http://informahealthcare.com/pdr ISSN: 1751-8423 (print), 1751-8431 (electronic) Dev Neurorehabil, 2015; 18(2): 122–130 ! 2015 Informa UK Ltd. DOI: 10.3109/17518423.2013.855275

ORIGINAL ARTICLE

An intervention to improve social participation for adolescents with autism spectrum disorder: Pilot study Sophie Goldingay1, Karen Stagnitti1, Loretta Sheppard2, Jane McGillivray3, Belinda McLean4, & Genevieve Pepin1 School of Health and Social Development, Deakin University, Geelong, Victoria, Australia, 2School of Allied and Public Health, Faculty of Health Sciences, Australian Catholic University, Melbourne, Victoria, Australia, 3School of Psychology, Deakin University, Melbourne, Victoria, Australia, and 4 Cottage by the Sea, Queenscliffe, Victoria, Australia Dev Neurorehabil Downloaded from informahealthcare.com by Nyu Medical Center on 05/28/15 For personal use only.

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Abstract

Keywords

Objective: To increase flexible thinking, self-regulation and empathy for adolescents with ASD. Method: Five adolescents (M ¼ 13.5 years; SD ¼ 0.84 years; four males) were assessed pre and post intervention for flexible thinking and social competence (as measured by the SSIS). Parents rated their adolescent’s social competence pre and post intervention. Results: A large decrease was found in parent rating of their child’s level of hyperactivity (12.8, SD ¼ 2.3; 11, SD ¼ 2.2) (p ¼ 0.034) (Cohen’s d ¼ 0.95). Parents increased their rating of their child’s cooperation and empathy (Cohen’s d ¼ 0.71 and 0.56, respectively). A medium effect for flexible thinking was observed in three items (Cohen’s d ¼ 0.5 to 0.62) and a large effect for one item (Cohen’s d ¼ 1.35). Adolescents decreased self-scoring on the social scale post intervention. Conclusion: Improvements were observed in adolescents’ flexible thinking and social insights, and parent’s perception of their child’s self-regulation.

Adolescents, autism spectrum disorder, empathy, flexible thinking, pretend play, self-regulation, social relationships

Introduction Autism Spectrum Disorder (ASD) is characterised by a triad of impairments: social interaction (non- verbal communication such as responding to and initiating eye contact and smiles), social communication (ability to share interests and ideas or to negotiate in a positive friendly way) and social imagination (consequential thinking) [1]. The implications of these impairments are significant for building and sustaining social relationships. For example, in the social imagination area, difficulty in predicting the impact of one’s own behaviour on self and others leads to problems in selfregulation [2, 3], and recognition and appropriate response to the emotions of others (empathy) [4]. Empathy and the capacity for self-regulation are also important to containing inappropriate behaviours and reactions which may be repellent to others and put social relationships at risk. Bierman and Montminy [5] noted that older children who are well liked socially demonstrated sustained interpersonal support and self-regulation. Under the ‘social communication’ category, difficulties in ability to negotiate and share (and receive others) ideas is associated with inflexible thinking [6]. Flexible thinking is also a central component of social skills as it enables people to alter their behaviour and social

Correspondence: Dr. Sophie Goldingay, School of Health and Social Development, Deakin University, Locked Bag 20001, Geelong 3220, Victoria, Australia. Tel: +61 3 52278461. E-mail: sophie.goldingay@ deakin.edu.au

History Received 7 October 2013 Revised 10 October 2013 Accepted 10 October 2013 Published online 7 November 2013

‘strategy’ according to the nuances of the particular social situation they face [7]. Adolescence is a time when peer relationships become particularly salient in a person’s life, and lack of social skills may cause ongoing exclusion and rejection which may precipitate engagement in risky, self-defeating and antisocial behaviour [8]. Isolation impairs quality of life and mental health, and may be a risk factor for suicidal ideation for adolescents [9]. Problems with empathy, self-regulation and flexible thinking are not the only symptoms for adolescents who have ASD, and they may be experienced in various degrees. Nevertheless, they are significant barriers to building and sustaining social relationships, indicating the need for intervention. A number of intervention strategies have been successfully trialled to address difficulties in flexible thinking, empathy and self-regulation in adolescents with ASD but few, if any strategies have targeted all three in one intervention. For example, Argott et al. [10] used a multiple-baselineacross-participants experimental design to assess the effectiveness of a script-fading procedure on increasing verbal statements of empathy in a study with two males and one female adolescent with autism. The intervention demonstrated that script fading was able to teach adolescents to recognise emotions connected with gestures and facial expressions and respond appropriately, first with script and eventually without script. In another study [11], also using multiple baseline testing with three adolescents with ASD, a collaborative virtual learning environment (CVLE) – 3D empathy system

