A Randomized Wait-List Control Trial of a Peer-Mediated, Theatre-Based Intervention to Improve Social Ability in Children with Autism Spectrum Disorder

Background:  Four interacting levels have been proposed involving the social brain, cognition, behavior, and functioning to explain variance in social ability. Impairment in social ability is central to autism spectrum disorder (ASD); therefore, treatments developed to improve social skills should aim to assess, treat and measure change across these levels. In the current intervention study, event related potentials (ERP) were used to measure brain activity, a neuropsychological task  (NEPSY) measured cognition,  direct group play observation measured behavior, and  questionnaires measured social functioning to examine the complex construct of ‘social ability’.

Objectives: The purpose of the study was to evaluate and extend the impact of a peer-mediated, theatre-based intervention on children with ASD with an emphasis on social functioning. The 10-session program incorporates theatrical approaches, trained typically developing peers and established behavioral strategies. Previous studies using pre-post designs have reported improvement in several skills, such as face memory, theory of mind and social cognition. A primary objective of this investigation was to utilize a true experimental design while evaluating social ability across multiple levels of analysis including neuropsychological, cognitive, behavioral, and functional outcomes. 

Methods:  Participants included 30 youth with ASD between 8 to 16 years randomly assigned to the Experimental treatment group (EXP, N = 17) and Wait-list control group (WLC, N = 13).  Measures included ERP (incidental memory), cognitive (memory for faces immediate and delayed), behavioral (group play) and functional (Social Responsiveness Scale, SRS) conducted before and after treatment and at a two-month follow-up.  An Analysis of Covariance (ANCOVA) model was used in which the post-intervention score served as the outcome variable, group (experimental or waitlist control) as a main independent variable, and baseline (pre-intervention) score as a covariate.

Results: Significant differences were observed between the EXP and the WLC groups on memory for faces immediate (MFI) F(2,28) = 4.02, p = 0.05 and memory for faces delayed; MFD) F(2,28) = 6.01, p = 0.02. Moreover, significant differences were observed on an incidental memory ERP task in which the EXP group showed increased parietal response to repeated faces, which was not observed in the WLC group F(8,122) = 2.63, p=.01. Differences were also observed in group play behavior F(2,28), 4.35, p = 0.04.  Regarding social functioning, significant differences were observed on the SRS (e.g., Social Communication F(2,28) 5.37, p = 0.03), and gains were maintained at  follow-up.

Conclusions:  The study replicates and extends previous findings showing that the theatre-based intervention contributes to improvement in core areas of social ability for youth with ASD.  In particular, gains in memory for faces and social interaction skills have been consistently demonstrated supporting the strong link between social cognition and behavior and how improvement in one level of processing can result in gains on another. The findings suggest that the intervention results in increased salience for social information even in the absence of explicit instruction. The importance of peer-mediation, reciprocal social engagement and active practice of socialization are discussed within the context of the findings.