Using Systemising to Facilitate Social Competence in Autism An Evaluation of The Transporters DVD and LEGO Therapy This dissertation is submitted for the degree of Doctor of Philosophy by Georgina Owens Clare College Autism Research Centre, Department of Psychiatry Declaration I confirm that the material in this dissertation is not copied from any published material nor is it a paraphrase or abstract of any published material, unless it is identified as such and a full source of reference given. I confirm that, other than as specified above, this dissertation is my own work and includes nothing which is the outcome of work done in collaboration except where specifically indicated in the text. No part of this dissertation has been, or is being, submitted for any other degree, diploma or other qualification at any other university. The length of this dissertation does not exceed 60 000 words, excluding figures, tables, appendices and references, as per the stipulations of the Degree Committee of Clinical Medicine and Clinical Veterinary Medicine, University of Cambridge. Part of the work in Chapters 3 and 6 of this thesis has been submitted for publication: Owens, G., Gordon, K. & Baron-Cohen, S. (2008) Treating autism spectrum conditions. In J. Trafton & W. Gordon (Eds). Best Practices in the Behavioral Management of Health from Preconception to Adolescence (Vol. 3). Los Altos, CA. Institute for Brain Potential. Owens, G., Granader, Y., Humphrey, A. & Baron-Cohen, S. (online early). LEGO® therapy and the Social Use of Language Programme: an evaluation of two social skills interventions for children with high functioning autism and Asperger syndrome. Journal of Autism and Developmental Disorders. Georgina Owens 27th May 2008 ii Abbreviations ABA Applied Behaviour Analysis ADHD Attention Deficit Hyperactivity Disorder ADI Autism Diagnostic Interview ADOS Autism Diagnostic Observation Schedule AS Asperger Syndrome ASC Autism Spectrum Condition ASD Autism Spectrum Disorder DTT Discrete Trial Teaching DZ Dizygotic E-S Empathising Systemising fMRI Functional Magnetic Resonance Imaging GARS AQ Gilliam Autism Rating Scale Autism Quotient GARS Gilliam Autism Rating Scale GARS-SI Gilliam Autism Rating Scale Social Interaction Subscale GF/CF Gluten Free/ Casein Free diet HFA High Functioning Autism LEAP Learning Experiences: An alternative program for preschoolers and parents MZ Monozygotic OT Occupation al Therapy PDD-NOS Pervasive Developmental Disorder Not Otherwise Specified PET Positron Emission Tomography RCT Randomised Control Trial RPMT Responsive Education and Prelinguistic Milieu Therapy SALT Speech and Language Therapy SCQ Social Communication Questionnaire SULP Social Use of Language Programme TD Typically Developing TEACCH Treatment and Education of Autistic and related Communication Handicapped Children VABS Vineland Adaptive Behaviour Scale iii Abstract Autism spectrum conditions (ASC) are a group of neurodevelopmental conditions characterised by impaired social interaction and communication alongside narrow interests and repetitive behaviour. Few interventions to improve social competence have a strong empirical basis to support their effectiveness, and skills learned rarely generalise outside the intervention setting. Using children’s natural interests may increase motivation and generalisation following intervention. Many individuals with ASC have superior ‘systemising’ abilities (the ability to analyse and construct systems in the world, e.g. maths) and find systems highly attractive. This thesis focuses on the possibility of using systemising to facilitate social competence in young children with ASC. Study 1 was a randomised control trial evaluating The Transporters DVD, a children’s cartoon series designed to teach emotion recognition. This harnesses systemising by putting human emotional expressions onto animated vehicles. Twenty children (mean age = 4.5 yr, sd = 0.8) who watched The Transporters for 15 min per weekday over 4 weeks improved more than controls in recognising emotions used in The Transporters. However, this did not generalise to recognising emotion in real faces. This contrasts with an earlier study using The Transporters that found generalisation to real faces in slightly older children (mean age= 5.9 yr, sd= 1.0). The differences between the studies are discussed. Study 2 was a matched comparison study of a naturalistic social skills approach using collaborative play with LEGO® (a systematic toy) with a non-systematic therapy (the Social Use of Language Programme) and no intervention. Seventeen children with ASC (mean age= 8.2 yr, sd= 1.8 yr) receiving LEGO® therapy for 1hr per week over 18 weeks improved more than controls in autism-specific social skills and maladaptive behaviour. Study 3 