Mathematics - Statistics INDIVIDUAL HOMEWORK 3

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Journal of Autism and Developmental Disorders (2019) 49:2581–2588 https://doi.org/10.1007/s10803-019-03911-7

BRIEF REPORT

Brief Report: Does Watching The Good Doctor Affect Knowledge of and Attitudes Toward Autism?

Stephanie C. Stern1 · Jennifer L. Barnes1

Published online: 2 February 2019 © Springer Science+Business Media, LLC, part of Springer Nature 2019

Abstract Individuals’ knowledge and attitudes about autism spectrum disorder (ASD) work together to shape the stigma held about ASD. One way that this information is communicated to the public is through popular media; however, little is known about the effectiveness of fictional depictions of ASD in educating and shaping attitudes about ASD. The purpose of this research was to investigate the impact media has on knowledge about and attitudes towards ASD, compared to that of a college lec- ture on the subject. Exposure to one episode of a fictional drama depicting ASD, compared to watching a lecture, resulted in more accurate knowledge, more positive characteristics associated with ASD, fewer negative characteristics associated with ASD, and a greater desire to learn more about ASD.

Keywords Autism spectrum disorder (ASD) · Stigma · Knowledge of autism · Media · Popular culture

A growing body of research has investigated the stigma faced by individuals with autism spectrum disorder (ASD), the relationship between this stigma and knowledge about ASD, and mechanisms for conveying knowledge and decreasing stigmatization (e.g., Brosnan and Mills 2016; Butler and Gillis 2011; Gillespie-Lynch et al. 2015; Harri- son et al. 2017; Matthews et al. 2015; Sasson and Morrison 2017). One likely source of knowledge and preconceptions about autism is media content. Holton et al. (2014) found that news media was often stigmatizing in its depiction of autism, focusing on negative outcomes and using labels that “other” individuals with ASD. Meanwhile, fictional depic- tions of autism often focus on savants (Draaisma 2009), reinforcing the commonly held myth that all people with ASD have a special talent or savant skill (e.g., John et al. 2017). Holton (2013) argued that fictional media is rarely told from the point of view of any autistic character(s) and instead frequently centers on the concerns of their loved ones. A notable recent exception to this is the popular tel- evision program The Good Doctor, which stars an autistic protagonist. The purpose of this experiment was to explore

the effects, if any, of watching The Good Doctor on college students’ knowledge about behaviors associated with ASD and their tendency to attribute positive and negative traits to individuals with ASD.

Although researchers have questioned the potentially harmful effects of popular fiction representations of ASD on attitudes toward and expectations of individuals with ASD in real life (e.g., Holton 2013; Draaisma 2009), research in media psychology has also highlighted the potential of fic- tional narratives to increase empathy (e.g., Bal and Veltkamp 2013; Johnson et al. 2013) and decrease stereotyping and prejudice toward marginalized groups (e.g., Kaufman and Libby 2012; Schiappa et al. 2006). For example, Bal and Veltkamp (2013) found that participants who were emotion- ally transported into an Arthur Conan Doyle story demon- strated increased real-world empathic concern 1 week later. Similarly, Kaufman and Libby (2012) found that participants who took on an African American or homosexual character’s perspective while reading exhibited more favorable attitudes toward that character’s group thereafter. Further research has found that participants randomly assigned to view an award-winning television drama, such as Mad Men or West Wing, subsequently outperformed those assigned to view an informational documentary, such as Through the Wormhole, on an advanced emotion-reading task (Black and Barnes 2017). In line with these results, Mar and Oatley (2008) have characterized fiction as a form of social simulation

* Stephanie C. Stern [email protected]

1 Department of Psychology, University of Oklahoma, Dale Hall Tower, Room 723, 445 W. Lindsey Street, Norman, OK 73019, USA

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that allows the audience to practice interpreting the internal worlds of others. To what extent, then, might fiction be able to teach audiences about autistic minds and influence atti- tudes toward individuals with ASD?

