Lawrence Bartak, PhD., Monash University, Melbourne.
Verity Bottroff, M.Ed., Flinders University, Adelaide.
Pam Langford, M.Psych., Holmesglen Institute of TAFE, Melbourne,
INTRODUCTION
There is still considerable confusion in the relationships existing
between intellectual disability, the pervasive developmental disorders
that are currently described and some other disorders yet to be
included. It is argued that intelectual disability and pervasive
developmental disorder refer to different aspects of disability
patterns and that features of pervasive developmental disorders
lie on continua as with the distribution of intelligence generally.
Categorical depiction of pervasive developmental disorders may
therefore be viewed as something of an administratively convenient
fiction, as in the case of intellectual disability where the underlying
continuum of ability is generally accepted but with co-existing
categorization of intellectual disability as a descriptive diagnosis.
The early description of autism involved some confusion with psychosis
and many authors such as Kolvin (1971) used terms like "early
onset psychosis". This was independent of views about aetiology
so that the term psychosis was used concurrently with acceptance
of the present prevailing view of autism as a pattern of developmental
disability. The distinction between autism on the one hand and
intellectual disability, learning disabilities and brain dysfunction
on the other was also confused but features enabling differential
diagnosis were gradually delineated by Rutter (1968) and others,
so that autism came to be seen as a separate syndrome with features
based upon Kanner's (1943) original description. Two features
of it are worthy of note. Firstly it was described as a behavioural
syndrome, i.e. it was defined in terms of observed behaviours
rather than of underlying pathology or aetiology. These were
unknown at the time and largely continue to generate controversy.
However, the second aspect was that autism was seen as entailing
a disorder of cognition involving social function in some way.
As Tonge et al (1994) have noted recently, it is still unclear
whether social or cognitive deficits are primary but it is clear
that both are involved.
A major issue is the extent to which autism and Asperger disorder
are distinct disorders or not and whether individuals have or
do not have a given disorder. This kind of decision is frequently
requested for administrative reasons to do with levels of service
provision. Clinicians frequently report that children have a
number of features of autism but are unwilling to describe them
as having the full syndrome. This then leads to a variety of
idiosyncratic labels such as "not autistic but has autistic
features", "not autistic but has pervasive developmental
disorder" or "not autistic but has Asperger disorder"
where the latter term and PDD are used as synonyms for collections
of autistic features.
These problems stress the need for a new approach which does not
depend solely on provision of qualitatively described behavioural
features. Two examples of possible directions come from consideration
of other disorders. Firstly, there is the case of intellectual
disability.
A consideration of the multiple kinds of ability and their continuous
distribution as emphasised by Guilford and others (1967) with
de-emphasis of defining categories of intellectual disability
and its own differentiation from "normal" ability has
led to better service provision for individual children. Few
would argue that someone with an IQ of 69 is different to someone
with an IQ of 71. A second example is with behaviour disorder
generally. The work of Achenbach (1983) has shown that it is
effective and conceptually coherent to describe a number of dimensions
of behavioural disturbance on which individuals may be placed,
rather than attempting to fit people into categorically described
syndromes. Can we do this for pervasive developmental disorders
on the basis of research findings?
It is likely that there are a number of behavioural dimensions
underlying the three areas of disturbance in autism which comprises
qualitative impairment in reciprocal social interaction, qualitative
impairment in verbal and non-verbal communication and markedly
restricted repertoire of activities and interests. However, at
present, we do not know what these are and further research is
required in order to elucidate them.
We do not have formally described dimensions of social and interpersonal
abilities, other than to state the obvious, namely that they are
likely to span expressive, receptive and central processing domains,
as with language. They are likely, however to include perception
of self, perception of others, perception of qualities of interaction
between self and others and of interactions amongst groups of
others. Each of these in turn is likely to consist of several
abilities.
The basic problem, it is argued here, in our present context is
one of categorical thinking. However, if, based upon social behavioural
systems, we set up a dimensional structure, it is likely to be
a simpler task to characterise individual children and adults
and to plan effective intervention programs based on their presenting
behaviour and cognitive assets. This would be so both for the
more severely affected for whom diagnosis is simple enough as
at present but also for the presumably greater numbers of people
with milder patterns who are currently neither recognized nor
assisted by service providers. We might then be in a better position
to avoid secondary psychiatric consequences in both groups which
at present are likely to be of considerable cost to the community.
