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Increasing the Understanding and Demonstration of Appropriate Affection in Children with Asperger Syndrome: A Pilot Trial

Increasing the Understanding and Demonstration of Appropriate Affection in Children with Asperger... Hindawi Publishing Corporation Autism Research and Treatment Volume 2011, Article ID 214317, 8 pages doi:10.1155/2011/214317 Research Article Increasing the Understanding and Demonstration of Appropriate Affection in Children with Asperger Syndrome: A Pilot Trial 1 1 1 2 Kate Sofronoff, Johann Eloff, Jeanie Sheffield, and Tony Attwood School of Psychology, The University of Queensland, St Lucia, Brisbane, QLD 4072, Australia School of Psychology, Griffith University, Mt Gravatt, Brisbane, QLD 4122, Australia Correspondence should be addressed to Kate Sofronoff, kate@psy.uq.edu.au Received 1 July 2011; Revised 14 October 2011; Accepted 14 October 2011 Academic Editor: Bennett L. Leventhal Copyright © 2011 Kate Sofronoff et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The study was conducted to examine relationships between affectionate behavior in children with Asperger syndrome and variables likely to influence its expression (e.g., tactile sensitivity, social ability). It also evaluated the impact of a cognitive behavioral intervention that aimed to improve a child’s understanding and expression of affection. Twenty-one children, aged 7 to 12 years, participated in the trial. The results showed significant correlations between measures of affection and tactile sensitivity and social ability. After attending the 5-week program, parents identified significant increases in the appropriateness of children’s affectionate behavior both towards immediate family and people outside the immediate family, despite reporting no significant changes in their child’s general difficulties with affectionate behavior. There was a significant improvement in children’s understanding of the purpose of affection. The findings are discussed as well as the limitations of the study. 1. Introduction AS are particularly likely to misread the intentions of others and may inadvertently engage in behaviors that are socially Affectionate communication is a form of social behavior that unacceptable or inappropriate in terms of touch, personal individuals with Asperger syndrome (AS) find problematic space, greetings, and gestures of affection that can lead to [1]. Affectionate communication comprises those actions embarrassment in others. through which humans express feelings of positive regard Parents of a child with AS face an increased number of such as liking, love, closeness, care, and gratitude to one stressors and report greater stress compared with parents of another by means of verbal, nonverbal, and supportive forms a typical child [9] or a child with another developmental of communication [2–4]. The capacity to express and receive disorder [10]. They also report distress associated with affection is considered a fundamental human need by social their child’s infrequent expressions of affection [1, 11]. For scientists such as Rotter et al. [5] and is considered vital example, a mother complained that her adolescent son with for the formation, maintenance, and quality of personal AS did not express enough affection, to which he replied relationships [2]. that he said that he loved her when he was six and was Children with AS have great difficulty in understanding puzzled as to why he should repeat this phrase [8]. The affection and expressing appropriate levels of affection [1]. absence of affection in close relationships is correlated with The clinical presentation of AS has many features that loneliness [12] and depression [13] and is an indicator of overlap with the personality trait alexithymia [6], in which relational deterioration [2]. Hence, the difficulties associated the individual has an impaired ability to recognise, process, with emotional reciprocity in AS are likely to reduce a and communicate their emotional state. Many individuals parent’s experience of reinforcement in their parenting role and produce an additional source of stress. with AS demonstrate an impaired capacity to recognise and communicate emotion-related information about them- Outside of the family context it is found that individuals selves and others [7]. According to Attwood [1, 8], those with who engage in high levels of affectionate communication 2 Autism Research and Treatment enjoymoresocialinvolvement [14]. Affectionate behavior participate in “getting to know you activities” and focus on such as laughter, smiling, praise, and excited verbal state- experiences and people that they like. They are introduced to ments have been shown to elicit positive peer reactions the concrete concept of placing items on a visual scale and in children [15]. Newcomb et al. [16]performed ameta- applying ratings (0–100) using post-it stickers. The session analysis of studies on peer relationships and found that moves to identifying ways that we can tell if someone likes popular children frequently exhibited prosocial behaviors or loves us, again using visual strategies and then to why we (including affectionate actions) and made positive comments express feelings of liking or loving people. The child is asked about others in comparison with children who were unpop- to complete some project work for the next session with the ular with peers. These findings suggest that affectionate com- help of a parent. munication may be a vital means through which children Session 2 reviews the project work and moves on to initiate interactions and form social relationships. constructing a Social Story [30] about how liking or loving There are several hypotheses that can potentially explain someone can affect feelings and thoughts. Some time is spent the difficulties with affectionate behavior that individuals constructing a schematic of the different people in each with AS experience. First, many children with AS experi- child’s environment and how we may do and say different ence heightened sensory perception [17], and sensitivity to things to each one to show that we like them. There are then touch has been found to occur in over 50% of children roleplays to practice this in the groups. The child is asked with AS [18]. It has been observed that some children to practice showing affection to a parent or sibling in the with AS find gestures of affection such as a hug or kiss following week and to report back to the group. aversive, as the sensory experience is unpleasant [1, 19, Session 3 reviews and demonstrates the practice done by 20]. Secondly, many individuals with AS have immature each child in the week. The session then moves on to the Theory of Mind skills and have difficulty recognising and concept of compliments and includes both discussion and understanding the thoughts, beliefs, desires, and intentions roleplay around this for a variety of people. There is also a of others [21]. Therefore, it may not occur to a child with focus on receiving compliments and practice agreed for the AS that another person is distressed and would appreciate home project. physical comfort or verbal reassurance to help restore their In Sessions 4 and 5 the children continue to discuss their emotional state. Thirdly, as well as difficulties recognising understanding of affection and to roleplay the various things emotions in others and themselves [22], individuals with that they can do and say in order to show a range of people AS experience difficulties reading social cues within a social that they like or love them. At the end of Session 5 there interaction. Poor interpretation of cues, such as the meaning is a review of what they feel has been learned. The sessions of a facial expression, a gesture, or tone of voice, may are able to be tailored to address