English

How Much Performance-Based Intervention is Needed to Show Generalization in Social Competency Among Children with Autism Spectrum Disorder?

A Research Proposal

Hope Lambert

George Mason University

Author Note

This paper was prepared for English 302-H09, taught by Joseph Killiany.

Introduction

The aim of this research

Children and youth with Autism Spectrum Disorder (ASD) and Asperger’s Syndrome (AS) often experience anxiety stemming from social limitations including difficulties with facial feature recognition, understanding social cues, and participating in reciprocal social interactions (Corbett et al., 2014). Evidence suggests that theatre and performance-based interventions can help to develop the social skills deficient in many individuals with AS and ASD (Corbett et al., 2011; Corbett et al., 2014; Corbett et al., 2016). What is unclear at this time is how much theatre and performance-based intervention is needed for individuals with ASD and AS to generalize and maintain the acquired social skills. In a promising pilot study conducted by Lerner, Mikami and Levine (2011), participants showed stability in gains made through a six-week summer performance-based program, called Socio-Dramatic Affective-Relational Intervention, or SDARI. There is evidence to suggest that neurological deficiencies in early childhood among individuals with ASD and AS might contribute to delayed social competency skills in adolescents, which in turn leads to an increase in anxiety and depression (Chasen, 2014, Back Through the Looking Glass section, para. 7). This research proposal aims to further investigate the amount of intervention necessary for children with ASD and AS to incorporate their gains in social competency into their everyday lives (i.e. generalizing the gains) and to maintain those gains from early childhood to adolescence.

Terminology

Stirring some controversy in the greater ASD community, the latest version of the Diagnostic and Statistical Manual of Mental Disorders 5th Edition (DSM-5) eliminates the AS diagnosis as well as another condition, similar in some ways to AS, known as Pervasive Developmental Disorder Not Otherwise Specified or PPD-NOS and puts both under the ASD umbrella (Chasen, 2014). Chasen (2014) argues that this change has presented a challenge in providing intervention plans as there are differences in behavior and severity of symptoms in children with AS, PPD-NOS, and, what some researchers refer to as, High Functioning Autism (Chapter 1, Matthew section, para. 2). For the purposes of this research proposal, the author intends to continue to distinguish between the diagnoses; therefore, the terms ASD, AS, PPD-NOS, and High Functioning Autism, and Nonverbal Learning Disability will continue to appear in this literature review when they have been referred to in the primary research sources as such.

Additionally, with regard to distinguishing between interventions, studies on the efficacy of theatre and performance-based interventions cover a range of programs and techniques. For example, Corbett et al. (2010) evaluate the Social Emotional NeuroScience Endocrinology (SENSE) Theatre in their pilot study with a focus on social functioning in children with ASD while also examining anxiety levels among participants. Godfrey and Haythorne (2013) look specifically at the effectiveness of a dramatherapy program (Roundabout) in a school setting. Guli, Semrud-Clikeman, Lerner, and Britton (2013) study the impact of the Social Competence Intervention Program (SCIP), a performance-based program, on children with ASD. And Wilmer-Barbrook (2013) highlights a single case study participant in a dramatherapy social competency intervention for adolescents with AS. For the purposes of this proposal, the author has determined that the thematic connection between those programs is the performance-based, practical nature of the intervention. Therefore, from this point forward, the author gathers all theater and performance-based interventions under one umbrella, calling them simply performance-based interventions.

What we Know So Far about ASD and AS – Symptoms and Severity

Social Competency

It is widely understood that individuals with ASD and AS experience delays in social competency (Corbett et al., 2014; Corbett et al., 2016; Gates, Kang, & Lerner, 2017; Godfrey & Haythorne, 2013). Corbett et al. (2016) describes these delays as an inability to read and understand facial and body cues in others and therefore the inability to respond appropriately in social situations. Gates et al. (2017) further suggest that these delays potentially contribute to a peer bullying and a sense of isolation for individuals with ASD and AS.

Anxiety

In addition to social isolation and bullying, or perhaps as a result of, youth in the ASD and AS communities often report experiencing anxiety particularly in social situations (Corbett et al., 2010). Godfrey and Haythorne (2013) further establish that as children with ASD reach their adolescent years, the awareness of their social limitations may also compound their anxiety especially as the intensity of social interactions increases disproportionately to the level of social functioning skills needed in the teen years. Therefore, it is necessary that researchers continue to examine the causes and contributors to ASD symptoms and which interventions provide the most consistent results in supporting the development of healthy social functioning.

