions targeting social skills, such as parent-assisted social skills groups.

PEERS Intervention: Social skills groups are common interventions for people with ASD, especially those with average to above-average cognitive skills . However, the majority of social skills training programs have focused on children aged 7-12, and few studies have examined the benefit of such groups for adolescents with ASD . Furthermore, few Randomized Controlled Trials (RCTs) have examined the effectiveness of social skills training for those with ASD. The proposed study aims to conduct the first RCT of a social skills training program for adolescents with ASD in Israel, using the well-established Program for the Education and Enrichment of Relational Skills (PEERS). PEERS , is a parent-assisted, manualized social skills training program for high-functioning adolescents with ASD, addressing crucial areas of social functioning for adolescents (see methods for a description). Ecologically valid skills for making and maintaining friends are taught using psychoeducational and cognitive-behavioral treatment techniques. Parents learn how to be social coaches to their teens in a separate group, running in parallel to the teens' group. Teens practice the taught skills in between sessions. Parents, as social coaches, are expected to supervise their teens' treatment fidelity, and in addition to practice the taught skills with their teens (e.g., running a two-way conversation, noticing the others' non-verbal cues, etc.). In North America, PEERS has been evaluated using RCTs, with its efficacy established for improving a variety of social skills in adolescents, including social skills knowledge, social responsiveness, social communication, social cognition, social awareness, social motivation, assertion, cooperation, and responsibility . PEERS related gains were maintained even 5 years post intervention. PEERS treatment effects have also been reflected in changes in the social brain as revealed through biomarkers of treatment outcome using EEG . A first cross-cultural validation study of PEERS in South Korea, yielded a significant improvement in teens' social skills knowledge, interpersonal skills, play/leisure skills, and a decrease in teens' autism symptoms and depression, as well as parents' anxiety. Recently, two preintervention child factors; parental report on teens' social skills, and teens' self-awareness of their popularity, were found to predict PEERS intervention outcome. PEERS positive effects on parents' self-efficacy have also been reported. However, although PEERS relies on parents as social coaches, the effect of parent-teen reciprocity on PEERS outcome has not been examined. As in everyday life, parents have a complex role in PEERS: On one hand, supervising their teens' work may call for more controlling, intrusive parenting. On the other hand, in order to effectively practice the taught social skills with their teens (and to meet the program's goals), parents and teens need to reciprocally collaborate. The use of reciprocity and intrusiveness in parent-teen interaction could therefore mediate the effect of PEERS on teens' social skills. In addition, since PEERS also teaches parents how to be less intrusive and more reciprocal with their teens, an improvement in parent-teen reciprocity is expected