the specific concerns raised limit expression of appropriate affectionate behavior [23]. A by each family and so different areas can be emphasized for fourth explanation is that children with AS may simply lack individual children. insight as to what appropriate affection entails. For instance, an individual with AS may show that he/she cares by carrying 3. Method out a practical deed (e.g., handing a distressed person a 3.1. Participants. Twenty-three children were recruited to tissue), discussing his/her own special interest (would make participate in the study via media outreach through local them feel better), or leaving the sad person alone to self- newspapers and schools. One child with nonverbal autism soothe rather than displaying conventional forms of affection was excluded from the trial, and two participants withdrew such as hugging. If this is the case, then it is possible to teach before the trial commenced. The final sample included what is appropriate in different situations [1]. twenty-one children (18 boys and 3 girls) aged 7 to 12 years There is a small body of literature that has shown with a mean age of 9.91 (SD = 1.56). Nineteen children had cognitive behavior therapy (CBT) to be effective in managing a primary diagnosis of AS, and two children had a primary problems faced by young people with AS [24]. Randomized diagnosis of high functioning autism (HFA). Participants controlled trials have evaluated the efficacy of CBT inter- resided in Brisbane, Australia. The Ethics Committee of the ventions in this population for anxiety [25–28], for anger School of Psychology, University of Queensland, approved [29], and for social and emotional understanding [7]. Each of the study. these trials has incorporated modifications to accommodate Inclusion criteria for the study required that each child the cognitive profile of autism spectrum disorders. have a diagnosis of AS or HFA as confirmed by a pediatrician The current study is a pilot trial of a 5-week intervention or a clinical psychologist as well as meeting criteria on the for children with AS that aims to increase understanding and Asperger Syndrome Diagnostic Interview (ASDI; [31]) and appropriate use of affectionate behavior in a family setting. an IQ score of 79 or higher on the Wechsler Abbreviated Scale The intervention has been tailored for children with AS and of Intelligence (WASI; [32]). Difficulties with affectionate uses strategies previously found to be effective. behavior were established based on parent report at the intake interview. 2. Intervention The program has five 2-hour sessions for children that are 3.2. Procedures. As parents expressed an interest in partici- held in small groups while the parents participate in a parallel pating in the program, they provided informed consent and parent session in a large group. In Session 1 the groups were allocated a time for both parent and child to complete Autism Research and Treatment 3 the interview and questionnaires. Children were allocated appropriately (ranging from 1, “Never Appropriate”, through to small groups based on age and gender. There were three to 7, “Always Appropriate”). The second part asked parents to children in each group with two therapists to run the group. provide a description of the amount that their child displayed The parent group was held at the same time, and all parents this affectionate gesture (with responses ranging from 1, were in one large group with two therapists. Each of the five “Not Enough”, to 7, “Too Much”). An “Appropriateness” 2-hour sessions was held on a Saturday. Measures were taken score and an “Amount” score were computed for the again immediately after program and at 3-month followup Giving Affection, Receiving Affection, and Communicating when families returned to attend an information session and Empathy subscales, and a “Total Appropriateness” score and receive certificates. a “Total Amount” score were calculated by adding the totals for each subscale. 3.3. Measures 3.3.5. Affection for You Questionnaire (AYQ). The AYQ [34] 3.3.1. Clinical Interview and General Affection Questions. A is another newly developed measure that aims to assess a brief standardized clinical interview was administered to all child’s ability to engage in affectionate interactions with parents prior to the intervention. The interview included their parents. The AYQ was developed with five subscales: questions pertaining to the child’s demographics, diagnoses, Giving Verbal Affection to You, Giving Physical Affection to current medications, and problems with affectionate behav- You, Receiving Verbal Affection from You, Receiving Physical ior. The ASDI was also administered as part of the intake Affection from You, and Communicating Empathy to You. procedure. Alpha coefficients for the subscales ranged from α = .90 to α = .95 in the current sample. The number of questions making up each subscale varies from 3 to 5 items per 3.3.2. Asperger Syndrome Diagnostic Interview (ASDI). The subscale, yielding a total of 19 questions. There were two ASDI [31] is a 20-item structured interview designed to parts to each question. The first asked parents to rate how capture the degree to which children display traits associated often the child completed the affectionate gesture (ranging with AS. The items assess the symptoms included in the from 1, “Never”, through to 7, “Twice a day or more”). diagnostic criteria for AS developed by I. C. Gillberg and C. The second part asked the parent to provide a description Gillberg [33] including social impairment, narrow interest, of the amount (ranging from 1, “Not Enough,” to 7, “Too compulsive need for routines and interests, speech and Much”). The first part of the question was only intended language peculiarities, nonverbal communication problems, for qualitative purposes, and therefore no total score was and motor clumsiness. Each item is rated as 0 or 1, with calculated for these items. As with the AOQ, an “Amount” 0 = criterion not met and 1 = criterion is met. Gillberg score was computed for each subscale, and a “Total Amount” et al. [31] reported excellent interrater reliability (kappa score was calculated by adding the totals for each subscale. = .91) and intrarater reliability (kappa = .92). 3.3.6. General Affection Questionnaire (GAQ). The GAQ [34] 3.3.3. Wechsler Abbreviated Scale of Intelligence (WASI). The WASI [32] is a standardised individually administered test aims to assess a child’s general difficulty with affectionate behavior. The GAQ comprises two subscales: Excessive of cognitive functioning in individuals aged 6–89 years. It Affection and Inadequate Affection. The GAQ has 12 is an abbreviated measure of intelligence and consists of statements that assess the amount of affection in which four subtests: Vocabulary, Block Design, Similarities, and the child engages (e.g., “He/she shows a lack of affection”), Matrix Reasoning. The examiner also has the option of administering the two-subtest format (i.e., Vocabulary and the appropriateness of the affection a child expresses (e.g., “He/she uses inappropriate expressions of affection”), the Matrix Reasoning), and this was used in the current study. impact that difficulties with affection has on various areas The WASI gives a global measure of intellectual ability. of the child’s life (e.g., “He/she has difficulties with affection that cause problems with his/her siblings”), and the child’s 3.3.4. Affection for Others Questionnaire (AOQ). The AOQ knowledge of affection (e.g., “I have had to spend time [34] is a newly developed measure that aims to assess a child’s teaching him/her about affection”). The scale ranges from 1, capacity to engage in affectionate behavior with “others” “Strongly Disagree,” to 7, “Strongly Agree”. The sum of all 12 (i.e., people outside of the child’s immediate family such