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MIAMI UNIVERSITY The Graduate School Certificate for Approving the Dissertation We hereby approve the Dissertation of Bethany Lynn Walker Candidate for the Degree Doctor of Philosophy ______________________________________ Vaishali Raval, Director ______________________________________ Jennifer Green, Reader ______________________________________ Julie Rubin, Reader ______________________________________ Amity Noltemeyer, Graduate School Representative ______________________________________ Stephanie Weber, Reader ABSTRACT EVALUATING THE EFFECTIVENESS OF A COMBINED EMOTION RECOGNITION AND EMOTION REGULATION INTERVENTION FOR PRESCHOOL CHILDREN WITH AUTISM SPECTRUM DISORDER by Bethany L. Walker Children with Autism Spectrum Disorder (ASD) often have difficulties in emotion recognition and emotion regulation, and these deficits have been implicated in the high rates of anxiety and behavior disorders in this population. Although an early intervention approach is warranted in order to achieve optimal emotion regulation development, few studies have evaluated the effectiveness of emotion regulation interventions with young children with ASD. A combined emotion recognition and emotion regulation intervention was implemented and evaluated using a multiple baseline design in a pilot study with two preschool children with ASD and a main study with three preschool children with ASD. Children participated in discrete trial training focused on identifying happiness, sadness, anger, and fear from three types of isolated cues: facial expressions, situational contexts, and tone of voice. They were successful in identifying emotions from facial expressions and situational context, but not tone of voice. In addition, children learned to use three adaptive emotion regulation strategies (squeezing a stress ball, blowing a pinwheel, and using a handheld fan) via video modeling. Adults also provided calm down coaching, which aimed to help children use these strategies during emotional episodes. Children showed increases in their adaptive emotion regulation behavior when calm down coaching was provided compared to when it was not provided. These findings support the use of an early intervention approach to facilitate the development of emotion recognition and emotion regulation in young children with ASD. EVALUATING THE EFFECTIVENESS OF A COMBINED EMOTION RECOGNITION AND EMOTION REGULATION INTERVENTION FOR PRESCHOOL CHILDREN WITH AUTISM SPECTRUM DISORDER A DISSERTATION Presented to the Faculty of Miami University in partial fulfillment of the requirements for the degree of Doctor of Philosophy Department of Psychology by Bethany L. Walker The Graduate School Miami University Oxford, Ohio 2017 Dissertation Director: Vaishali V. Raval © Bethany Lynn Walker 2017 TABLE OF CONTENTS Introduction………………………………………………………………………………………..1 Emotion Recognition and Emotion Regulation…………………………………………………...1 Difficulties in Emotion Recognition and ER in Children with ASD……………………………...4 Emotion Recognition Training for Children with ASD…………………………………………...6 ER Training for Children with ASD……………………………………………………………....9 Creation and Description of Study Materials…………………………………………………….11 Pilot Study Method………………………………………………………………………………13 Participants.....................................................................................................................................13 Procedure.......................................................................................................................................14 Measures........................................................................................................................................17 Research Design.............................................................................................................................17 Results............................................................................................................................................19 Pilot Study Discussion...................................................................................................................22 Pilot Study Issues Identified……………………………………………………………………..23 Pilot Study Issues Addressed…………………………………………………………………….24 Current Study.................................................................................................................................24 Method...........................................................................................................................................25 Participants.....................................................................................................................................25 Procedure.......................................................................................................................................26 Results............................................................................................................................................27 Current Study Discussion………………………………………………………………………..31 General Discussion………………………………………………………………………………34 Conclusion.....................................................................................................................................41 References……………………………………………………………………………………….42 iii LIST OF TABLES 1. Pilot Study Nonoverlap of All Pairs, Confidence Intervals, and p-values for Each Participant’s Correct and Incorrect Responses for Each Cue Type....................................................................51 2. Current Study Nonoverlap of All Pairs, Confidence Intervals, and p-values for Each Participant for Each Cue Type…………………………………………………………………...52 3. Means and Standard Deviations of Percentages of Correct Responses by Cue Type and Emotion…………………………………………………………………………………………..53 4. Frequencies and Percentages that Children Engaged in Adaptive ER Behavior During Emotional Episodes in the Baseline and Intervention Phases…………………………………...54 iv LIST OF FIGURES 1. Child 1 DTT Receptive Identification of Emotions…………………………………………...55 2. Child 2 DTT Expressive Identification of Emotions………………………………………….56 3. Child 3 DTT Expressive Identification of Emotions………………………………………….57 4. Child 4 DTT Expressive Identification of Emotions………………………………………….58 5. Child 5 DTT Expressive Identification of Emotions………………………………………….59 v ACKNOWLEDGEMENTS I would like to thank the volunteers who helped me create and test the materials for this intervention, the EIBI classroom team, the director of the EIBI classroom, the children who participated in this study and their parents, my advisor, and the members of my dissertation committee. vi Evaluating the Effectiveness of a Combined Emotion Recognition and Emotion Regulation Intervention for Preschool Children with Autism Spectrum Disorder Autism Spectrum Disorder (ASD) is a neurodevelopmental disorder characterized by deficits in social communication, as well as restricted or repetitive behaviors and interests (American Psychiatric Association, 2013). Problems in social communication may include deficits in social-emotional reciprocity, deficits in nonverbal social communication, and/or deficits in developing or understanding relationships. Examples of restricted or repetitive behaviors and interests include stereotyped motor movements (e.g., hand flapping), use of objects (e.g., lining up toys), or speech (e.g., echolalia), insistence on sameness (e.g., refusal to deviate from routine), highly restricted interests that are unusual in intensity or focus (e.g., fixation on vacuum cleaners), and sensory seeking or avoidant behavior (e.g., excessive smelling of objects). As the word spectrum indicates, individuals with ASD present with a wide range of functioning across domains, including cognitive functioning, language, and socioemotional functioning. Severity ratings and specifiers are often used to qualify each individual’s ASD diagnosis to better reflect how these deficits impact his or her functioning. ASD is diagnosed during childhood and affects individuals across the life span. In the United States, it is estimated that 1 in 68 children is affected by ASD (Centers for Disease Control, 2015), an increase of about 30% from the 2008 estimate of 1 in 88 (Centers for Disease Control, 2014). Emotion Recognition and Emotion Regulation Emotion regulation (ER) has been defined as “the extrinsic and intrinsic processes responsible for monitoring, evaluating, and modifying emotional reactions” (Thompson, 1994; p. 27-28). This definition highlights the roles of both child self-regulation and parent-child co- regulation or mutual regulation of a child’s emotions. Whereas self-regulation involves self- directed strategies to regulate emotions, mutual regulation involves a caregiver’s attunement to the child’s emotional state and the caregiver’s sensitive responses to regulate the child’s emotions (Prizant, Wetherby, Rubin, & Laurent, 2003). Both mutual and self-regulation include pre-linguistic or sensorimotor strategies (e.g., a comforting object) and linguistic or cognitive- based strategies (e.g., requesting a break from a task; Prizant et al., 2003). This approach is useful in conceptualizing ER strategies in young children with ASD, as it highlights the important roles of adult support and child developmental level. A second approach delineates ER strategies on a voluntary (e.g., solving the upsetting problem) versus involuntary (e.g., 1 rumination) dimension and an engagement versus disengagement with the stressor dimension (Connor-Smith, Compas, Wadsworth, Thomsen, & Saltzman, 2000; Mazefsky,