Social participation for adolescents with ASD

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DOI: 10.3109/17518423.2013.855275

was used over a 5-month period. This too indicated positive effects on participant use of empathy, as demonstrated by the CVLE 3D empathy system and in terms of maintaining learning in understanding empathy. A small number of interventions have been trialled to address difficulties in self-regulation for adolescents with ASD, including music therapy [12], art therapy [13] and a writing skills intervention which targeted goal setting, selfmonitoring and self-reinforcement [14]. This last intervention was only designed to improve writing skills and is not necessarily transferable to social skills. The music therapy intervention assessed progress in various social communication domains with 33 clients at risk of ASD between the ages of 1.5 and 32 years using the SCERTS (Social Communication, Emotional Regulation and Transactional Support) interdisciplinary assessment tool. The assessment revealed that while music therapy was effective at meeting transactional (i.e. interpersonal support) goals, there was little evidence for successful outcomes with respect to self-regulation. Similarly, a case study using art therapy with one 18-year-old female adolescent with ASD [13] connected difficulties with selfregulation as contributing to social difficulties for adolescents with ASD but did not target this directly. Instead, the goal was to open new channels of communication, improve self-esteem and self-concept and gain insight into personal struggle. There are few studies describing interventions designed to improve flexible thinking in adolescents with ASD. One study identified difficulties associated with behavioural flexibility and reversal learning for 41 individuals diagnosed with ASD (mean age of 15 years) but did not specifically address flexible thinking in a social situation [15]. However, a number of studies have found positive significant correlations between the development of flexible thinking, self-regulation and pretend play skills in younger children [16–18]. In addition, Russ et al. [19] reported that the quality of a child’s pretend play predicted their flexible thinking four years later and this was independent of IQ. Further studies have discussed the value of pretend play to child development because it requires participants to understand the social context, the roles of other players, the functions of the props and the meaning within the play [20, 21], as well as the appropriate use of language associated with that particular play scene [22]. To pretend in play requires a young person to logically sequence and order their play actions over several weeks [21], problem solve and negotiate with peers [23] and extend on other young people’s ideas [23]. They also need to be able to self-regulate their own emotions and actions to maintain interactions that sustain the play [24]. In the younger years, social shared pretend play activities are important for the acquisition of sustained interactive narrative and reciprocal play and social interaction [5, 18–20]. Peer interactions become increasingly complex with age and 11 to 14 years is a developmental period where there are large changes in children’s social reasoning enabling them to integrate social information in a more complex fashion [5]. However, if adolescents have not developed the foundational skills of shared pretend play activities, then going into puberty would put them at a disadvantage for building more complex social reasoning ability. Go¨ncu¨ and Perone [25] argued that pretend play is a life span activity with the

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example that improvisation involves skills that underlie pretend play and these skills contribute to emotional selfregulation. If pretend play is indeed ‘an adaptive human activity’ [24, p. 137] then pretend play would be relevant to adolescence. People with ASD are known to have difficulties in pretend play ability in childhood [22]. There is some evidence showing a link between early pretend play and later ability in adolescents as Sigman and McGovern [26] found, in a longitudinal study with 48 individuals from pre-school to mid-school, that a child’s play skills and joint attention at preschool were precursors of language ability in adolescents with autism. Bierman and Montminy note that ‘With the coming of adolescence, ‘‘play’’ no longer accurately describes the focus of most peer interactions’ [5, p.233]. However, pretend play supports the development of social abilities such as social understanding, flexible thinking, self-regulation, selfawareness and empathy [21] as well as sustained reciprocal interaction, narrative understanding, understanding of roles, flexible thinking, metacognition and problem solving. These are foundational skills for the further development in complex social interactions. We therefore put forward the proposition that for adolescents with ASD, there may be poor development of skills related to early pretend play ability and that these skills could be the focus of an age appropriate intervention program to build ability in sustained social interaction, through increasing flexible thinking, self-regulation and empathy. The purpose of this article is to present the findings of a pilot study on an intervention program that was aimed at increasing the social competence through increasing flexible thinking, self-regulation and empathy of adolescents with a diagnosis of ASD.