The studies to be reported here examine some interpersonal dimensions
upon which people with a variety of disabilities may vary. Underlying
our investigation was the basic question whether our subject groups
showed any differences on the dimensions selected and if so whether
these were categorical in nature or developmental and differences
of degree.
In this section of the paper, we report on recent research into
specific impairments in social cognitions and social behaviours
in a group of adolescents and young adults with autism and offer
some points on developing social competence and social skills
training with this group.
The contrasting group in the research design was a group of adolescents
and young adults with other developmental disabilities which included
learning disabilities, specific learning difficulties and mild
intellectual disabilities. The groups were matched on verbal
ability via the Picture Peabody Vocabulary Test (PPVT) and non-verbal
reasoning ability via the Ravens Progressive Matrices.
The nature of social impairments in individuals with autism, since
Kanner, has been investigated from a number of theoretical positions,
including whether social deficits are primary or secondary to
perceptual, cognitive or linguistic deficits. The focus of recent
reviews and research has circled back to Kanner's first suggestion
of the centrality of the social skill impairments evident in autism
with questions about whether the primary deficit is cognitive
with an underlying neurological deficit that disrupts the social
(Leslie, 1987, Baron-Cohen, 1988) or the affective (Hobson, 1987,
1990) development of the individual. The study was an attempt
to define the social deficits of autism during adolescence more
precisely and therefore to expand the available literature on
this important developmental stage in the life of the individual
with autism. Social skill training programs have become an important
vehicle for providing support to adolescents with autism and Asperger's
Syndrome to access mainstream educational programs and to survive
in the everyday social interactions with their peer groups. An
understanding of the primary impairments in autism, the modes
of learning most relevant to individuals with autism, the developmental
stages and the potential range of individuals with the disorder,
provides the educator and the clinician with a valid base for
making program and curriculum decisions.
SOCIAL BEHAVIOURS
Developmental tasks in adolescence include an adjustment of the
focus of interactions with significant others (often family, care
and teaching staff) to social interactions with peers assuming
primary importance. Questions of peer acceptance and competence
in social behaviours gain urgency with membership of the peer
group in adolescence depending upon the ability to merge with
the identity of the group and appropriate conduct within the group
can be prescribed rigidly.
As reported later in this paper, adolescents with autism show
an increased interest in peer social interactions but they continue
to experience difficulties with social skills and relating to
others. Peer interactions and friendships have been found to
play an important role in facilitating the personal social and
moral development of individuals. Social skill deficits and failure
to gain peer acceptance are related to the social, vocational
and psychological difficulties experienced by some individuals
with developmental disabilities in adolescence and adulthood.
In the first part of this study, we expected that adolescents
with autism would demonstrate more significant difficulties with
a range of social behaviours on a self-report and parent's report
measure of social skills (Gresham and Elliott, 1990) than adolescents
with other developmental disabilities. Analysis of the results
showed no significant differences between the two groups with
both groups and their parents reporting scores on social behaviours
that fell 1.0 to 1.5 standard deviations below the normal range
of scores on social behaviours provided by Gresham and Elliott
(1990).
From these reports it was determined that some of the areas of
difficulty in social behaviours related to issues of personal
responsibility, being able to predict the consequences of behaviours
and the ability to relate to others in a mutually reinforcing
fashion which includes adapting one's own behaviours to the demands
of the interpersonal situation. One of the tasks facing researchers
in this field is to operationalize the behaviours that make up
the social spectrum and that add up to social competence. In
the past, social skills training has focussed on improving eye
contact, conversational skills, topic generation and maintenance,
assertiveness and staunch efforts to reduce negative or problem
behaviours, in other words, discrete behaviours mostly taught
in a classroom setting.
The development of social skills training programs requires the
analysis of social behavioural systems rather than discrete behaviours.
The social deficits in autism involves the behavioural and cognitive
level that is, that we need to know what the individual with autism
understands at an intellectual level and the outcomes of that
understanding in behavioural terms. In this study, we found that
high-functioning individuals with autism could think about concepts
associated with social interaction but did not demonstrate social
skills at a higher level than low-functioning individuals with
autism. Possibly confounding the development of better social
skills in high-functioning individuals is the impact of social
withdrawal in the young child with autism and the consequent lack
of social-affective experiences (Hobson, 1993) on which to base
reciprocal social behaviours.