The current study focuses on 2017s top-rated television drama, The Good Doctor, which follows a young surgical resident named Shawn Murphy, who is identified as hav- ing ASD (Hennings Santiago 2017). We randomly assigned undergraduate participants to watch either a taped, multi- media lecture on ASD, given by an experienced professor of abnormal psychology, or a portion of the pilot episode of The Good Doctor. Afterwards, participants completed two tasks, one aimed at assessing knowledge of behaviors associated with ASD and one tapping attitudes. Based on prior research on the capacity of fiction to decrease prej- udice (e.g., Kaufman and Libby 2012), we predicted that while participants in the lecture condition might show an advantage on the knowledge test, those assigned to watch The Good Doctor would attribute more positive traits and fewer negative traits to individuals with ASD.

Method

Participants

Data were collected from 146 undergraduate students at a large Midwestern University. A total of 144 participants (109 female, mean age = 19.3 years) remained after one participant was excluded from each condition due to failure to respond to more than 50% of the survey. One participant in the final sample identified as gender-non-binary and was excluded from analyses including gender. The sample was 72.6% Caucasian, 5.6% African American, 11.1% Asian/ Asian American, 9% Native American, 8.3% Hispanic, and 1.4% other. Of the 144 participants included in the final sam- ple, 40 had seen The Good Doctor before (27.8%). Although efforts were made to determine participants’ experience with

ASD in their own lives, a survey glitch resulted in no infor- mation about prior experience with ASD being recorded. Recruitment was conducted through the Psychology Depart- ment’s online recruitment platform, where introductory psychology students receive credit for voluntary research participation.

Comparisons of participant demographics across the fic- tion and lecture conditions can be found in Table 1. The two experimental groups did not differ on age, gender, or prior exposure to The Good Doctor.

Procedure

Upon coming into the lab, participants were randomly assigned to either the fiction condition (watching the first 28 min of the pilot episode of The Good Doctor) or the lec- ture condition (watching a taped, 28 min lecture on ASD). The consent form indicated that the purpose of the study was to look at the relationship between visual media and learning, and participants were told that they would watch a video and answer questions about what they saw. Par- ticipants began by answering demographic questions on individual computers, then viewed their assigned video in groups of one to three. After watching the assigned material, participants returned to their own computers and completed a battery of measures aimed at assessing their knowledge of and attitudes toward ASD, as described below.

Stimuli

Fiction Condition Participants in the fiction condition watched the first 28 min of the pilot episode of The Good Doctor, which focuses on protagonist Dr. Shawn Murphy’s quest to become a surgical resident at a prestigious hospital in San Jose. The pilot flashes between scenes in Shawn’s present, scenes from his traumatic childhood, and scenes involving other medical personnel at the hospital, including the board, which is debating the appropriateness of his inclu-

Table 1 Demographic distribution by condition

Fiction condition Lecture condition Chi-square test

Gender  Male 23 11 χ2 = 2.78  Female 56 53 p = .09

Viewing history  Yes 23 17 χ2 = 0.23  No 53 47 p = .63

Fiction condition Lecture condition T-test

M SD M SD t = 0.71

Age 19.48 1.93 19.22 2.58 p = .48

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sion in the residency program, based on his ASD diagno- sis. Although Shawn often avoids eye contact and becomes frequently overwhelmed in social situations, “his medical knowledge is encyclopedic, his memory flawless, and he has a computer’s ability to think in three-dimensions and rotate complex anatomical structures in his head” (Zuger 2018, p.  1848). Consistent with the assertion that depictions of ASD in fiction often focus on individuals with nearly super- human skills (e.g., Draaisma 2009), Shawn is explicitly described as a savant. Various aspects of the DSM-V criteria for ASD (American Psychiatric Association 2013) are dem- onstrated through Shawn’s behavior, memories, and interac- tions with other characters. For example, one scene shows Shawn as a child in a conversation with his younger brother. The brother is attempting to persuade Shawn to try to make friends with boys in their neighborhood. Shawn responds by asking what the point of having friends is, illustrating both the deficits individuals with ASD have in developing, maintaining, and understanding relationships and the need for symptoms of ASD to be present early in life.

Lecture Condition Participants in the lecture condition watched a 28 min lecture given by an experienced abnormal psychology professor and practicing clinical psychologist. The lecture covered diagnostic criteria, etiology, and treat- ment of ASD, as well as general statistic and demographic information associated with ASD. The video, which was recorded in the faculty members office, featured PowerPoint slides taken from the professor’s highly rated abnormal psychology course, as well as a smaller feed in the bottom

corner of the screen where the professor could be seen pre- senting the information. The lecture materials also included a video featuring a young boy with ASD.