What are the Suspected Contributors to these Symptoms?

Facial Recognition

With an estimated 1 in 68 U.S. diagnosis rate, researchers are still working to uncover what might be the root cause of ASD and AS symptoms and symptom severity (Zwaigenbaum et al., 2015). Research shows that individuals with ASD and AS experience delays in social functioning beginning in early childhood and continuing throughout adolescence (Corbett et al., 2014; Corbett et al., 2016; Eussen et al., 2015; Guli, Semrud-Clikeman, Lerner, & Britton, 2013). Corbett et al. (2011) suggest that this delay in social functioning contributes to elevated anxiety for those with ASD. One study conducted in the Netherlands, designed to examine the association between facial feature recognition plus emotion identification and ASD symptom severity in adolescents, found that there appears to be a connection between an individual’s ability to accurately identify emotions as well as to quickly and accurately recall facial features and the individual’s social aptitude (Eussen et al., 2015). Eussen et al. (2015) hypothesize that the limitations in facial recognition and emotion identification in early childhood contribute to the inability of individuals with ASD and AS to engage with new peers and to function in a social setting similarly to their typically developing peers. Eussen et al. (2015) further suggest that these early childhood delays in face and emotion processing contribute to the delays in social competency gains and, thus, toward anxiety in adolescents with ASD and AS. In other words, the ability to recognize faces and emotions in early childhood feeds a social competency feedback loop and if one component is missing, the loop breaks down in later childhood.

Attention Deficit Hyperactivity Disorder (ADHD)

Semrud-Clikeman, Walkowiak, Wilkinson, and Minne (2010), put forward the idea that children with AS and Nonverbal Learning Disability (a condition sometimes confused with AS and High Functioning Autism), show greater deficits in emotion recognition and reading body language. Semrud-Clikeman et al. (2010) set out to investigate differences in social competencies among children with AS, NLD, and ADHD. Their research led to a possible conclusion that the social deficits children with AS display in childhood coupled with attention deficits (ADHD and AS often share a comorbidity) might be the root cause of the social competency issues children with AS face. In other words, the neurological delays in facial recognition and processing coupled with attention deficits might be the basis of the delays in understanding social cues (Semrud-Clikeman et al, 2010).

Neurological Connections

In his book Engaging Mirror Neurons to Inspire Connection and Social Emotional Development in Children and Teens on the Autism Spectrum: Theory into Practice through Drama Therapy, Lee Chasen (2014) highlights the need for children with autism to have ample opportunity to practice the social skills necessary to engage successfully with the world around them (Back Through the Looking Glass, para. 13). Chasen (2014) recalls the accidental though significant mirror-neuron discovery of the 1990s which established that human brains are wired in such a way that we learn to understand human behavior and to develop empathy by observing other people (Back Through the Looking Glass section, para. 1). In other words, we can watch an athlete score a goal and understand that that person is the one who scored the goal and still we feel the elation and the triumph with the athlete. For individuals with ASD, there is evidence to suggest that the neurological connection that allows humans to connect socially and to understand human behavior (i.e. mirror neurons) is lacking (Chasen, 2014, Back Through the Looking Glass section, para. 7). Chasen (2014) goes on to suggest that with what we now understand regarding neuroplasticity (or the human brain’s ability to reroute neurological connections) that performance-based interventions offer the kind of practice opportunities required to develop the neurological deficiencies necessary for appropriate and rewarding social interaction (Back Through the Looking Glass section, para. 12).