items yields a “Total Difficulty with Affection” score. Alpha as teachers, classmates, family friends, and professionals). coefficients were adequate (α = .75 and .87) in the current The AOQ was designed with five subscales: Giving Verbal sample. Affection to Others, Giving Physical Affection to Others, Receiving Verbal Affection from Others, Receiving Physical Affection from Others, and Communicating Empathy to 3.3.7. Touch Inventory for Elementary-School-Aged Children Others. The Cronbach’s alpha coefficient for the subscales of (TI). The TI [35] is a 26-item parent report scale designed the AOQ ranged from α = .85 to α = .94 in the present to measure a child’s tactile sensitivity. Each item requires study, suggesting high internal consistency. Each subscale the participant to indicate the level of their child’s reaction includes 4 questions making a total of 20 questions. Each to various forms of touch (e.g., “does it bother your child item has two parts. The first asks parents to rate whether their to be hugged or held?” or “does it bother your child to child was able to complete each of the affectionate gestures have their face touched?”). The TI has a high test-retest 4 Autism Research and Treatment reliability with a seven-day interval (r = .91, P< .01) [36]. Table 1: Correlations between measures of affection and other variables. The TI has also demonstrated discriminant validity with an ability to differentiate between children identified as being GAQ AOQ Walk in the Forest tactile defensive and nontactile defensive with an 85% correct Touch Inventory .384 −.258 .175 classification rate (Wilk’s Λ = .58, df = 26, P = .007) [37]. Social Skills ∗∗ ∗∗ The scale showed good reliability in the present study with −.759 .831 −.104 (SSQ-P) α = .87. Social Competence ∗∗ ∗∗ −.633 .710 .213 (SCPQ-P) 3.3.8. Social Skills Questionnaire-Parent(s) (SSQ-P). The GAQ: General Affection Questionnaire; AOQ: Affection for Others Ques- SSQ-P [38] is a 30-item parent report questionnaire designed ∗∗ tionnaire; N = 21; P< .001. to assess a child’s social skills in the four weeks prior to completion of the measure. Parents are asked to rate the accuracy of a series of statements (ranging from “Not true” the total scores on the SCPQ-P were significantly inversely to “Mostly true”). The questionnaire showed good reliability correlated. The total scores on the GAQ and the total scores in the present study, α = .93. on the SSQ-P were significantly negatively correlated. These findings indicate that, as general difficulty with affection 3.3.9. Social Competence with Peers Questionnaire-Parent(s) increases, social ability decreases. The correlation between (SCPQ-P). The SCPQ-P [38] consists of 9 statements the total scores on the AOQ and the total scores on the SSQ- regarding a child’s social competence with peers in the past P was significant. In addition, the correlation between total four weeks. Parents are asked to rate the extent to which each scores on the AOQ and the total scores on the SCPQ-P was of the statements is true (ranging from “Not true” to “Mostly significant. These results suggest that as the appropriateness true”). The measure correlates significantly with teacher and of affection increases, then so does social ability. child ratings of competence with peers and with the SSQ- P. The scale showed good reliability with the current sample 4.2. Intervention Effects α = .90. 4.2.1. General Problems with Affection. The child’s general 3.3.10. Walk in the Forest Test (WFT). The WFT is a measure difficulty with affection was measured via parent report using specifically designed by Attwood [39] for the current study the GAQ. A series of within-subjects, repeated measures to assess a child’s understanding of affection. The measure ANOVAs was conducted to compare parent reports of child consists of a hypothetical scenario that describes an inter- affection difficulties across time (pre-, post-, and followup). action between the child and an alien in the forest. During Results from the GAQ showed that the mean total scores the interaction, the alien asks the child why humans are on the GAQ were not significantly different from pre- to affectionate with each other. The child is then prompted postintervention, and this result was maintained at followup. to generate possible reasons that people express affection. Administration is standardised, with the scenario read aloud 4.2.2. Appropriateness of Affection with Others. Appropriate to the child by the examiner, and the child’s responses expression of affectionate behavior towards “others” (i.e., recorded and rated for appropriateness. The WFT is scored people other than immediate family) was measured by parent by allocating one point for each appropriate response. Two report on the AOQ. The “Total Appropriateness” score was independent examiners were used to evaluate interrater used to measure this construct. Within-subjects repeated reliability, which was 98%. measures ANOVAs were conducted to compare parent reports of the children’s ability to engage in appropriate affection across time (pre-, post-, and followup). Analyses 4. Results were conducted for the total scale and for the three subscales Analyses were conducted using the statistical computer of the AOQ, “Giving Affection to Others,” “Receiving Affec- program PASW Statistics for Windows Version 17.0. Four tion from Others,” and “Communicating Empathy to Oth- missing values were identified and replaced using mean ers.” substitution. Twelve of the participants attended all five Results from the AOQ showed that the mean total sessions, and one child withdrew from the study after scores on the AOQ were significantly different from pre- attending session one. The data for this child was handled to postintervention, F(1, 20) = 15.403, P< .001, partial using an intention-to-treat procedure. Family-wise Bonfer- η = .435, indicating that parents reported an increase in roni correction was conducted to limit the likelihood of Type the appropriateness of the affectionate interactions between 1 errors in the univariate analyses [40]. The significance children and “others” at postintervention, and this finding levels determined after the Bonferroni adjustment were P< was maintained at followup. .006 for all the mean comparisons. The significance levels Results from the “Giving Affection” subscale of the used for the correlations were P< .05. AOQ showed that mean scores on the Giving Affection subscale of the AOQ were significantly different from pre- 4.1. Correlations. The correlations discussed in this section to postintervention, F(1, 20) = 15.254, P< .001, partial are presented in Table 1. The total scores on the GAQ and η = .433, such that parents reported an increase in the Autism Research and Treatment 5 Table 2: Means scores on the AOQ by testing time. Means Measure Pre- Post- Followup MSDMSD M SD ∗∗ AOQ total 68.67 (25.46) 84.91 (17.31) 83.43 (16.63) ∗∗ AOQ—Giving Affection 25.67 (9.33) 33.00 (7.18) 31.86 (7.58) AOQ—Receiving Affection 29.14 (12.76) 34.43 (7.16) 33.95 (6.40) AOQ—Comm. Empathy 13.86 (5.84) 17.48 (4.52) 17.62 (4.30) Significantly higher than preintervention score at P< .006. ∗∗ Significantly higher than preintervention score at P< .001. Table 3: Number and percentage (parentheses) of participants in appropriateness of the children’s ability to give affection the low-affection, adequate affection, and high-affection groups at to others after intervention, and this was maintained at pre-, post-, and followup. followup. Results from the “Receiving Affection” subscale of the Group Time AOQ AYQ AOQ showed that mean scores on the Receiving Affection Pre 14 (66.67%) 9 (42.86%) subscale of the AOQ were not significantly different from Low affection Post 6 (28.57%) 1 (4.76%) pre- to postintervention, and this was maintained at fol- Followup 6 (28.57%) 3 (14.29%) lowup. Pre 7 (33.33%) 11 (52.38%) Results from the “Communicating Empathy” subscale of Adequate affection Post 15 (71.43%) 20 (95.24%) the AOQ showed that mean scores on the Communicating Empathy subscale of the AOQ were significantly different Followup 15 (71.43%) 18 (85.71%) from pre- to postintervention, F(1, 20) = 10.057, P< .005, Pre 0 1 (4.76%) partial η = .335, with parents reporting an increase in High affection Post 0 0 the appropriateness of the children’s ability to communi- Followup 0 0 cate empathy to others after intervention. This result was maintained at followup. Means and standard deviations are provided in Table 2. Participants were divided into three groups based on their baseline Total Amount scores derived from the AOQ 4.2.3. Understanding of the Purpose of Affection. The child’s and AYQ. The participants with baseline Total Amount understanding of the purpose of affection was assessed scores of 59 and below on the AOQ and of 57 and below on via child report using the “A Walk in the Forest Test.” A the AYQ were categorized as the “Low Affection” group. The within-subjects repeated measures ANOVA was conducted participants with baseline scores between 59 and 100 on the to compare children’s understanding of the function of AOQ and between 57 and 95 on the AYQ were labeled as the affection across time. Results from the WFT showed that “Adequate Affection” group. Participants with baseline scores the mean scores on the WFT were significantly different of 101 and over on the AOQ and of 96 and over on the AYQ from pre- to postintervention, F(1, 20) = 21.929, P< were regarded as the “High Affection” group. The results are 0.001, partial η = .523, indicating that the children’s displayed in Table 3. understanding increased after intervention, and this was Total Amount scores on the AOQ indicate that there maintained at followup. was a substantial increase from pre- to postintervention in the number of children reported by parents to express more adequate levels of affection to others with eight children 4.2.4. Amount of Affection Expressed. Parents’ perceptions (38.1%) moving from the low affection to the adequate of the amount of affection their child expressed to others affection category, and this was maintained at followup. Total (i.e., people outside their immediate family) and to them Amount scores on the AYQ at pre- and postintervention also as parents were assessed by means of the AOQ and AYQ. indicate that there was a marked increase in the number The Total Amount score from each scale was summed of children perceived by their parents to express adequate to measure this construct. In this section, the number of levels of affection to them as parents. Nine children (42.86%) children showing improvement was examined, in order to moved from the low affection to the adequate affection give a more meaningful description of the results in terms of group, and one child moved from the high affection group clinical outcomes. No statistical analyses were applied to this with results maintained at followup. data as the scale on the AOQ and AYQ where parents rate their perception of the affectionate behavior of their child is not linear; that is, increases as well as decreases on this rating 4.2.5. Qualitative Findings. At postintervention, parents scale can suggest improvement in the child’s appropriate were asked to complete a brief questionnaire regarding their demonstration of affectionate behavior as long as the child’s experience of the program. The majority of parents reported score moved towards the middle of the scale. that they observed improvements in their child’s affectionate 6 Autism Research and Treatment behavior after completing the program. These improvements engaging in certain behaviors they will be more likely to included an increased understanding of affectionate behavior modify their behavior [1]. and its importance, an increased awareness of affectionate behavior in self and others, higher levels of giving verbal (e.g., 5.1. Qualitative Findings. The qualitative data collected from compliments) and nonverbal (e.g., hugs and kisses) affection, the study, congruent with empirical findings, provide power- more tolerance in terms of receiving verbal and nonverbal ful testimony to the program’s application for creating pos- affection, and an increased capacity to engage in appropriate itive change within households. Parents observed improve- affectionate behaviors. Some parents stated that the program ments in their child’s understanding and consciousness of provided a good foundation on which to build and refine affectionate behavior, displays of verbal and nonverbal affec- their child’s skills in affectionate behavior. These qualitative tion, tolerance of receiving verbal and nonverbal affection, findings are consistent with the empirical results. and in the appropriateness of affectionate behaviors. Some parents believed that the program would provide a good foundation for assisting their child to develop further skills in 5. Discussion affectionate behavior in the future. This potential is apparent Children with Asperger syndrome have a propensity to be in those cases where improved scores on the “A Walk in the inappropriate in their expression of affectionate behavior Forest” test were maintained at followup, implying a retained [1]. The results from this pilot study indicated a significant insight into the purpose and importance of affection after increase in the overall appropriateness of children’s affec- completing the program and 3 months after the intervention. tionate behavior towards others (i.e., those people outside their immediate family) reported by parents at postinter- 5.2. Limitations and Future Directions. There are some limi- vention and followup. In particular, there was a significant tations that need to be taken into consideration when improvement in the appropriateness of affection given and interpreting the results of this research. First, the outcomes the empathy communicated to others. However, there was no were primarily evaluated by means of parent-report ques- significant improvement in the appropriateness of children’s tionnaires. Therefore, as with many studies that rely on the responses to the affection they received from others. A report of parents, the data is subjective and may be open possible explanation for this finding is that, although some to bias. Also, some parents reported that they had been work was done on responding appropriately to affection diagnosed with AS, which may have impacted on their ability initiated by others, the program predominantly focussed to produce reliable data; that is, individuals with AS can be on initiating appropriate affection. It is also the case that very black and white in their thinking [1] and, therefore, children with AS do not like the unexpected and whereas when answering a questionnaire, may have a tendency to they can control self-initiated affectionate behaviors they are provide extreme responses that may over- or underestimate unable to control those behaviors initiated by others. This their child’s actual abilities. It may therefore be beneficial to may also be associated with tactile sensitivity issues. employ observations of parent-child interactions in future A marked increase was reported in the number of research to provide objective findings. The positive change children that changed categories to be described by parents in the parents’ perception of their children’s affectionate as engaging in more adequate levels of affectionate behavior, behavior is nonetheless an important outcome achieved both toward parents and toward individuals outside the through the current intervention. immediate family. Although it is unclear whether these improvements are statistically significant, it certainly appears References that the “Exploring Feelings: Affection” program is effective in increasing affectionate behavior in those children who [1] T. Attwood, The Complete Guide to Asperger’s Syndrome, Jessica exhibit unusually low levels of affection. These results Kingsley Publishers, London, UK, 2007. are consistent with the findings of previous studies that [2] L. K. Guerrero and K. 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Increasing the Understanding and Demonstration of Appropriate Affection in Children with Asperger Syndrome: A Pilot Trial