CONCEPTS OF SELF AND CONCEPTS OF FRIENDSHIP
Stage two of the research reports on some of the major findings
on how adolescents and young adults with autism think about concepts
associated with friendship, concepts of self and others and affects
of self and others, compared with individuals who are developmentally
delayed and individuals whose development is considered to be
within the normal range.
The interview consisted of the following main areas: attributes
of self and others; friends; affects of self and others. In addition
to the samples of adolescents and young adults with autism and
adolescents with other developmental disabilities, this phase
of the research also included 42 individuals ranging in age from
4-18 years, developing within expected norms.
For data comparison this latter group was divided into the following
subgroups; 4-8 years, 8-12 years, and 12-18 years. Utilising
a developmental profile (Piagetian), the youngest grouping represents
mostly preoperational thinking, the next grouping mostly concrete
operational thought and the oldest group represents formal operational
thinking.
The necessity to be brief permits reporting only on a small selection
of questions within each category. However, the selection of
items to report has taken into account the major trends of the
results. Overall the analysis of data from the interviews, indicated
surprisingly significant differences between the groups with autism
and other developmental disabilities. However, differences were
found in respect to developmental trends in cognitive functioning
associated with friendships and social behavioural patterns, when
the two groups with developmental disabilities were compared with
the three normal groups. The analysis of data involving friendships
utilised the developmental profiles of Rubin (1980) and Selman
(1980). Individuals with autism responded at a lower developmental
level when defining "a friend", explaining the process
of "making friends" and cognitions about why "others
would or would not see them as a friend". Individuals with
autism also demonstrated difficulties with citing peer friends
when compared to individuals from the other groups. Responses
from the autistic sample were comparable to the developmental
level of the 8-12 year group when "defining a friend"
and explaining "why individuals would see them as a friend"
but when describing "how you make a friend', their developmental
level was comparable to the 4-8 year level.
High functioning individuals with autism ( defined with a score
on the PPVT of 70 and above) performed better on all the above
measures than individuals with autism classified as low functioning.
No differences were found between non-autistic developmentally
delayed controls, similarly classified as high and low functioning.
A greater number of individuals with autism (80.95%) than controls
reported difficulties with "making friends" and the
reasons given for these difficulties indicated a developmental
profile comparable to the 4-8 year level. As reported in the
first part of this study, individuals with autism were more likely
to cite external factors than internal factors when thinking about
problems with "making friends". The control group with
other developmental disabilities (61%) were the next highest group
experiencing difficulties in making friends but this difference
did not reach significance when compared to the group with autism.
However, this control group cited greater internal reasons associated
with difficulties in making friends.
The difficulties experienced by the group with autism in the questions
above on friendship were not experienced in responding to questions
about how they saw themselves as different from others and in
providing descriptions of themselves. The responses were examined
utilising content analysis categories from person perception research
in childhood and adolescence (Hater, 1983; Livesley & Bromley,
1973; Selman, 1980). The levels of discrimination involved :
physical appearance and condition; identity, social roles and
possessions; behavioural constructs such as abilities and disabilities,
interests, likes and dislikes; personal characteristics such as
traits, temperaments and motivations; attitudes and beliefs.
There is no time for a detailed description of these findings
but in outline, high and low functioning groups with autism differed
developmentally from each other and from the other groups. No
group was without ability in this area.
The results from questions involving attributes of self and comparisons
of self with others have provided evidence that individuals with
autism, in particular high functioning individuals, as defined
for this study, can develop an ability to view themselves as a
psychological self which may involve some aspects of a theory
of mind, as well as an ability for introspection which includes
personal characteristics such as feelings, traits and motivations.
CONCLUSIONS FROM RESEARCH AND PRACTICAL IMPLICATIONS
1 . The theory of mind hypothesis has been used as an "explanatory
tool" (Baron-Cohen & Howlin, 1993) for understanding
the fundamental cognitive deficits in autism, This study provides
further support to the likelihood of a developmental delay in
theory of mind in autism rather than a specific deficit with pervasive
behavioural effects (Eisenmajor & Prior, 199l).