Coding In order to assure that The Good Doctor did not contain more information about ASD than the lecture, two analyses were conducted to compare the content of the lec- ture and television stimuli. First, the amount of time spent discussing or illustrating ASD was calculated for each video. The lecture condition spent the entire 28 min on ASD, com- pared to 16 min spent discussing or illustrating ASD in The Good Doctor. The remaining 12 min of the episode focused on other characters; Shawn was not present in these scenes, and ASD was not discussed.

Next, a coder analyzed each video to assess for the pres- ence of content addressing each aspect of the DSM-V cri- teria for ASD (American Psychiatric Association 2013). In addition to coding whether this content was present in each video, the coder also coded whether the information was conveyed through explicit explanation or through an illus- trative example or both (see Table 2). The lecture explic- itly discussed all of the diagnostic criteria for ASD, while providing illustrative examples of five specific categories, including a video depicting stereotyped behaviors. The episode of The Good Doctor only explicitly discussed one aspect of the diagnostic criteria, deficits in social communi- cation. Significantly, however, The Good Doctor did show Shawn behaving in ways consistent with the DSM-V criteria, providing illustrative examples of all aspects of the diag- nostic criteria. Thus, while both the lecture and television

Table 2 Diagnostic criteria explained versus illustrated in the lecture and television stimuli

Criteria Lecture Television

Explained Illustrated Explained Illustrated

Criteria A  Deficits in social communication and interaction across multiple contexts X X X   (1) Deficits in social–emotional reciprocity X X X   (2) Deficits in nonverbal communication X X X   (3) Deficits in relationships X X

Criteria B  Restricted, repetitive patterns of behavior, interests, or activities X X   (1) Stereotypes or repetitive motor movements, use of objects, or speech X X X   (2) Insistence on sameness, inflexibility, or ritualized patterns of behavior X X   (3) Highly specific, fixed interests X X X   (4) Hyper- or hyporeactivity to sensory input X X

Criteria C  Symptoms present in early development X X X

Criteria D  Symptoms cause clinically significant impairment X X

Criteria E  Disturbances not better explained by intellectual disability or developmental delay X X

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conditions contained similar amounts of information about the behaviors and characteristics associated with ASD, the television condition did so by providing significantly more illustrative examples of the diagnostic criteria than the lec- ture condition, X2(1, N = 24) = 9.88, p < .01, whereas the lec- ture condition provided more explicit explanations than the television condition, X2(1, N = 24) = 20.31, p < .001.

Dependent Measures

Knowledge of ASD A 30 item behavioral checklist, devel- oped by White et al. (2016) for use with college students, was used to assess participants’ post-manipulation knowl- edge of behaviors associated with ASD. This measure aims specifically to examine college-aged participants’ under- standing of autism, with an eye toward how they may view classmates or peers with ASD. Participants were presented with a list of behaviors and asked to select the ones they believe an individual with ASD would exhibit. Sixteen items on the list were behaviors characteristic of ASD (e.g., “avoiding eye contact” and “bringing up irrelevant topics in class”) while the remaining 15 were behaviors not associ- ated with ASD (e.g., “trouble learning” and “being overly friendly with other students”).1

Based on the items participants checked off, two scores were computed: number of correct behaviors selected (α = 0.67) and number of incorrect behaviors selected (α = 0.69).

Attitudes Towards Individuals with ASD Prior research has suggested that one way of stigmatizing individuals with ASD is through labeling them with negative or othering traits (Corrigan 2000); simultaneously, other scholars have argued that “many autistic traits can function in neutral or positive way, although other people may misunderstand or stigmatize atypical behaviors” (Kapp 2018, p. S362). Thus, a second checklist measure—intended to parallel the struc- ture of the knowledge measure—was developed to assess participants’ likelihood of attributing positive and negative traits to individuals with ASD. Past research on stigmati- zation towards individuals with mental disorders and other mental health issues have implemented this type of approach (Siperstein et al. 1977; Sahin et al. 1994), as has literature on other (racial, ethnic) types of stigmatization (Krueger 1996; Niemann et al. 1994; Stephan et al. 1993).