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Copyright © 2011 Kate Sofronoff et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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Hindawi Publishing Corporation Autism Research and Treatment Volume 2011, Article ID 214317, 8 pages doi:10.1155/2011/214317 Research Article Increasing the Understanding and Demonstration of Appropriate Affection in Children with Asperger Syndrome: A Pilot Trial 1 1 1 2 Kate Sofronoff, Johann Eloff, Jeanie Sheffield, and Tony Attwood School of Psychology, The University of Queensland, St Lucia, Brisbane, QLD 4072, Australia School of Psychology, Griffith University, Mt Gravatt, Brisbane, QLD 4122, Australia Correspondence should be addressed to Kate Sofronoff, kate@psy.uq.edu.au Received 1 July 2011; Revised 14 October 2011; Accepted 14 October 2011 Academic Editor: Bennett L. Leventhal Copyright © 2011 Kate Sofronoff et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The study was conducted to examine relationships between affectionate behavior in children with Asperger syndrome and variables likely to influence its expression (e.g., tactile sensitivity, social ability). It also evaluated the impact of a cognitive behavioral intervention that aimed to improve a child’s understanding and expression of affection. Twenty-one children, aged 7 to 12 years, participated in the trial. The results showed significant correlations between measures of affection and tactile sensitivity and social ability. After attending the 5-week program, parents identified significant increases in the appropriateness of children’s affectionate behavior both towards immediate family and people outside the immediate family, despite reporting no significant changes in their child’s general difficulties with affectionate behavior. There was a significant improvement in children’s understanding of the purpose of affection. The findings are discussed as well as the limitations of the study. 1. Introduction AS are particularly likely to misread the intentions of others and may inadvertently engage in behaviors that are socially Affectionate communication is a form of social behavior that unacceptable or inappropriate in terms of touch, personal individuals with Asperger syndrome (AS) find problematic space, greetings, and gestures of affection that can lead to [1]. Affectionate communication comprises those actions embarrassment in others. through which humans express feelings of positive regard Parents of a child with AS face an increased number of such as liking, love, closeness, care, and gratitude to one stressors and report greater stress compared with parents of another by means of verbal, nonverbal, and supportive forms a typical child [9] or a child with another developmental of communication [2–4]. The capacity to express and receive disorder [10]. They also report distress associated with affection is considered a fundamental human need by social their child’s infrequent expressions of affection [1, 11]. For scientists such as Rotter et al. [5] and is considered vital example, a mother complained that her adolescent son with for the formation, maintenance, and quality of personal AS did not express enough affection, to which he replied relationships [2]. that he said that he loved her when he was six and was Children with AS have great difficulty in understanding puzzled as to why he should repeat this phrase [8]. The affection and expressing appropriate levels of affection [1]. absence of affection in close relationships is correlated with The clinical presentation of AS has many features that loneliness [12] and depression [13] and is an indicator of overlap with the personality trait alexithymia [6], in which relational deterioration [2]. Hence, the difficulties associated the individual has an impaired ability to recognise, process, with emotional reciprocity in AS are likely to reduce a and communicate their emotional state. Many individuals parent’s experience of reinforcement in their parenting role and produce an additional source of stress. with AS demonstrate an impaired capacity to recognise and communicate emotion-related information about them- Outside of the family context it is found that individuals selves and others [7]. According to Attwood [1, 8], those with who engage in high levels of affectionate communication 2 Autism Research and Treatment enjoymoresocialinvolvement [14]. Affectionate behavior participate in “getting to know you activities” and focus on such as laughter, smiling, praise, and excited verbal state- experiences and people that they like. They are introduced to ments have been shown to elicit positive peer reactions the concrete concept of placing items on a visual scale and in children [15]. Newcomb et al. [16]performed ameta- applying ratings (0–100) using post-it stickers. The session analysis of studies on peer relationships and found that moves to identifying ways that we can tell if someone likes popular children frequently exhibited prosocial behaviors or loves us, again using visual strategies and then to why we (including affectionate actions) and made positive comments express feelings of liking or loving people. The child is asked about others in comparison with children who were unpop- to complete some project work for the next session with the ular with peers. These findings suggest that affectionate com- help of a parent. munication may be a vital means through which children Session 2 reviews the project work and moves on to initiate interactions and form social relationships. constructing a Social Story [30] about how liking or loving There are several hypotheses that can potentially explain someone can affect feelings and thoughts. Some time is spent the difficulties with affectionate behavior that individuals constructing a schematic of the different people in each with AS experience. First, many children with AS experi- child’s environment and how we may do and say different ence heightened sensory perception [17], and sensitivity to things to each one to show that we like them. There are then touch has been found to occur in over 50% of children roleplays to practice this in the groups. The child is asked with AS [18]. It has been observed that some children to practice showing affection to a parent or sibling in the with AS find gestures of affection such as a hug or kiss following week and to report back to the group. aversive, as the sensory experience is unpleasant [1, 19, Session 3 reviews and demonstrates the practice done by 20]. Secondly, many individuals with AS have immature each child in the week. The session then moves on to the Theory of Mind skills and have difficulty recognising and concept of compliments and includes both discussion and understanding the thoughts, beliefs, desires, and intentions roleplay around this for a variety of people. There is also a of others [21]. Therefore, it may not occur to a child with focus on receiving compliments and practice agreed for the AS that another person is distressed and would appreciate home project. physical comfort or verbal reassurance to help restore their In Sessions 4 and 5 the children continue to discuss their emotional state. Thirdly, as well as difficulties recognising understanding of affection and to roleplay the various things emotions in