2. The difficulties experienced by individuals with autism in
responding to questions of friendship suggest factors apart from
or in addition to theory of mind concepts. The focus of Hobson's
( l986a, 1986b, 1989, 1991, 1993) research on the difficulties
experienced by individuals with autism in basic perceptual-affective
abilities and propensities that are required for a person to engage
in 'personal-relatedness' with others, may have direct relevance
to the area of friendship. The results of this research also
highlight significant differences in affect and emotion, particularly
qualitative differences. Operationally, one of the earliest effects
of combined affective cognitive disturbance is deficient joint
attention skill development (often called proto-declarative skills)
which exists in children with autism (Mundy et al., 1993). Currently
there is particular interest in examining the relations between
joint attention and the emergence of metarepresentation, such
as symbolic-play development (Baron-Cohen and Howlin, 1993, Mundy
et al. 1993). Questions still remain concerning the possible
link between joint-attention skills and theory of mind development
and this research highlights in particular, the need to explore
links between joint-attention skills and the development of social
cognition associated with friendship.
3. What are the practical implications from this study and the
findings of others researching similar areas of social cognition?
A major point is that the findings from research which focuses
on individuals with a recognised significant social cognitive
deficit provides information about development which has relevance
to curriculum design and implementation, not only for those with
autism but other areas of disability, for example, those individuals
represented in the control group utilised in this study.
4. Another important concern is whether mental-state concepts
associated with the areas of social cognitive functioning discussed
in this paper can be taught. The results of this research and
studies such as Eisenmajor & Prior (1991), provide evidence
that at least a reasonable percentage (54.5% in this study) of
individuals with a verbal mental age of 70 and above were able
to manage some aspects of the theory of mind concept. This suggests
a likelihood of a developmental delay in theory of mind in autism
rather than a specific deficit. Baron-Cohen and Howlin (1993)
point out that research concerning the ability to teach theory
of mind concepts is really still in its infancy and these researchers
are currently engaged in a study which focuses on teaching a range
of mental states including belief, desire, knowledge,pretences
deception, and emotion.
Some aspects of theory of mind, e. g. emotions, may have particular
relevance to the concept of friendship and this aspect requires
further research. In addition, it would appear appropriate to
highlight the importance of "shared experiences" as
well as making use of developmental stages associated with different
aspects of friendships. The following quotation from one young
man with autism highlights the need for understanding basic concepts
associated with friendships. 'I never could have a friend. I
really don't know what to do with other people, really.' (Cohen,1980,
p. 388).
Mayes et. al. (1993) make the observation than more often than
not, even the brighter, more self-aware individuals with autism
are puzzled by the depth of human relationships; they seem unable
to get it, and their relations with others lack the spontaneity,
the affective variation, the empathic quality that characterises
relatedness learned early in life by most individuals. This can
cause the person considerable despair as expressed by one self-aware
respondent in this study and his predicament highlights the vulnerability
to depression which is an aspect of genuine concern in the results
of this study.
"I can form an excelllent first impression. I can talk
and be cheerful and after that.... I want to take things a bit
closer, I want to be with people more of the time and, you know,
invite them around to my place and get invited around to theirs
and share in their lives a bit more and have them share in my
life and all the rest of it but somehow that just never seems
to materialise. I mean you can't make people like you but by
the same token, it makes life pretty awful"
SOCIAL COMPETENCE ANS SOCIAL SKILLS TRAINING
Students at Holmesglen Institute of TAFE in Melbourne, take part
in Personal Development and Group Dynamics classes for at least
4 sessions each week during a year long program. The emphasis
is on understanding the self and on understanding the self in
relation to others. We explore behaviours, environmental events
that maintain or reinforce behaviours, personal control over behaviours,
the effect on others of target behaviours and social and group
issues that affect the individual. Rules are developed to guide
interactions and to develop new skills. We use role plays and
guided practice with homework assignments and education of parents,
employers, etc. to reinforce efforts. All classes are interactive
with students identifying appropriate and inappropriate social
skills in a specific situation. Topics include:
Personal Development Skills
The student focuses on their own abilities and talents via a number of self-esteem exercises.
They learn how to describe themselves to group members and how to take responsibility for their own behaviours.
Self-control (including control of angry outbursts) and coping with being upset or depressed is increased via relaxation procedures and visual imagery.
Development of a personal value system and the role of values
in making decisions are explored and skills levels in choosing
appropriate responses are increased.
Knowledge of social issues and legal and social responsibilities
are developed in studies of community and current topics.
Peer directed interactive skills
Greetings, listening skills, conversational abilities including
topic maintenance and question asking are taught in role plays
and in vivo practices.