Aim The aim of the pilot study was to trial an intervention, based on pretend play skills, which was designed to increase social understanding in adolescents with a diagnosis of ASD. Specifically, the pilot worked to develop skills such as flexible thinking, self-regulation, developing a narrative (i.e. understanding of the language and meaning behind the play, and using it appropriately) and understanding of character (i.e. empathy or understanding what it would feel like to be that character). Hypotheses (1) Associate Fluency Test (AFT) scores would increase after the intervention, suggesting an increase in flexible thinking. (2) The adolescents’ scores on the Social Skills Improvement System (SSIS) related to empathy and self-regulation would decrease after the intervention suggesting enhanced insight into their social competence. (3) The parent’s scores on the SSIS related to empathy would increase after the intervention. (4) Parent SSIS scores would decrease in items related to self-regulation. (5) The Animated Movie Test (AMT) scores would increase after the intervention indicating increased understanding of narrative and character.

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Method

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Participants A total of seven adolescents were recruited to the study through contacts with social service agencies working with young people with ASD. Attendance at a mainstream school and accessing services due to difficulties in peer and social interactions were prerequisites for inclusion in the study. Of the initial seven, two adolescents did not complete the intervention. One withdrew due to family circumstances and the other chose not to continue. Five adolescents, four boys and one girl, with a mean age of 13.5 years (SD ¼ 0.84 years) completed the intervention program. Parents reported their child’s diagnosis. Two of the participants had a diagnosis of Asperger’s Syndrome (AS), one had a diagnosis of High Functioning Autism and two had a duel diagnosis of AS and Attention Deficit Hyperactivity Disorder. All participants lived within the family home and came to the intervention sessions with one parent. All participants attended a mainstream school indicating the IQs were higher than 70. In addition, participations were also assessed on the Hayes Ability Screening Index (HASI) to gain more information on their cognitive function. Measures Hayes Ability Screening Index The HASI was administered to all participants to establish their level of cognitive functioning. The HASI was developed to screen for individuals with an intellectual disability within the justice system. It is designed to be used by a broad range of professionals and takes 10 minutes to administer. Validity testing of the HASI with the Kaufman Brief Intelligence Test and the Wechsler tests found no significant differences between the test scores for individuals [27]. The correlation between the HASI and the Vineland Adaptive Behaviour Scales for males was r ¼ 0.65 (p50.01) and with the Kaufman the correlation was r ¼ 0.7 (p50.01). For females, the correlations were r ¼ 6.6 and r ¼ 6.8 (p50.01). A cut-off score of 89 was found optimum for adolescents, meaning that adolescents who scored below this were vulnerable for intellectual disability [27]. Associate Fluency Tests The AFT was administered to measure flexible thinking [28, 29]. It was chosen because it assessed the adolescent’s ability to think of objects in different ways and to be flexible in understanding meaning. There was no time limit, although assessors were instructed to move to the next question when it was felt that the young person has no more suggestions. There are no right or wrong answers. All instructions had a standardised format with a standardised score sheet. This assessment is divided into two sections, ‘Instances’ and ‘Uses’. ‘Instances’ is verbally based, with the adolescent asked to think of objects with certain characteristics, for example, things that are round. In the ‘Alternative Uses’ section, the adolescent was asked to give as many alternative uses as they can to named objects. For example, they were asked ‘Tell me all the different ways you can use a newspaper’. The ‘Similarities’ section explores the

Dev Neurorehabil, 2015; 18(2): 122–130

adolescents’ ability to think of many similarities between named objects as they can, for example, the similarities between a potato and a carrot. The last two sections of this assessment are ‘Pattern Meanings’ and ‘Line Meanings’, where the adolescent was presented with cards of patterns and then lines. They were instructed to think of as many things as possible that the patterns and lines could be. The scoring of the AFT is by frequency and unique score. Frequency scores are based on how many different answers the adolescent could think of for each question. Repetitive type answers were not counted, for example, if they said musical instruments and then said piano, violin, only the answer ‘musical instruments’ was scored. Unique scores are given for those answers where the adolescent was the only one in the sample to think of such an answer. Unique scores are a measure of creativity [29]. Split half reliability was found to be strong by Wallach and Kogan [29] with split reliability coefficients being from 0.51 to 0.93 with 9 of the 10 items being 0.75 to 0.93. High interrater agreement has been found ranging from 96% [28] to 99% [30]. Cropley and Maslany [31] found Kuder–Richardson reliability coefficients were 0.67 to 0.90 with eight of the items being 0.82 or above showing good to excellent reliability. Cropley and Maslany [31] carried out factor analysis and correlations with Primary Mental Abilities test and concluded that the Wallach–Kogan tests ‘measure a stable and internally consistent intellective mode’ (p. 398). Social Skills Improvement System The SSIS is a 15-minute paper and pencil test that measures social skills (including communication, cooperation, assertion, responsibility, empathy, engagement and self-control) and problem behaviours (including externalising, bullying, hyperactivity/inattention, internalising and autism spectrum). Both the parent and adolescent version of the SSIS were used. The questions relating to social skills are rated by importance as well as relevance to the individual. The problem behaviours are rated on relevance only. If the adolescents could not understand the question, the assessor would read out the question and then explain its meaning. Scores can be compared to a large nationally representative sample of similarly aged individuals [32]. Internal consistency reliability of the Social Skills and Problem Behaviours range from the mid to upper 90 s for each age group [32]. Test–retest reliability coefficients for the parent form ranged from 0.7 to 0.92, indicating good reliability [32]. The student form test–retest reliability ranged from 0.58 to 0.8, indicating moderate to good reliability [32, 33]. Animated Movie Test The AMT is a new assessment developed by the second author and was used in this study for the first time. It aims to assess the ability to plan a cohesive narrative, add characters and symbols to the narrative and initiate a flow of ideas. Further research is being carried out on its reliability and validity. The adolescent is presented with seven sets of props as well as unstructured materials such as felt pieces and pipe cleaners. Instructions are that the adolescent is the director of