others and themselves [22], individuals with that they can do and say in order to show a range of people AS experience difficulties reading social cues within a social that they like or love them. At the end of Session 5 there interaction. Poor interpretation of cues, such as the meaning is a review of what they feel has been learned. The sessions of a facial expression, a gesture, or tone of voice, may are able to be tailored to address the specific concerns raised limit expression of appropriate affectionate behavior [23]. A by each family and so different areas can be emphasized for fourth explanation is that children with AS may simply lack individual children. insight as to what appropriate affection entails. For instance, an individual with AS may show that he/she cares by carrying 3. Method out a practical deed (e.g., handing a distressed person a 3.1. Participants. Twenty-three children were recruited to tissue), discussing his/her own special interest (would make participate in the study via media outreach through local them feel better), or leaving the sad person alone to self- newspapers and schools. One child with nonverbal autism soothe rather than displaying conventional forms of affection was excluded from the trial, and two participants withdrew such as hugging. If this is the case, then it is possible to teach before the trial commenced. The final sample included what is appropriate in different situations [1]. twenty-one children (18 boys and 3 girls) aged 7 to 12 years There is a small body of literature that has shown with a mean age of 9.91 (SD = 1.56). Nineteen children had cognitive behavior therapy (CBT) to be effective in managing a primary diagnosis of AS, and two children had a primary problems faced by young people with AS [24]. Randomized diagnosis of high functioning autism (HFA). Participants controlled trials have evaluated the efficacy of CBT inter- resided in Brisbane, Australia. The Ethics Committee of the ventions in this population for anxiety [25–28], for anger School of Psychology, University of Queensland, approved [29], and for social and emotional understanding [7]. Each of the study. these trials has incorporated modifications to accommodate Inclusion criteria for the study required that each child the cognitive profile of autism spectrum disorders. have a diagnosis of AS or HFA as confirmed by a pediatrician The current study is a pilot trial of a 5-week intervention or a clinical psychologist as well as meeting criteria on the for children with AS that aims to increase understanding and Asperger Syndrome Diagnostic Interview (ASDI; [31]) and appropriate use of affectionate behavior in a family setting. an IQ score of 79 or higher on the Wechsler Abbreviated Scale The intervention has been tailored for children with AS and of Intelligence (WASI; [32]). Difficulties with affectionate uses strategies previously found to be effective. behavior were established based on parent report at the intake interview. 2. Intervention The program has five 2-hour sessions for children that are 3.2. Procedures. As parents expressed an interest in partici- held in small groups while the parents participate in a parallel pating in the program, they provided informed consent and parent session in a large group. In Session 1 the groups were allocated a time for both parent and child to complete Autism Research and Treatment 3 the interview and questionnaires. Children were allocated appropriately (ranging from 1, “Never Appropriate”, through to small groups based on age and gender. There were three to 7, “Always Appropriate”). The second part asked parents to children in each group with two therapists to run the group. provide a description of the amount that their child displayed The parent group was held at the same time, and all parents this affectionate gesture (with responses ranging from 1, were in one large group with two therapists. Each of the five “Not Enough”, to 7, “Too Much”). An “Appropriateness” 2-hour sessions was held on a Saturday. Measures were taken score and an “Amount” score were computed for the again immediately after program and at 3-month followup Giving Affection, Receiving Affection, and Communicating when families returned to attend an information session and Empathy subscales, and a “Total Appropriateness” score and receive certificates. a “Total Amount” score were calculated by adding the totals for each subscale. 3.3. Measures 3.3.5. Affection for You Questionnaire (AYQ). The AYQ [34] 3.3.1. Clinical Interview and General Affection Questions. A is another newly developed measure that aims to assess a brief standardized clinical interview was administered to all child’s ability to engage in affectionate interactions with parents prior to the intervention. The interview included their parents. The AYQ was developed with five subscales: questions pertaining to the child’s demographics, diagnoses, Giving Verbal Affection to You, Giving Physical Affection to current medications, and problems with affectionate behav- You, Receiving Verbal Affection from You, Receiving Physical ior. The ASDI was also administered as part of the intake Affection from You, and Communicating Empathy to You. procedure. Alpha coefficients for the subscales ranged from α = .90 to α = .95 in the current sample. The number of questions making up each subscale varies from 3 to 5 items per 3.3.2. Asperger Syndrome Diagnostic Interview (ASDI). The subscale, yielding a total of 19 questions. There were two ASDI [31] is a 20-item structured interview designed to parts to each question. The first asked parents to rate how capture the degree to which children display traits associated often the child completed the affectionate gesture (ranging with AS. The items assess the symptoms included in the from 1, “Never”, through to 7, “Twice a day or more”). diagnostic criteria for AS developed by I. C. Gillberg and C. The second part asked the parent to provide a description Gillberg [33] including social impairment, narrow interest, of the amount (ranging from 1, “Not Enough,” to 7, “Too compulsive need for routines and interests, speech and Much”). The first part of the question was only intended language peculiarities, nonverbal communication problems, for qualitative purposes, and therefore no total score was and motor clumsiness. Each item is rated as 0 or 1, with calculated for these items. As with the AOQ, an “Amount” 0 = criterion not met and 1 = criterion is met. Gillberg score was computed for each subscale, and a “Total Amount” et al. [31] reported excellent interrater reliability (kappa score was calculated by adding the totals for each subscale. = .91) and intrarater reliability (kappa = .92). 