Improving the Social Skills of Children with High-Functioning Autism Spectrum Disorder: an Intervention Study

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Improving the Social Skills of Children with High-Functioning Autism Spectrum Disorder: an Intervention Study IMPROVING THE SOCIAL SKILLS OF CHILDREN WITH HIGH-FUNCTIONING AUTISM SPECTRUM DISORDER: AN INTERVENTION STUDY by Cynthia Aileen Waugh A thesis submitted in conformity with the requirements for the degree of Doctor of Philosophy Graduate Department of Applied Psychology and Human Development Ontario Institute for Studies in Education University of Toronto © Copyright by Cynthia Waugh 2015 Improving the Social Skills of Children with High-Functioning Autism Spectrum Disorder: An Intervention Study Cynthia A. Waugh Doctor of Philosophy Department of Applied Psychology and Human Development Ontario Institute for Studies in Education University of Toronto 2015 Abstract Previous research has found that although most children with high-functioning autism spectrum disorder (HFASD) desire friendship, they have fewer and less stable friendships and report more loneliness than their peers. They also tend to be socially naïve, vulnerable to deception and more often bullied. A significant contributor to their challenges is an impaired Theory of Mind (ToM), which is the ability to reason about mental states (e.g. knowledge, emotions, desires, beliefs, intentions). While social difficulties define ASD, research suggests that visual processing may be a relative strength. This bias favoring visual information over verbal mental representations appears to have enabled some children to gain mental state understanding via the use of visual supports. Since peer acceptance is a powerful predictor of mental health and the risks of peer rejection— and benefits of friendship— extend into adulthood, it is important to teach friendship-making skills. This was the broad objective of the study, which drew upon research demonstrating that ii despite deficits in ToM, children with HFASD have strengths in visual processing which can be utilized to enhance learning. A visually scaffolded, social skills and Theory of Mind intervention (S.S.ToM) for children with HFASD was designed and evaluated and compared to Children’s Friendship Training (CFT), a well-respected social skills intervention and a delayed treatment control group (DTC). Between- group comparisons revealed significant differences between the S.S.ToM and DTC groups on two measures of social responsiveness. Within-group differences for the S.S.ToM group were significant for all social responsiveness and ToM measures. Between- and within-group results were not as strong for the CFT group, however, there were fewer participants in this group and the lack of significance could be attributed to a lack of power. As a preliminary examination this study suggests that the S.S. ToM is an effective intervention but further research is needed. iii Acknowledgments I have many people to acknowledge and thank for their support of this work. First and foremost I would like to thank my supervisor Dr. Joan Peskin for her guidance and mentorship throughout my years at OISE. Her insights and attention to detail along the way were always invaluable. Her words of encouragement have meant more to me than words can express. I am especially thankful for her belief in this project and in me, and for pushing me to achieve. I also wish to thank my committee members, Dr. Judith Wiener and Dr. Joseph Ducharme for their insights, advice and encouragement. Their time, attention and wisdom have been very much appreciated. And to external examiners, Dr. Jessica Brian and Dr. Jonathan Weiss I extend thanks for their insights, questions and affirmations and for their participation in the final oral defence. I am grateful for the staff and volunteers at Autism Ontario, Durham Chapter and Precious Minds Support Services for assisting with the intervention through the commitment of time and resources. Importantly, I would like to thank the children and their parents who participated in this study. Although my goal was to teach them, they became my teachers. I will never forget the lessons I learned from them and through them. Finally thank you to my immediate and extended family who celebrated successes along the way and cheered me on when challenges seemed to exceed my ability and stamina. Thank you especially to my children Aaron, Jamie (& Casey), and Rebecca for taking interest in my work and helping out whenever they could. Thank you to my parents and other family members for all the encouragements along the way that helped me to stay the course. To my husband Clive, I can’t begin to express how much I love you and appreciate you. You have been a rock of stability and a constant source of encouragement and perspective throughout this journey, willingly managing details of our lives that I either could not manage or neglected. Thank you for ensuring that I made it to the finish line. “It is not knowledge, but the act of learning, not possession but the act of getting there, which grants the greatest enjoyment.” Carl Friedrich Gauss iv Table of Contents List of Tables……………………………………………………………………………..