Participants were presented with a list of 40 traits (20 pos- itive, α = 0.61; 20 negative, α = 0.72) and asked to select the

characteristics they thought would apply to someone with ASD. The items for this checklist were adjectives, gener- ated in matched pairs. Nine pairs (18 items) consisted of opposites (e.g., “empathetic”/“unfeeling,” “helpless”/“able”) while the remaining 11 pairs of traits consisted of synonyms, with one word possessing a more negative valence (e.g., “arrogant”) and one more positive (e.g., “confident”). The 20 negative traits were generated by an individual with experi- ence in autism research. Four types of negative traits were generated: those that directly corresponded to characteris- tics of ASD, documented in either the diagnostic criteria or prior research (e.g., “obsessive,” “repetitive,” “bogged down in detail”); those that corresponded to common stereotypes of ASD (e.g., “unfeeling,” “weird”); those that focused on general functioning (e.g., “helpless,” “childlike”); and more generalized negative traits that had no particular associa- tions with ASD in college populations (e.g., “unintelligent”). Positive traits were then generated from the list of negative traits, either by generating an opposite or by generating a synonym with a more positive valence. Thus, participants could attribute positive traits to individuals with ASD either by denying they have certain negative characteristics (and circling the opposite instead) or by choosing to view certain traits in a positive, rather than negative, light. Total scores were calculated for the total number of negative traits and the total number of positive traits selected.

Perceived Understanding Participants were asked to indi- cate whether they understood ASD extremely well, very well, moderately well, slightly well, or not well at all. Simi- larly, they were asked to report how well they understood what it would be like to have ASD on the same scale.

Interest in  ASD Participants were asked to indicate how interested they were in learning more about ASD (not inter- ested, somewhat interested, or very interested).

Results

Preliminary correlational analyses were conducted to examine the relationship between gender and each of our dependent measures, as well as between prior exposure to The Good Doctor and each of our dependent measures. A Pearson correlation revealed that gender was only sig- nificantly correlated with participants’ desire to learn more about ASD [r(143) = 0.24, p < .01], with men (M = 2.06) having less desire to further their knowledge of ASD than women (M = 2.34). In contrast, past experience viewing The Good Doctor only showed a significant correlation with par- ticipants’ perceived understanding of ASD, r(140) = 0.21, p = .02 (see Table 3).

1 In constructing this measure, White and colleagues acknowledged that, due to the heterogeneous nature of ASD, some individuals with ASD may demonstrate some of the “incorrect” behaviors; however, these behaviors were not considered typical of college students with ASD.

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ANCOVAS were then conducted to compare performance across the two conditions on the four dependent measures, controlling for gender2 and, where appropriate, prior expo- sure to The Good Doctor. ANCOVA results are reported using Bonferroni adjusted p-values.

Knowledge About ASD

After controlling for gender, there was not a difference in the number of correct behaviors (i.e., those associated with ASD) selected by participants as typical of ASD in the fic- tion (M = 8.03, SD = 3.12) and lecture (M = 8.92, SD = 2.72) conditions, F(1,139) = 3.18, p = .56, η �2

p = 0.02. Contrast-

ingly, participants who viewed The Good Doctor (M = 2.59, SD = 2.12) selected significantly fewer incorrect behaviors (i.e., those not typically associated with ASD) than those who viewed the video lecture (M = 4.69, SD = 2.59), F(1,139) = 31.81, p < .01, �2

p = 0.19.

Attitudes Toward Individuals with ASD

Participants in the fiction condition attributed significantly more positive traits to someone with ASD (M = 7.35, SD = 3.24) than those in the lecture condition (M = 5.53, SD = 3.12), F(1,139) = 10.75, p = .01, �2

p = 0.07. Similarly,

participants in the fiction condition also attributed signifi- cantly fewer negative traits to an individual with ASD (M = 4.23, SD = 2.53) than those in the lecture condition (M = 5.64, SD = 2.35), F(1,139) = 14.17, p < .01, �2

p = 0.09.