We structure interactions via chess games etc., provide help with
interpreting and reading social cues, and teach positive responses
to others to reduce teasing and negative feedback.
Assertive responses are practised rather than aggressive or passive
replies. The students learn to respond with dignity and calmness
to hassles from others and to make a response that indicates their
needs and feelings but that doesn't denigrate the other person.
Students learn how to use humour to improve relationships, to
make their own problems lighter and the role of humour in maintaining
relationships.
We concentrate on understanding our own actions and behaviours
and reading others, how our thoughts affect our feelings and how
to cope with criticism, and we promote acceptance of differences
and supportive social behaviours. The students learn about the
importance of role models and the influences of family, school,
peers, media, etc. in their lives.
Achievable behavioural vocational and educational goals are established
and reviewed for short and long term outcomes. Each student takes
part in an Individual Educational Plan which includes personal,
behavioural and group goals and is reviewed 4 times a year.
Personal organization, planning for beginning and completing tasks,
personal response or belongings and review and practice of procedures
helps increase generalization to other settings.
Rules for developing friendships are taught, including appropriate
complimenting, how to maintain relationships, characteristics
to admire in friends, use of group projects to facilitate inclusion
and interactions and encouraging supportive behaviours.
Coping Skills
Students learn how to negotiate and solve problems and how to
deal with conflicts and with teasing.
Dealing with authority figures such as employers, teachers, parents
is explored with teaching about responding to requests, following
instructions, following workplace, social or classroom rules and
developing good work habits.
Students learn that behaviour is influenced by internal states
rather than manipulated by others and they learn to use breathing
techniques, progressive muscle relaxation, guided visual imagery
and projective stories for learning that change in a pattern of
responses is possible and that they can adopt constructive attitudes.
References cited in this paper can be obtained from the authors.
Verity M. Bottroff M.Ed.
Associate Dean/Senior Lecturer, School of Special Education and
Disability Studies, Flinders University of South Australia; Vice-President
of the Autism Association of South Australia; VicePresident, Autism
Association of South Australia; State Representative on the National
Association for Autism (Australia): Professional Committee. Experience
in early intervention programs including developing symbolic play
skills in children with autism, supporting work with families
, advisory work in the inclusion of children with autism into
mainstream schools, development of social skills programs for
adolescents and young adults with autism. Conducting University
courses in autism spectrum disorders for professionals working
in the field of disability studies/ special education. Research
in social cognition, including perceptions of self and others,
affects, and the development of friendships for people with autism/Asperger's
syndrome.
Dr Lawrence Bartak is a clinical and educational psychologist
who is Director of the Elwyn Morey Child Study Centre in the Faculty
of Education at Monash University in Melbourne, Australia. He
is Vice-President of Autism Victoria and Chairman of the Professional
Advisory Committee of the National Association for Autism of Australia.
He has been President and is currently a Psychologist Member
of the Intellectual Disability Review Panel a quasi-judicial tribunal
of the State Government of Victoria, Australia. He has been involved
in research on diagnosis and treatment of autism spectrum disorders
and clinical consultancy for a number of years and is currently
involved in research on the cognitive bases of empathy and false
belief (theory of mind) skills in adults with autism. He is a
Senior Consultant in the Monash University Department of Paediatrics.
Pam Langford is a psychologist and teacher at Holmesglen
Institute of TAFE, Melbourne, Australia and has been working with
adolescent students with a range of learning difficulties and
developmental disorders since 1978. She has been involved in
designing and implementing programs for students with autism spectrum
disorders and other developmental disorders, particularly in preparation
for vocational areas. Pam's research focus has been on social
cognitions, social development, friendship issues and depression
in adolescents with autism and Asperger's Syndrome. Pam also
practises clinically with children, adolescents and adults with
autism spectrum disorders in assessment and diagnosis and provides
educational support and consultation for individuals from kindergarten
to the tertiary sector.
Professor Bruce Tonge
Professor Tonge is Chairperson of Monash University's Department of Psychological Medicine as well as being Chairperson of Monash Medical Centre, Division of Psychiatry and Head of the Centre for Developmental Psychiatry. Currently, Professor Tonge is conducting a major follow-up study of a large group of children and adolescents with intellectual disability, including groups of children with Autism and Asperger Syndrome. He coordinates an extensive clinical service for children with developmental behaviour problems.