Social Competency Interventions

GSSI

Seeking to prove and improve the efficacy of social competency interventions for children with AS and ASD, researchers have examined Group Social Skills Interventions (GSSI) as well as performance-based interventions. According to McMahon, Lerner, and Britton (2013), GSSI are a group-based, social skills intervention working mainly with high functioning individuals with an ASD diagnosis. They go on to suggest that GSSI are the primary intervention used in the development of social competency among the AS and ASD communities (McMahon, Lerner, & Britton, 2013). Interestingly, in a study conducted by Gates et al. (2017) to determine the efficacy of GSSI, the researchers discovered, through a meta-analysis of past research, that GSSI greatly vary in length of the intervention overall, duration of individual sessions, as well as content and programming, making a conclusive study of GSSI efficacy a challenge . Still, Gates et al. (2017) conclude that GSSIs show only modest improvement in social competency among youth with ASD. Furthermore, through examining self-reporting methods typically used in ASD intervention research, Gates et al. (2017) suggest that it is possible that children with ASD gain an understanding of behaviors attributed to social aptitude but do not incorporate them into home and school life. They hypothesize that this might be because of the pedagogical nature of GSSI and that by creating environments conducive to practicing social skills, GSSI might show greater gains social competency outcomes and generalization of skills (Gates, Kang, & Lerner, 2017).

Theatre and Performance-based Interventions

As Goldstein, Lerner, and Winner (2017) suggest, the arts in general are a missed research opportunity for developmental and behavioral psychologists despite the broad inclusion of arts in the educational, psychological, and therapeutic worlds. However, recent studies have highlighted the improvements in social competency made by performance-based interventions especially among adolescents with AS and ASD (Corbett et al., 2011; Corbett et al., 2014; Corbett et al., 2016; Godfrey & Haythorne, 2013; Guli et al., 2013; Lerner, Mikami, & Levine, 2011; and Wilmer-Barbrook, 2013). More specifically, Corbett et al. (2010) suggest that performance-based interventions can provide the opportunities for individuals with AS and ASD to develop social skills through practice. Chasen (2014) supports this idea by suggesting that through neuroplasticity, children and adolescents with AS and ASD can potentially improve neurological deficiencies in the areas which support social skills development by practicing social reciprocity, observing and naming emotions, and by expressing the emotions of a character/role (inherent activities of a performance-based intervention) (Back Through the Looking Glass section, para. 12).

Conclusion

Understanding the root causes of AS and ASD symptom severity is a key component in answering the question of how best to support social competency development in those with ASD as well as to determine which interventions are the most successful. Eussen et al. (2015) hypothesize that children with ASD cognitively process facial features differently than their neurotypical peers, suggesting that a possible neurological cause leads to the difference in facial recognition and facial feature recall early in childhood. According to Eussen et al. (2015) and supported by Chasen (2014) this neurological difference could be a contributing factor to the symptoms of anxiety and depression later in adolescence when social pressures become elevated all while developmental social milestones have been missed. Further research, expanding upon existing studies that investigate the efficacy of performance-based interventions, is needed to uncover how much time spent in performance-based interventions allows for improvements in social functioning and for those improvements to cross-over into every day life, to be generalized.

Method

This research proposal will establish a longitudinal study of children diagnosed with ASD, starting in the elementary school-age years and culminating in the adolescent years. Through 3 consecutive four-week summer programs, followed by 2 per consecutive school year, six-week after-school (running once in the fall and once in the spring) sessions, this researcher will conduct pre-and-post tests to determine facial recognition accuracy and speed, as well as submit surveys to participants, parents, and teachers querying the success of social functioning in areas such as: social reciprocity, establishing initial contact with new peers, understanding and responding appropriately to social cues, developing friendships inside and outside the program, and which of these skills continue during breaks in the intervention as well as for a year post-study. Participants will begin the study in the elementary school-age years, between the ages of seven and ten. For three consecutive summers and corresponding school years, participants will attend a four-week performance-based summer program, as well as 2 six-week, after-school performance-based sessions. Inviting participants to engage in the study for three consecutive summers as well as during the school year will provide the participants consistency in programming and content as well as providing the researcher an opportunity to collect data on improvements in social competency over a span of years. This researcher hypothesizes that the earlier children with ASD begin a performance-based intervention and the more time spent working with the intervention, the higher probability of successful outcomes.

References

Chasen, L. R. (2014). Engaging Mirror Neurons to Inspire Connection and Social Emotional Development in Children and Teens on the Autism Spectrum: Theory into Practice through Drama Therapy [Kindle Fire Version]. Retrieved from Amazon.com.