Perceived Understanding

After controlling for participants’ viewing history and gen- der, there was no significant difference between the fiction condition (M = 2.72, SD = 0.86) and the lecture condition (M = 2.89, SD = 0.80) in regards to participants’ perceived understanding of what ASD is, F(1,135) = 1.10, p = 1.0, � 2 p = 0.01. Participants in the fiction condition also did not

differ in self-reported understanding of what it is like to have ASD (M = 1.87, SD = 0.97) from participants in the lecture conditions (M = 2.33, SD = 1.05), F(1,139) = 6.78, p = .07, � 2 p = 0.05.

Interest in ASD

Participants who watched The Good Doctor demonstrated a greater interest in learning more about ASD, with 44.3% of participants very interested, 53.2% moderately interested, and 2.4% not interested, compared to 28.1% very interested, 59.4% moderately interested, and 12.5% not interested in the lecture condition, χ²(1, N = 143) = 7.77, p = .02. Because gender was a significant predictor of a desire to learn more about ASD, an ANCOVA was conducted looking at the effect of condition on interest above and beyond the impact of gender. Condition remained a significant predictor of desire to learn more, F(1,139) = 11.02, p = .01, �2

p = 0.07.

Discussion

In this experiment, college students were randomly assigned to watch roughly half an hour of either a lecture on ASD or the television pilot of The Good Doctor, which features a protagonist, Shawn Murphy, who has ASD. After watch- ing the assigned material, participants then completed two

Table 3 Correlations between variables of interest

*p < .05, **p < .01

Variables 1 2 3 4 5 6 7 8 9 10 11

(1) Gender – (2) Age − 0.12 – (3) Understanding of autism − 0.12 − 0.01 – (4) Understanding having autism 0.03 0.15 0.51** – (5) Interest in learning more − 0.23** 0.01 0.14 0.02 – (6) Viewing history − 0.12 0.02 − 0.21* − 0.08 − 0.14 – (7) Correct behaviors 0.06 0.08 0.14 − 0.01 0.16 − 0.06 – (8) Incorrect behaviors − 0.10 − 0.24** 0.00 0.04 − 0.08 0.06 0.20* – (9) Accuracy 0.09 0.25** 0.12 − 0.04 0.20* − 0.09 0.70** − 0.56** – (10) Positive traits − 0.02 − 0.11 0.12 0.04 0.22** − 0.13 0.29** − 0.02 0.26** – (11) Negative traits − 0.12 0.09 0.03 − 0.02 − 0.12 0.05 0.38** 0.53** − 0.07 − 0.14 –

2 Despite the fact that gender was only related to the desire to learn more about ASD, we controlled for gender in our analyses across dependent measures, as requested by a reviewer due to the imbalance of male and female participants in our sample.

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checklists: one of behaviors they believed to be associated with autism and one of traits that they believed someone with ASD would have. Participants who watched The Good Doctor were no less accurate than controls at identifying behaviors associated with autism and were in fact less likely to demonstrate false positives (i.e., choosing behaviors not typically associated with ASD from the checklist). Moreo- ver, participants who watched The Good Doctor chose more positive traits and fewer negative traits from a checklist of adjectives when asked to choose words that described peo- ple with ASD. Participants in both conditions self-reported equal levels of understanding of what autism is and what it would be like to have autism, but participants who watched The Good Doctor reported a greater desire to learn more about ASD in the future.

These results are significant for several reasons. First, they suggest that fiction—in this case, a popular television show—may be an effective means of influencing attitudes towards individuals with ASD. Although The Good Doctor shares many of the pitfalls identified by scholars as endemic in the portrayal of characters with ASD, such as the focus on a savant (e.g., Draaisma 2009), the fact that the character with ASD is the protagonist, rather than a mere player in someone else’s story (Holton 2013), may allow the audi- ence to form more of a connection with the character and further their understanding of what it means to have ASD. Strikingly, however, participants who watched The Good Doctor did not perceive themselves as having a higher level of understanding of what it would be like to have ASD than those who watched the lecture, despite the fact that the show often invites readers into Shawn’s head, via memories and visual depictions of Shawn’s thinking. Significantly, even though participants in both conditions demonstrated simi- lar self-appraisals of their understanding, participants who watched The Good Doctor were significantly more likely to report a high level of interest in learning more about ASD. The differences found between these two measures may reflect differences in the scales used to assess perceived understanding and the desire to learn more; alternatively, it is possible that while participants in both groups felt they had a similar level of understanding, participants who watched The Good Doctor may have been more motivated to understand ASD—and Shawn—more fully.