3.3.6. General Affection Questionnaire (GAQ). The GAQ [34] 3.3.3. Wechsler Abbreviated Scale of Intelligence (WASI). The WASI [32] is a standardised individually administered test aims to assess a child’s general difficulty with affectionate behavior. The GAQ comprises two subscales: Excessive of cognitive functioning in individuals aged 6–89 years. It Affection and Inadequate Affection. The GAQ has 12 is an abbreviated measure of intelligence and consists of statements that assess the amount of affection in which four subtests: Vocabulary, Block Design, Similarities, and the child engages (e.g., “He/she shows a lack of affection”), Matrix Reasoning. The examiner also has the option of administering the two-subtest format (i.e., Vocabulary and the appropriateness of the affection a child expresses (e.g., “He/she uses inappropriate expressions of affection”), the Matrix Reasoning), and this was used in the current study. impact that difficulties with affection has on various areas The WASI gives a global measure of intellectual ability. of the child’s life (e.g., “He/she has difficulties with affection that cause problems with his/her siblings”), and the child’s 3.3.4. Affection for Others Questionnaire (AOQ). The AOQ knowledge of affection (e.g., “I have had to spend time [34] is a newly developed measure that aims to assess a child’s teaching him/her about affection”). The scale ranges from 1, capacity to engage in affectionate behavior with “others” “Strongly Disagree,” to 7, “Strongly Agree”. The sum of all 12 (i.e., people outside of the child’s immediate family such items yields a “Total Difficulty with Affection” score. Alpha as teachers, classmates, family friends, and professionals). coefficients were adequate (α = .75 and .87) in the current The AOQ was designed with five subscales: Giving Verbal sample. Affection to Others, Giving Physical Affection to Others, Receiving Verbal Affection from Others, Receiving Physical Affection from Others, and Communicating Empathy to 3.3.7. Touch Inventory for Elementary-School-Aged Children Others. The Cronbach’s alpha coefficient for the subscales of (TI). The TI [35] is a 26-item parent report scale designed the AOQ ranged from α = .85 to α = .94 in the present to measure a child’s tactile sensitivity. Each item requires study, suggesting high internal consistency. Each subscale the participant to indicate the level of their child’s reaction includes 4 questions making a total of 20 questions. Each to various forms of touch (e.g., “does it bother your child item has two parts. The first asks parents to rate whether their to be hugged or held?” or “does it bother your child to child was able to complete each of the affectionate gestures have their face touched?”). The TI has a high test-retest 4 Autism Research and Treatment reliability with a seven-day interval (r = .91, P< .01) [36]. Table 1: Correlations between measures of affection and other variables. The TI has also demonstrated discriminant validity with an ability to differentiate between children identified as being GAQ AOQ Walk in the Forest tactile defensive and nontactile defensive with an 85% correct Touch Inventory .384 −.258 .175 classification rate (Wilk’s Λ = .58, df = 26, P = .007) [37]. Social Skills ∗∗ ∗∗ The scale showed good reliability in the present study with −.759 .831 −.104 (SSQ-P) α = .87. Social Competence ∗∗ ∗∗ −.633 .710 .213 (SCPQ-P) 3.3.8. Social Skills Questionnaire-Parent(s) (SSQ-P). The GAQ: General Affection Questionnaire; AOQ: Affection for Others Ques- SSQ-P [38] is a 30-item parent report questionnaire designed ∗∗ tionnaire; N = 21; P< .001. to assess a child’s social skills in the four weeks prior to completion of the measure. Parents are asked to rate the accuracy of a series of statements (ranging from “Not true” the total scores on the SCPQ-P were significantly inversely to “Mostly true”). The questionnaire showed good reliability correlated. The total scores on the GAQ and the total scores in the present study, α = .93. on the SSQ-P were significantly negatively correlated. These findings indicate that, as general difficulty with affection 3.3.9. Social Competence with Peers Questionnaire-Parent(s) increases, social ability decreases. The correlation between (SCPQ-P). The SCPQ-P [38] consists of 9 statements the total scores on the AOQ and the total scores on the SSQ- regarding a child’s social competence with peers in the past P was significant. In addition, the correlation between total four weeks. Parents are asked to rate the extent to which each scores on the AOQ and the total scores on the SCPQ-P was of the statements is true (ranging from “Not true” to “Mostly significant. These results suggest that as the appropriateness true”). The measure correlates significantly with teacher and of affection increases, then so does social ability. child ratings of competence with peers and with the SSQ- P. The scale showed good reliability with the current sample 4.2. Intervention Effects α = .90. 4.2.1. General Problems with Affection. The child’s general 3.3.10. Walk in the Forest Test (WFT). The WFT is a measure difficulty with affection was measured via parent report using specifically designed by Attwood [39] for the current study the GAQ. A series of within-subjects, repeated measures to assess a child’s understanding of affection. The measure ANOVAs was conducted to compare parent reports of child consists of a hypothetical scenario that describes an inter- affection difficulties across time (pre-, post-, and followup). action between the child and an alien in the forest. During Results from the GAQ showed that the mean total scores the interaction, the alien asks the child why humans are on the GAQ were not significantly different from pre- to affectionate with each other. The child is then prompted postintervention, and this result was maintained at followup. to generate possible reasons that people express affection. Administration is standardised, with the scenario read aloud 4.2.2. Appropriateness of Affection with Others. Appropriate to the child by the examiner, and the child’s responses expression of affectionate behavior towards “others” (i.e., recorded and rated for appropriateness. The WFT is scored people other than immediate family) was measured by parent by allocating one point for each appropriate response. Two report on the AOQ. The “Total Appropriateness” score was independent examiners were used to evaluate interrater used to measure this construct. Within-subjects repeated reliability, which was 98%. measures ANOVAs were conducted to compare parent reports of the children’s ability to engage in appropriate affection across time (pre-, post-, and followup). Analyses 4. Results were conducted for the total scale and for the three subscales Analyses were conducted using the statistical computer of the AOQ, “Giving Affection to Others,” “Receiving Affec- program PASW Statistics for Windows Version 17.0. Four tion from Others,” and “Communicating Empathy to Oth- missing values were identified and replaced using mean ers.” substitution. Twelve of the participants attended all five Results from the AOQ showed that the mean total sessions, and one child withdrew from the study after scores on the AOQ were significantly different from pre- attending session one. The data for this child was handled to postintervention, F(1, 20) = 15.403, P< .001, partial using an intention-to-treat procedure. Family-wise Bonfer- η = .435, indicating that parents reported an increase in roni correction was conducted to limit the likelihood of Type the appropriateness of the affectionate interactions between 1 errors in the univariate analyses [40]. The significance children and “others” at postintervention, and this finding levels determined after the Bonferroni adjustment were P< was maintained at followup. .006 for all the mean comparisons. The significance levels Results from the “Giving Affection” subscale of the used for the correlations were P< .05. AOQ showed that mean scores on the Giving Affection subscale of the AOQ were significantly different from pre- 4.1. Correlations. The correlations discussed in this section to postintervention, F(1, 20) = 15.254, P< .001, partial are presented in Table 1. The total scores on the GAQ and η = .433, such that parents reported an increase in the Autism Research and Treatment 5 Table 2: Means scores on the AOQ by testing time. Means Measure Pre- Post- Followup MSDMSD M SD ∗∗ AOQ total 68.67 (25.46) 84.91 (17.31) 83.43 (16.63) ∗∗ AOQ—Giving Affection 25.67 (9.33) 33.00 (7.18) 31.86 (7.58) AOQ—Receiving Affection 29.14 (12.76) 34.43 (7.16) 33.95 (6.40) AOQ—Comm. Empathy 13.86 (5.84) 17.48 (4.52) 17.62 (4.30) Significantly higher than preintervention score at P< .006. ∗∗ Significantly higher than preintervention score at P< .001. Table 3: Number and percentage (parentheses) of participants in appropriateness of the children’s ability to give affection the low-affection, adequate affection, and high-affection