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DOI: 10.3109/17518423.2013.855275

an animated movie and there is 30 minutes for the adolescent to plan, set up and act out the movie with the given props. The AMT is filmed by the assessor. The scores are based on the coherence of the movie plot, character development, use of symbols and problem solving within the movie plot. This assessment is based on skills embedded in earlier pretend play ability with reference to logical sequential thinking and narrative development as well as understanding of character.

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Procedure Following ethics approval, families were recruited via local agencies who work with adolescents with social difficulties. All participants were assessed pre and post the intervention by four members of the research team who were only involved in assessment. Two members of the research team were involved in the intervention. The assessment team members and intervention team members were blinded to the assessment results and intervention. respectively. The AFT, the student SSIS, the newly developed Animated Movie Test and the parent SSIS were administered at pre- and post-intervention. Participants were recruited in July 2012, underwent preintervention assessment in August and then received the intervention between September and October 2012. The intervention was run over eight weeks with one-hour intervention sessions being held with all five participants. They were re-assessed in December 2012. The facilitator of the intervention had extensive experience working with adolescents in community mental health settings. The intervention had a number of activities. Firstly, it included activities designed to develop flexible thinking, for example, passing a box around the group and asking each one to think of something different a box could be used for. There were also warm-up activities to help the cohesiveness of the group. The main activity each week was to work as a group to develop a storyboard with accompanying characters and narrative, with the group aim being to prepare a ‘movie’ to film on the final week of the study. They then negotiated a storyboard with their fellow participants and designed and set up props for the movie. The culmination of the eight weeks was the filming of a movie by all five participants. Analysis Data were analysed using SPSS version 21 (Armonk, NY, USA). Descriptive statistics were calculated for the sample for each assessment. As the sample was small, a Wilcoxon Signed Ranks Test was used to examine any significant changes between pre and post assessments. Wilcoxon Signed Ranks Test can be used for samples as small as 5 [34], with tables given for small samples. Cohen’s d was calculated based on mean and standard deviation for each test item to provide an indication of size of the effect of the intervention. A small effect was regarded as 0.2, a medium effect is 0.5 and a large effect is 0.8 or above [35], with effects of 1.0 indicating one standard deviation difference before and after intervention. As the sample was small, individual scores were also examined for change and a Reliable Change Index was calculated for clinical significance for the SSIS scores as the test–retest reliability coefficient was available.

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Results HASI HASI scores ranged from 82 to 93, with four of the five adolescents scoring 89 or higher, indicating that they were not vulnerable for intellectual disability. Pre–post assessments Because the sample was small, and the effect size needed for change was unknown for this new intervention, an alpha level of 0.10 was chosen to reduce the risk of committing a Type II error [35–37] and to maximize statistical power [36, 38]. Cohen’s d was also calculated to provide information on effect size for this quasi-experimental design [35, 38]. For each assessment individual scores pre and post are also presented with SISS scores also including a Reliable Change Index [39] score for adolescents and parents. Associative fluency The descriptive statistics for pre and post scores on the AFT and the results of the Wilcoxon Signed Ranks Tests and Cohen’s d are presented in Table I. Table II presents the individual scores and change in the raw score for each item in the AFT. As can be seen from Table I, there was a significant difference between pre- and post-frequency scores for pattern meaning, and unique scores for alternate uses and line meaning. Cohen’s d indicated there was a medium effect size for line meaning frequency scores, and unique scores for alternate uses and similarities, and a large effect for line meaning unique scores. In all items except instances, the scores increased from pre to post assessment, showing increased creativity in thinking. From Table II, the biggest positive change was in line meaning. Hypothesis 1 was partially supported. SSIS for adolescents Pre and post scores for the Adolescent SSIS can be found in Table III which also includes the Wilcoxon Signed Ranks test

Table I. Pre and post scores with significance and effect size for the Associative Fluency Scores.