reports a pilot baseline study evaluating the use of LEGO® therapy in a school over 6 weeks for 9 children with ASC (mean age = 9 yr, sd = 1.3). Results showed LEGO® therapy to be appropriate and effective in school given sufficient staff training. The results from all 3 studies are discussed in terms of the empathising-systemising (E-S) theory, and with respect to the status of intervention research in ASC. iv Acknowledgements There have been so many people that have made it possible for me to do a PhD and for this I would like to say thank you. Firstly, I would like to thank Professor Simon Baron-Cohen. When I initially emailed him as a PGCE student asking whether it would be possible to do some research assistant work or do a Masters at the ARC, his encouragement and suggestion of ‘Why don’t you do a PhD?’ have got me where I am now. As a supervisor, he has been thoughtful, encouraging, and inspiring and I am very grateful for the ideas, support, guidance and hard work that he has given to make it possible for me to complete this thesis. Equally I would like to warmly thank Dr Ayla Humphrey. She has been a constant support throughout my PhD, and her enthusiasm for my work has been really encouraging. I am grateful for her tirelessly reading thesis drafts over the past few months, for her help with recruiting participants and for her inspiration and good advice for my future career. There have been a vast number of people who made it possible for me to carry out the research for this thesis. Thank you to Dan LeGoff for letting me stay with his family while teaching me how to do Lego therapy. Thanks to Wendy Rinaldi for teaching me the principles of SULP. I would also like to extend my gratitude to the research assistants, Yael Granader, Michelle Beeson, Alex Hunter and Alex Pollitt without whom it would not have been possible to complete this project. Also thank you to all the undergraduate volunteers who helped with running therapy groups. I wish to thank Jenny Hannah for helping to organise the logistics of running groups, for her wonderful administrative support, and for finding somewhere to put 65 kg of Lego! Thank you to Nadia for helping me sort out the 65 kg of Lego according to colour, for feeding me when I came home exhausted after groups and for being an all round fantastic friend. Thanks also to everyone at Douglas House for putting up with v the noise and disruption of having several 6-11 yr olds and their families taking over the library and downstairs waiting area each week. I would also like to thank the MRC and the Department of Psychiatry for agreeing to fund me throughout this thesis. I am also grateful to Clare College for supporting me financially over the past 6 months, and for providing a second home. Thanks also to Lego Ltd for providing free Lego for use in this study. None of this research would have been possible without the dedication and enthusiasm of the children and their families who participated. They have taught me so much and I feel extremely lucky to have had the opportunity to get to know them all so well. Thank you to Birgitta Haraldson, Jane Taylor, Umbrella Autism, Matthew Downie and Khairoun Abji for their help with putting me in touch with these wonderful families. It has been a real delight to be a part of the ARC and I would like to thank everyone for their friendship, laughs and advice over the past years. Thanks to Greg, Bhisma, Ofer, and Emma for their advice, feedback and friendship. Thank you to Carrie and Bonnie for the unending support, chats and for being wonderful friends. Thanks to Paula for the laughs and for co-founding the Spanish Speaking Hamster Appreciation Society! I would like to thank Ramón, my husband-to-be, for his amazing support, love and encouragement over the past few years. It has been fantastic to have someone who understands exactly what it means to do a PhD, and I could not have done it without him. Thank you for being crazy enough to propose in the middle of it all- it has been the best carrot-on-a-stick for finishing on time that I could imagine! Finally, but very importantly, it remains to thank Mum, Dad and my sister, Katie. I would not have embarked on this PhD without their encouragement and advice. They have always known exactly the right thing to say during the ups and downs and I feel very privileged to have such a fantastic family. vi Table of Contents DECLARATION _________________________________________________________________ II ABBREVIATIONS ______________________________________________________________ III ABSTRACT ____________________________________________________________________ IV ACKNOWLEDGEMENTS_________________________________________________________ V TABLE OF CONTENTS___________________________________________________________