groups at to others after intervention, and this was maintained at pre-, post-, and followup. followup. Results from the “Receiving Affection” subscale of the Group Time AOQ AYQ AOQ showed that mean scores on the Receiving Affection Pre 14 (66.67%) 9 (42.86%) subscale of the AOQ were not significantly different from Low affection Post 6 (28.57%) 1 (4.76%) pre- to postintervention, and this was maintained at fol- Followup 6 (28.57%) 3 (14.29%) lowup. Pre 7 (33.33%) 11 (52.38%) Results from the “Communicating Empathy” subscale of Adequate affection Post 15 (71.43%) 20 (95.24%) the AOQ showed that mean scores on the Communicating Empathy subscale of the AOQ were significantly different Followup 15 (71.43%) 18 (85.71%) from pre- to postintervention, F(1, 20) = 10.057, P< .005, Pre 0 1 (4.76%) partial η = .335, with parents reporting an increase in High affection Post 0 0 the appropriateness of the children’s ability to communi- Followup 0 0 cate empathy to others after intervention. This result was maintained at followup. Means and standard deviations are provided in Table 2. Participants were divided into three groups based on their baseline Total Amount scores derived from the AOQ 4.2.3. Understanding of the Purpose of Affection. The child’s and AYQ. The participants with baseline Total Amount understanding of the purpose of affection was assessed scores of 59 and below on the AOQ and of 57 and below on via child report using the “A Walk in the Forest Test.” A the AYQ were categorized as the “Low Affection” group. The within-subjects repeated measures ANOVA was conducted participants with baseline scores between 59 and 100 on the to compare children’s understanding of the function of AOQ and between 57 and 95 on the AYQ were labeled as the affection across time. Results from the WFT showed that “Adequate Affection” group. Participants with baseline scores the mean scores on the WFT were significantly different of 101 and over on the AOQ and of 96 and over on the AYQ from pre- to postintervention, F(1, 20) = 21.929, P< were regarded as the “High Affection” group. The results are 0.001, partial η = .523, indicating that the children’s displayed in Table 3. understanding increased after intervention, and this was Total Amount scores on the AOQ indicate that there maintained at followup. was a substantial increase from pre- to postintervention in the number of children reported by parents to express more adequate levels of affection to others with eight children 4.2.4. Amount of Affection Expressed. Parents’ perceptions (38.1%) moving from the low affection to the adequate of the amount of affection their child expressed to others affection category, and this was maintained at followup. Total (i.e., people outside their immediate family) and to them Amount scores on the AYQ at pre- and postintervention also as parents were assessed by means of the AOQ and AYQ. indicate that there was a marked increase in the number The Total Amount score from each scale was summed of children perceived by their parents to express adequate to measure this construct. In this section, the number of levels of affection to them as parents. Nine children (42.86%) children showing improvement was examined, in order to moved from the low affection to the adequate affection give a more meaningful description of the results in terms of group, and one child moved from the high affection group clinical outcomes. No statistical analyses were applied to this with results maintained at followup. data as the scale on the AOQ and AYQ where parents rate their perception of the affectionate behavior of their child is not linear; that is, increases as well as decreases on this rating 4.2.5. Qualitative Findings. At postintervention, parents scale can suggest improvement in the child’s appropriate were asked to complete a brief questionnaire regarding their demonstration of affectionate behavior as long as the child’s experience of the program. The majority of parents reported score moved towards the middle of the scale. that they observed improvements in their child’s affectionate 6 Autism Research and Treatment behavior after completing the program. These improvements engaging in certain behaviors they will be more likely to included an increased understanding of affectionate behavior modify their behavior [1]. and its importance, an increased awareness of affectionate behavior in self and others, higher levels of giving verbal (e.g., 5.1. Qualitative Findings. The qualitative data collected from compliments) and nonverbal (e.g., hugs and kisses) affection, the study, congruent with empirical findings, provide power- more tolerance in terms of receiving verbal and nonverbal ful testimony to the program’s application for creating pos- affection, and an increased capacity to engage in appropriate itive change within households. Parents observed improve- affectionate behaviors. Some parents stated that the program ments in their child’s understanding and consciousness of provided a good foundation on which to build and refine affectionate behavior, displays of verbal and nonverbal affec- their child’s skills in affectionate behavior. These qualitative tion, tolerance of receiving verbal and nonverbal affection, findings are consistent with the empirical results. and in the appropriateness of affectionate behaviors. Some parents believed that the program would provide a good foundation for assisting their child to develop further skills in 5. Discussion affectionate behavior in the future. This potential is apparent Children with Asperger syndrome have a propensity to be in those cases where improved scores on the “A Walk in the inappropriate in their expression of affectionate behavior Forest” test were maintained at followup, implying a retained [1]. The results from this pilot study indicated a significant insight into the purpose and importance of affection after increase in the overall appropriateness of children’s affec- completing the program and 3 months after the intervention. tionate behavior towards others (i.e., those people outside their immediate family) reported by parents at postinter- 5.2. Limitations and Future Directions. There are some limi- vention and followup. In particular, there was a significant tations that need to be taken into consideration when improvement in the appropriateness of affection given and interpreting the results of this research. First, the outcomes the empathy communicated to others. However, there was no were primarily evaluated by means of parent-report ques- significant improvement in the appropriateness of children’s tionnaires. Therefore, as with many studies that rely on the responses to the affection they received from others. A report of parents, the data is subjective and may be open possible explanation for this finding is that, although some to bias. Also, some parents reported that they had been work was done on responding appropriately to affection diagnosed with AS, which may have impacted on their ability initiated by others, the program predominantly focussed to produce reliable data; that is, individuals with AS can be on initiating appropriate affection. It is also the case that very black and white in their thinking [1] and, therefore, children with AS do not like the unexpected and whereas when answering a questionnaire, may have a tendency to they can control self-initiated affectionate behaviors they are provide extreme responses that may over- or underestimate unable to control those behaviors initiated by others. This their child’s actual abilities. It may therefore be beneficial to may also be associated with tactile sensitivity issues. employ observations of parent-child interactions in future A marked increase was reported in the number of research to provide objective findings. 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