AFT Variable

Pre scores M (SD)

Post scores M (SD)

Frequency scores Instances Alternate uses Similarities Pattern meaning Line meaning

28.4 12.8 11.6 13.0 12.2

(6.8) (6.3) (4.3) (7.2) (3.9)

25.4 13.4 12.4 13.8 16.4

Unique scores Instances Alternate Uses Similarities Pattern meaning Line meaning

13.8 5.6 3.4 8.8 4.6

(5.5) (3.9) (2.9) (5.4) (2.6)

11.8 8.2 5.8 9.8 10.8

*Alpha ¼50.10

p Value

Cohen’s d

(6.1) (6.3) (6.5) (6.5) (8.8)

0.35 0.46 0.68 0.10* 0.18

0.46 0.09 0.14 0.12 0.62

(5.8) (5.2) (6.1) (6.2) (6.1)

0.42 0.07* 0.35 0.13 0.08*

0.35 0.57 0.50 0.17 1.35

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Table II. Pre and post raw scores for individual participants. AFT Variable Frequency scores Instances

Alternative uses

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Similarities

Pattern meaning

Line meaning

Unique scores Instances

Alternate uses

Similarities

Pattern meaning

Line meaning

Table III. Pre and post scores for the SSIS for the adolescents.

Pre

Post

Change

36 24 31 32 19 16 10 16 19 3 10 8 11 19 10 18 8 13 22 4 14 6 14 16 11

28 27 22 33 17 14 10 14 23 6 14 7 10 23 8 18 9 14 22 6 19 9 18 29 7

8 3 9 1 2 2 0 2 4 3 4 1 1 4 2 0 1 1 0 2 5 3 4 13 4

21 10 17 14 7 8 2 10 7 1 2 2 7 6 0 12 6 8 16 2 4 1 8 4 6

17 11 9 18 4 10 4 10 15 2 9 1 2 15 2 14 5 9 18 3 12 7 11 20 4

4 1 8 4 3 2 2 0 8 1 7 1 5 9 2 2 1 1 2 1 8 6 3 16 2

and Cohen’s d results. Table IV presents the individual scores and a Reliable Change Index for each participant for each item. RCIs were developed to aid researchers in clinical psychology to objectively determine change in response to intervention [39]. A RCI that is greater than þ1.96 represents significant improvement across time, a RCI less than 1.96 represents a significant decrease in performance, and an RCI [1.96 5 x 5 þ1.96] represents a non-significant change [39]. As noted in Table IV, one participant made clinically significant changes in communication and responsibility.

SSIS variables

Pre assessment M (SD)

Post assessment M (SD)

Communication Cooperation Assertion Responsibility Empathy Engagement Self-control Standard Score

12.6 14.6 14.4 14.4 11.8 12.8 12.2 98.6

13.0 15.6 13.4 14.4 10.6 11.4 10.8 95.8

(4.2) (5.6) (6.4) (5.3) (4.8) (5.5) (4.1) (25.1)

(4.2) (4.2) (5.7) (3.9) (3.5) (5.5) (4.2) (20.2)

p Value

Cohen’s d

0.59 0.68 0.19 1.00 0.28 0.14 0.16 0.42

0.09 0.20 0.16 0 0.29 0.25 0.33 0.12

Table IV. Pre and post raw scores for each participant for SISS for adolescents with Reliable Change Index. SSIS variables

Pre

Post

Reliable Change Index

Communication

18 10 16 8 1 20 13 21 10 9 20 10 21 15 6 21 12 19 11 9 17 9 17 9 7 18 12 18 11 5 15 8 18 10 10

18 10 17 11 9 21 12 18 11 16 17 8 20 15 7 18 10 19 12 13 15 6 13 10 9 18 10 14 12 3 13 6 16 7 12

0 0 0.45 1.36 3.65 0.37 0.37 1.12 0.37 1.12 1.02 0.67 0.34 0 0.34 0.98 0.98 0 0.49 1.96 0.86 1.29 1.73 0.43 0.86 0 0.86 1.73 0.43 0.86 0.72 0.72 0.72 1.07 0.72

Cooperation

Assertion

Responsibility

Empathy

Engagement

Self-control

Overall, there were no significant differences in scores on the SSIS for adolescents between the pre and post assessment. Cohen’s d indicated small and mostly negative effect sizes. The mean raw scores for communication and cooperation increased after the intervention and the mean raw scores for assertion, empathy, engagement and self-control decreased after the intervention. Hypothesis 2, that SSIS scores would decrease after intervention, was partially supported.