Further, while promising, the positive effects seen in this experiment should be interpreted with some caution. Although watching media that depicts savants may decrease stigmatization of autism, it is unclear what the real-world repercussions of exposure might be when individuals sub- sequently encounter real people with ASD who may pre- sent with more severe symptoms and no savant-like abilities. Future research is needed to know whether real individuals with ASD are judged more harshly in comparison to fictional savants like Shawn Murphy.

A variety of other limitations of this research must also be acknowledged. The focus here was on a single show, and more research is needed to investigate the generalizability of these effects. In particular, there is a need for research examining whether depictions of more diverse presentations of ASD would lead to similar results. Such research could help distinguish whether the effects found here are due to an increase in empathy (e.g., Bal and Veltkamp 2013) and/ or having spent time with and gotten to “know” a fictional person with ASD (e.g., Schiappa et al. 2006) or whether the more positive attitudes in The Good Doctor condition are simply a spillover from positive appraisals of the protago- nist’s extraordinary savant-like skills. Similarly, it is unclear whether similar effects would be found after watching a documentary, rather than a fictional (and melodramatic) portrayal.

Another key limitation here involves differences between the stimuli in the lecture and fiction conditions. Although coding revealed that The Good Doctor spent less time focused on autism and contained no more information about the diagnostic criteria for ASD than the lecture condition, the television show was more likely to convey the charac- teristics of ASD through illustrative examples, showing them in action rather than explaining them per se. Future research examining the role that this difference might play in the audience’s motivation and ability to learn about ASD is needed. Although we did not measure engagement with the videos presented to participants, it is also likely that The Good Doctor was seen as more entertaining and engaging than the lecture, particularly given that our sample consisted of college students, for whom sitting in lecture is a daily, required experience. Similarly, the instructions given to par- ticipants indicated that this experiment was about learning, which may have resulted in participants in The Good Doctor condition making more of an attempt to extract information from the show than they would when viewing purely for pleasure. Future research is needed to examine these pos- sibilities, as well as explore whether the results found in this study would replicate with participants who are not college students, predominantly female, and relatively close in age to the protagonist of The Good Doctor.

Further consideration must also be given to the dependent measures used in this experiment. For example, the knowl- edge measure used in this task, developed by White et al. (2016) for use with college students, focused specifically on behaviors associated with ASD in college student popula- tions; it seems likely that a more comprehensive knowledge measure, looking at participants’ understanding of etiology, interventions, prevalence, neurodiversity, and so on (e.g., Gillespie-Lynch et al. 2015; Harrison et al. 2017) might have yielded different results. Indeed, the “knowledge” measure in this task may be capturing attitudes as much as knowl- edge: participants in the Good Doctor condition scored

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better because they were less likely to associate incorrect (often negative) behaviors with ASD. Furthermore, both the knowledge and attitude assessments used in this study had α values that indicate potentially questionable reliabil- ity. Future research using stronger assessment tools would further our understanding of the relationships found here. Future research is also needed to expand this work to other measures of attitudes, such as measures of social distance (e.g., Butler and Gillis 2011). Moreover, it is worth noting that past research on stigmatization has focused not only on participants’ attitudes toward individuals explicitly labelled as having ASD, but also those who demonstrate behaviors associated with ASD; indeed, labeling in these cases seems to decrease stigmatization of behaviors (e.g., Butler and Gil- lis 2011; Sasson and Morrison 2017; Matthews et al. 2015). Thus, it is an open question whether viewing a show like The Good Doctor would affect participants’ attitudes toward behaviors in absence of a labelled diagnosis. Finally, future research is needed to examine the role that prior knowledge of or experience with ASD might play in the effects found here; as such, researchers may find pre-/post- designs par- ticularly useful in extending this work.

Although these results are preliminary, they highlight the need for empirical exploration of the effects that popu- lar media has on public knowledge of and attitudes toward ASD. This is an area ripe for future research.

Author Contributions The following authors contributed to this research: Stephanie C. Stern and Jennifer L. Barnes. Both authors are affiliated with the University of Oklahoma.

Compliance with Ethical Standards

Conflict of interest All authors declare that they have no conflict of interest.

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