Corbett, B. A., Gunther, J. R., Comins, D., Price, J., Ryan, N., Simon, D., Schupp, C.W., Rios, T. (2011). Brief report: Theater as therapy for children with autism spectrum disorder. Journal of Autism and Developmental Disorders, 41: 505-511. DOI 10.1007/s10803-010-1064-1

Corbett, B. A., Key, A.P., Qualls, L., Fecteau, S., Newsome, C., Coke, C., Yoder, P. (2016). Improvement in social competence using a randomized trial of theatre intervention for children with autism spectrum disorder. Journal of Autism and Developmental Disorders, 46 (2016): 658-672. DOI 10.1007/s10803-015-2600-9

Corbett, B. A., Swain, D. M., Coke, C., Simon, D., Newsom, C., Houchins-Juarez, N., Jenson, A., Wang, L., Song, Y. (2014). Improvement in social deficits in autism spectrum disorders using a theatre and performance-based, peer-mediated intervention. Autism Research, 7: 4-16. https://doi.org/10.1002/aur.1341

Eussen, M. L. J. M., Louwerse, A., Herba, C. M., Van Gool, A. R., Verheij, F., Verhulst, F. C., Greaves-Lord, K., (2015). Childhood facial recognition predicts adolescent symptom severity in autism spectrum disorder. Autism Research, 8, 261-271. https://doi.org/10.1002/aur.1443

Gates, J. A, Kang, E., Lerner, M. D. (2017). Efficacy of group social skills interventions for youth with autism spectrum disorder: A systematic review and meta-analysis. Clinical Psychology Review, 52, 164-181. http://dx.doi.org/10.1016/j.cpr.2017.01.006

Godfrey, E., Haythorne, D. (2013). Benefits of dramatherapy for autism spectrum disorder: A qualitative analysis of feedback from parents and teachers of clients attending Roundabout dramatherapy sessions in schools. Dramatherapy, 35:1, 20-28. DOI: 10.1080/02630672.2013.773131

Goldstein, T. R., Lerner, M. D., Winner, E. (2017). The arts as a venue for developmental science: Realizing a latent opportunity. Child Development, 8:5, 1505-1512. https://doi.org/10.1111/cdev.12884

Guli, L. A., Semrud-Clikeman, M., Lerner, M. D., Britton, N. (2013). Social competence intervention program (SCIP): A pilot study of a creative drama program for youth with social difficulties. The Arts in Psychotherapy, 40, 37-44. http://dx.doi.org/10.1016/j.aip.2012.09.002

Lerner, M. D., Mikami, A. Y., Levine, K. (2011). Socio-dramatic affective-relational intervention for adolescents with Asperger syndrome & high functioning autism: Pilot study. Autism, 15:1, 21-42. DOI: 10.1177/1362361309353613

McMahon, C. M., Lerner, M. D., Britton, N., (2013). Group-based social skills interventions for adolescents with higher-functioning autism spectrum disorder: A review and looking to the future. Adolescent Health, Medicine and Therapeutics, 4, 23-38. http://dx.doi.org/10.21.47/AHMT.S25402

Semrud-Clikeman, M., Walkowiak, J., Wilkinson, A., Minne, E. P. (2010). Direct and indirect measures of social perception, behavior, and emotional functioning in children with Asperger’s disorder, nonverbal learning disability, or ADHD. Journal of Abnormal Child Psychology, 38, 509-519. DOI: 10.1007/s10802-009-9380-7

Wilmer-Barbrook, C. (2013). Adolescence, Asperger’s and acting: Can dramatherapy improve social and communication skills for young people with Asperger’s syndrome? Dramatherapy, 35:1, 43-56. DOI: 10.1080/02630672.2013.773130

Zwaigenbaum, L., Bauman, M. L., Choueiri, R., Fein, D., Kasari, C., Pierce, K.,…Wetherby, A. (2015). Early identification and interventions for autism spectrum disorder: Executive summary. Pediatrics 136: S1, S1-S9. DOI: 10.1542/peds.2014-3667B

�Just to clarify that the limitations result from a difficulties with these things, not the things themselves.

�Good clarification.

�Good—this starts to get at the significance of the research proposed

�Good—this clearly conveys the concepts from the literature you want the readers to pick up on

�No publisher for this work is noted on the citation page. How do you know it’s authoritative?

�Good point—this is very important to consider if you want to determine amount of contact time needed for an intervention to work