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Table V. Pre and post scores for the parent version of the SSIS.

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SSIS variables

Pre assessment M (SD)

Post assessment M (SD)

p Value

Cohen’s d

SSIS social subtests Communication Cooperation Assertion Responsibility Empathy Engagement Self-control Standard Score

9.6 8.2 10.3 7.8 6.6 7.8 7 66.4

(3.3) (2.7) (3.8) (3) (3.8) (2.7) (3.9) (15.3)

10 10.4 9.3 8.8 9.2 8 7 71.6

(3.8) (3.4) (6.6) (3.2) (5.3) (9.2) (4.8) (19.7)

0.85 0.08y 0.47 0.18 0.07y 0.32 1.0 0.17

0.11 0.71 0.19 0.32 0.56 0.03 0 0.29

SSIS problem behaviours Externalising Bullying Hyperactivity/inattentive Internalising Standard score

14 2.2 12.8 10.2 130

(8) (2.2) (2.1) (6.9) (18.8)

12 2 9.2 9 111.4

(6.1) (3.1) (4.9) (6.1) (43.5)

0.14 0.78 0.02* 0.58 0.14

0.28 0.07 0.95 0.18 0.56

*p50.05 yalpha ¼ 0.10 Table VI. Pre and post raw scores for the parent version of the SSIS with Reliable Change Index. SSIS variables

Pre

Post

Reliable Change Index

Communication

14 6 8 12 8 12 6 6 10 7 12 8 14 15 6 11 5 7 11 5 11 1 5 8 8 10 4 10 9 6 7 1 7 12 8

16 6 8 11 9 14 5 10 12 11 14 2 14 15 11 13 5 7 11 8 14 1 7 13 11 10 4 11 9 5 7 0 5 12 11

0.94 0 0 0.47 0.47 1.05 0.53 2.11 1.05 2.11 0.74 0.4 0 0 1.85 0.88 0 0 0 1.32 0.78 0 0.78 1.97 1.18 0 0 0.39 0 0.39 0 0.37 0.75 0 1.14

Cooperation

Assertion

Responsibility

Empathy

Engagement

Self-control

Parent SSIS Pre and post scores for the Parent SSIS can be found in Table V, which also includes the Wilcoxon Signed Ranks test and Cohen’s d results. Table VI presents the pre and post raw scores with a Reliable Change Index for each item for each parent.

From Table V, parents rated their child significantly higher for cooperation and empathy and significantly lower for hyperactivity/inattentiveness following the intervention. These same items showed medium to large effects of the intervention. Hypothesis 3 was supported as empathy score increased. Hypothesis 4 was supported as parents noted a significant decrease in hyperactivity/inattention suggesting that the adolescent had improved in their self-regulation. From Table VI, two parents rated their child’s positive change in cooperation to clinically significant levels and one parent rated their child as clinically significantly improved in empathy. Parent and adolescent comparisons on SSIS Further analysis was carried out on differences in preassessment SSIS scores between parent and adolescent. Pre intervention, a significant difference between parents (7.33, SD 3.2) and adolescents (13.7 SD 5.5) for responsibility (p ¼ 0.04) and cooperation (parent 7.3, SD 2.9; adolescent 13.7, SD 5) (p ¼ 0.04) was found. For post assessment scores, there were no significant differences between parent and adolescent for any of the SSIS sub-scores. Animated Movie Test As can be seen in Table VII, there was no significant difference between the pre and post scores for the AMT and all raw scores were lower with Cohen’s d indicating a small effect. Within the study, the adolescents took a maximum of 17 minutes to complete the test with most of the movie plots lasting two minutes. Table VIII lists the movie scripts in the pre and post assessments. Hypothesis 5 was not supported. Table IX presents the pre and post raw scores for each participant for each item of the AMT. One participant gained higher scores in Movie set up at the post assessment and another participant gained higher scores in Movie itself.