……....xi List of Figures……………………………………………………………………………..…….xiii List of Appendices..……………………………………………………………………..………xiv Chapter One: Introduction……………………...…………………………………………………1 Chapter Two: Autism Spectrum Disorder…………………...……………………………………5 2.1 Diagnostic Criteria and Prevalence of Autism Spectrum Disorder…………….………5 2.2 High-Functioning Autism Spectrum Disorder………………....…………….…………7 2.2.1 Social characteristics and challenges…………….……………….…………..7 2.2.2 Friendship in HFASD……………………….……………..………………….8 2.2.3 Bullying and mental health outcomes……....………………………………..10 2.2.4 Friendship as a protective factor…………..……......….…………….………13 2.3 Summary………………………….………………………………...…………..…...…13 Chapter Three: Cognitive Explanations of High-Functioning Autism Spectrum Disorder……...15 3.1 An Overview of Cognitive Explanations……………………………………….……..15 3.2 Social Cognition……………………….…………………………………….………...16 3.2.1 Weak social motivation theory……...…………………………….….……...16 3.2.2 Theory of Mind………………………………………………....……………17 3.2.3 Social information processing……………….………..….…….………...….18 3.2 Non-Social Cognition…………………………..………………………………...……19 3.3.1 Executive functions……………...……………..……………………………20 3.3.2 Visual information processing…………………..……...……………………21 3.3.3 Weak central coherence……………………………….…………….….……22 v 3.4 Summary……………………………………………………………………………...…23 Chapter Four: Evidence-Based Practices for Social Skills Interventions………………………..25 4.1 Evidence-Based Practices among Autism Interventions…………………..…………..25 4.2 Focused Interventions………………………………………………………..…….…..26 4.3 Social Skills Training……………………………………………………….……..…..26 4.4 Cognitive Behavioural Interventions……………………………..…………….…..….27 4.5 Social Narratives……………………………………………….…………….………..28 4.6 Parent-Assisted Interventions…………………………….……………….…….……..29 4.7 Visual Supports……………………………………….…………………..…….……..29 4.8 Summary…………………………………….………………………………....………30 Chapter Five: The Study…………………………………............................................................31 5.1 Rationale and Overview……………………….……………………………..………..31 5.2 Objectives and Hypotheses………………………….………………………...………33 Chapter Six: Methods……...…………………………………………………………………….36 6.1 Participants……………………………………………………………….……………36 6.2 General Procedures……………………………………………………….…….….…..38 6.3 Instruments………………………………………………………………...…………..39 6.3.1 Descriptive measures………………………………...……………..…………39 6.3.2 Social responsiveness measure …..….……………………………….…….…39 6.3.3 Friendship measure ….…………………………………...……………...……40 6.3.4 Theory of Mind measures …….…………………………...…………….……40 6.3.4.1 Revised version of the Strange Stories test…..….…………....……..40 6.3.4.2 Theory of Mind Inventory…….…………..………………..………..41 6.3.5 Diagnostic-only measures….……………………………………..…………..……41 vi 6.3.5.1 Autism Spectrum Quotient – Adolescent Version ……….......……..41 6.3.5.2 Autism Spectrum Quotient – Child Version ………………...….…..42 6.3.5.3 Vineland Adaptive Behavior Scales – Second Edition, Survey Form…...42 6.4 Testing Procedures…………………………………………………………..…..………43 6.5 Intervention Curricula………………………..………………………………….………43 6.5.1 CFT curriculum……………………………………………………………..….…43 6.5.2 S.S.ToM curriculum…………………………………………………..…….……44 6.5.3 DTC group……………………………………………………………….……….46 6.6 Research Setting and Group Leaders………………………….………………….……..48 6.7 Treatment Integrity……………………………………………….…………….……….49 6.8 Data Analyses……………...………………………………………………..….……….50 6.9 Summary………………………………………………………………………..……….51 Chapter Seven: Results…………………………………………………………………………..52 7.1 Preliminary Analyses………………………………………………………………..…..52 7.2 Demographics………………………………………………………………………..….54 7.2.1 Family demographics……………………………………….….…..…………….54 7.2.2 Family configuration……………………………………………….………….…54 7.3 Outcome Measures……………………………………………………………..……….56 7.3.1 Between group outcome comparisons………………………………….…..…….56 7.3.1.1 Group comparisons of social responsiveness……………………...………56 7.3.1.1.1 SRS Total………………………………….………………..……..56 7.3.1.1.2 Social awareness..……………...……………………………...…..56 7.3.1.1.3 Social cognition..……………...……..………………………...…..56 7.3.1.1.4 Social communication.………....……………………………...…..57 vii 7.3.1.1.5 Social motivation….…………...……………………………...…..57 7.3.1.1.6 Restricted interests and repetitive behaviour..………………...…..57 7.3.1.2 Group comparisons of Theory of Mind…………………..………………..59 7.3.1.3 Group comparisons of friendship quality.………………..………………..60 7.3.2 Within-group outcome comparisons……………………………………….….….62 7.3.2.1 S.S.ToM treatment effects at post-test and follow-up……………….…….62 7.3.2.1.1 Social responsiveness………………………………….…………..62 7.3.2.1.1.1 SRS Total……………………………………….……..……..62 7.3.2.1.1.2 Social
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