Discussion The intervention program trialled in this study aimed to increase participants’ flexible thinking, self-regulation and empathy, to improve their ability to build successful and

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sustainable social relationships. Even though this was a small pilot study, medium and large effects of the intervention were found for adolescents’ flexible thinking and parent’s ratings of increased cooperation, empathy and self-regulation (decreased inattention/hyperactivity). Clinical significance was noted for communication (one adolescent and two parents), responsibility (one adolescent) and empathy (one parent). The results of this small pilot study indicate that the intervention had a noticeable impact on adolescent participants’ flexible and creative thinking as measured by the AFT. There was a medium to large effect for four items of creativity. For example, increased scores in the AFT Unique Scores for ‘alternate uses’, ‘similarities’ and ‘line meaning’ suggest an increase in lateral thinking and creativity. In similarities, the adolescent had to see what was common between unrelated objects. This may relate to lateral thinking which enables an acceptance of diversity and difference [7]. The AFT showed increased creativity post intervention, suggesting that ongoing practice in thinking of new uses for objects supported the development of new abilities for participants. The individual scores showed most improved scores in line meaning. Such activities thus have potential to assist those with ASD in finding novel ways of addressing interpersonal situations and relationships. An especially interesting finding was with the adolescents’ own ratings of their social skills after the intervention, as they were lower than before the intervention. For example, they

rated themselves lower on assertion, empathy, engagement and self-control after the intervention. This fact, together with the post assessment SSIS scores of the adolescents and parents being more closely aligned, demonstrate the impact of the program. Participants were able to discern some difficulties in their own social functioning that they could not prior to the intervention, indicating increased insight and self-awareness. In contrast, parent ratings of their child’s empathy and cooperation increased after the intervention and these ratings by the parents showed a medium effect, indicating the intervention had a noticeable change in these areas. It is possible that the process of developing characters and a narrative, and acting out scenes in the pretend setting of the movie each week, helped build an understanding of the movie characters and what they might be thinking and feeling. As noted by Whitehead et al. [40], engaging in pretence is a prerequisite for self-awareness and awareness of others. This suggests that by undertaking the intervention program, participants’ ability to understand the feelings of others improved. One parent noted a clinically significant improvement in their child’s empathy. Participants also rated themselves higher on communication and cooperation as measured by the SSIS at post assessment, although these changes were small and insignificant for the overall group, individually one adolescent rated

Table VII. Animated Movie Test pre and post scores for adolescents (n ¼ 5).

AMT Item

Pre

Post

Change

Movie setup

10 10 12 12 12 9 10 28 11 22

6 10 18 29 7 0 0 34 9 9

4 0 6 17 5 9 10 6 2 11

AMT variables Animated Movie Setup Animated Movie – Movie score Animated Movie Test total score

Table IX. Pre and post raw scores for each participant for each item of the AMT.

Post Pre assessment assessment M (SD) p Value Cohen’s d M (SD) 11.2 (1.1) 16 (8.5)

10.8 (8.3) 15.2 (12.9)

0.16 0.72

0.07 0.07

27.4 (9.2)

26 (13.7)

0.59

0.12

Movie Score

Table VIII. Animated Movie Test movie scripts. Pre assessment movie scripts Literal script of a vet with a camel that fell over

Space scene on Mars. Script is repetitive, lots of crashing, script is not coherent, for example, a taxi is on the moon and tries to run over the astronaut. Movie was titled ‘Space the Final Frontier’. Many props with a space vehicle going to Mars, crashing, Neil Armstrong, monkeys in space. People dying and the ending was everyone was sucked into a nebular. Created a chess set with knights, dragons and other figures and carried out a game of chess by repetition of props moving and knocking out other props. Set up a scene reflecting a family scene at Christmas. Described the scene.

Post assessment movie scripts More props utilised with African scene with African animals and four caretakers. Characters say ‘hello’, animals move and characters move. Literal moving of characters and minimal description. Space scene. Utilises similar props to pre assessment but less number of props. Script is a linear story with problems resolved. That is, astronauts land, they have a race, a dragon comes, they fight the dragon, they get a stronger space buggy, after the fight they fly away. Movie titled ‘Mystery of the Minnesota Corn Fields Shenanigans’. Props were unstructured, for example, ice-cream sticks were people, pipe cleaners were aliens, yellow felt was corn field. Story of police going into corn field, mixture of body snatching, changing form and people disappearing. Complex plot that maintained a coherent thread of thought with sub-plots. Created a chess set with knights, dragons and other figures and carried out a game of chess by repetition of props moving and knocking out other props. Set up a farm scene. Described the scene and the sale of the farm due to poor resources.

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DOI: 10.3109/17518423.2013.855275

Social participation for adolescents with ASD

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themselves clinically significantly higher in communication and two parents rated their children clinically significantly higher. A clinically significant difference indicates real-world difference [39]. The communication section measured selfreported behaviours such as using eye contact when talking, saying please and thank you. The cooperation section measured self-reported habits of following rules and completing tasks without bothering others. The intervention program aimed to have participants work as a group towards a final goal and this may have contributed to participants’ skills in communication and cooperation. Parents observed a significant decrease in hyperactivity post intervention. Parent ratings on the SSIS of their adolescents’ behaviours, such as acts without thinking, being inattentive and having temper tantrums, were significantly lower after the intervention with the intervention showing a large effect in this area. This suggests improved self-regulation skills of the adolescents as noticed by the parents. The Animated Movie Test results at pre intervention indicated that while all the adolescents could set up a scene and engaged enthusiastically with the assessment; only one could develop a cohesive narrative with characters and plot development with problems and resolutions. Observations of their abilities during this assessment showed that they all struggled with pretend play ability as measured through selfinitiating original ideas within a coherent narrative that involved characters and problem resolution. Three of the five participants were literal in their movie plots by stating what props they had put out or they had set up a scene from their life and reiterated what happened in that scene (e.g. Christmas lunch with the family). The decrease in scores post intervention was disappointing as this suggests a decreased ability to develop a coherent narrative and embed characters. Two participants did have a more cohesive movie script at post assessment and one participant utilised more props. One possible reason for the lack of improvement in AMT results is that the adolescents did not improve in this ability. Four of them carried out similar ideas that they had produced in the pre-assessment and many of these ideas were scripts from movies they had seen. For example, if the space props were used there were consistent references to ‘one small step for man’, or scenes from movies such as ‘Total Recall’. Another reason however could be that the testing environment may have also influenced this assessment. The post-assessments were carried out in a different building to the intervention and by members of the research team who were not involved in the intervention and so were unknown to the adolescents. A further reason may be that the intervention needed to be longer for the adolescents to consolidate their skills and for changes to be picked up in an assessment situation. Therefore, further work needs to be carried out on refinement of scoring criteria and reliability of this assessment, including a longer trial and carrying out the assessment and interventions in settings and with personnel who are familiar to the participants.

It has often been assumed that pretend play is not relevant past late childhood [41–43]. This assumption has been challenged by researchers such as Go¨ncu¨ and Perone [25] who suggest pretend play is relevant past late childhood. Smith and Lillard [43] found that pretending still occurred in the daily life of 38% of those in their sample who had a mean age 18.7 years. For adolescents with ASD, the findings of this study suggest that interventions based on pretend play are potentially effective. Even though this study is small, the medium and large effects and clinically significant changes were in flexible thinking, two adolescent’s self-rating of communication and responsibility, and parent’s ratings of communication, empathy and self-regulation. This suggests that further research would prove valuable.

Implications for practice

Declaration of interest

This study trialled an intervention to social skills training by focussing on underlying skills related to pretend play.

The authors report no conflicts of interest. The authors alone are responsible for the content and the writing of this article.

Limitations While these findings were clinically significant for some of those who participated, the study was only with a small sample and only eight weeks of intervention, with no follow-up. The fact that participants underwent the AFT twice might suggest the possibility that the ‘practice effect’ would enhance participants’ scores in the AFT as opposed to the therapeutic benefit of the intervention. However, this is unlikely as there were more unique scores, indicating that more of the adolescents were able to generate their own original ideas for answers which suggest that the repetition of the test did not impact on the validity of the scoring. Future directions The program has potential to be developed further as it provided a lot of information about participants’ abilities in flexible thinking, empathy and self-regulation and did so in an engaging, enjoyable and non-threatening way. Future research is recommended to include a larger study with a randomised control trial cross-over design and a longer intervention program including follow-up. We suggest the program be further trialled in schools for easier access for participants whose anxiety (and/or transport issues) may preclude them from attending a program in unfamiliar surroundings with unfamiliar peers. All of the adolescents who participated in the intervention stated that they enjoyed the AMT assessment indicating clinical viability. Further development on the scoring and interpretation, reliability and validity of this new test seems warranted.

Conclusion While the sample was small, the results indicated that an ageappropriate intervention based on the principles of pretend play resulted in a large improvement in self-regulation (decrease in hyperactivity scores from the parent), and medium size effects in empathy, cooperation and flexible thinking. This pilot has provided emerging understanding of a new approach to intervention, aimed at improving adolescents with ASD’s ability to build successful and sustainable relationships.

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S. Goldingay et al.

We wish to acknowledge the support of a [University, School] funding grant.

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