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head: TEACHING ASSERTIVE COMMUNICATION SKILLS

Teaching Assertive Communication Skills to Adolescents with Aspergers Syndrome and Comorbid Depression and Anxiety Using Behavioural Skills Training

Chris Law University of British Columbia

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Teaching Assertive Communication Skills to Adolescents with Aspergers Syndrome and Comorbid Depression and Anxiety Using Behavioural Skills Training Recent studies have shown that more and more children and youth with Autism Spectrum Disorder (ASD) suffer from mental illness (Mazzone, Ruta, & Reale, 2012). Children and youth diagnosed with Asperger syndrome (AS) or high functioning autism (HFA) seem to be particularly susceptible to mental illnesses like depression and anxiety (Green, Gilchrist, Burton, & Cox, 2000; Barnhill, 2001; Meyer, Mundy, Van Hecke, & Durocher, 2006; Sukhodolsky et al., 2008; Whitehouse, Durkin, Jacquet, & Ziatas, 2009). In their 2000 study on the prevalence of mental illness in AS and HFA populations, Kim, Szatmari, Bryson, Streiner and Wilson found that 13 percent of their sample met criteria for mood and anxiety disorder compared to a random sample of community children. It is suspected that better verbal skills and stronger cognitive abilities in some children with AS or HFA contribute to a stronger awareness of the discrepancy between their social skills and those of their same-aged peers (Bauminger, 2002; Rao, Beidel, & Murray, 2008). Despite this superior skill set, compared to lower functioning children with autism, the awareness that children with AS and HFA may have of the gap that exists between them and typical peers may be a contributing factor of increased prevalence of mental illness. In fact, children with AS are reported to experience loneliness and depression significantly more than same-aged peers (Whitehouse et al., 2009). Not surprisingly, Whitehouse et al. (2009) described findings of poor quality friendships correlated to higher levels of loneliness. Bauminger (2002) refers to a vicious cycle where weak social skills inherent in characteristics of children with AS, a desire to have friends, and the awareness of and experience in social failure combine to equal few quality friendships, loneliness and mental illnesses like depression and anxiety, which then contribute to fewer social opportunities where a child could learn and

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practice their social skills. Taking the perspective that social skill deficits start a chain of events that lead to mental illness in children and youth with AS and HFA, it stands to reason that social skills interventions might alleviate some of the mental health issues that this population faces. Assertive communication skills are one type of social skills that are particularly important if one wants to maintain a relationship already established. A person judged to be assertive in the expression of their needs and wants is able to get his or her needs met at the same time as fostering trusting and open relationships with others. A person judged to be unassertive might have difficulty getting his or her needs met without causing some harm (emotionally or physically) to the communication partner. An unassertive person may have to resort to aggression when interacting with other people to get his or her needs met. Such a person might, alternatively, find ways to meet his or her needs by taking advantage of someone else or using them without regard for their feelings (McGee, Krantz, & McClannahan, 1984). As might be expected, Macintosh and Dissanayake (2006) found that children and youth with AS or HFA have inferior assertive skills compare to typical peers. Therefore, teaching assertive communication skills to children and youth with AS and HFA would be an important step to improving overall social skills and hopefully decreasing the prevalence of mental illnesses like anxiety and depression. Of the many interventions described in the literature, Behavioural Skills Training (BST) has been shown to be effective at teaching a variety of skills, including safety skills in children to prevent gun play (Himle, Miltenberger, Flessner, & Gatheridge, 2004), mand training behaviours of staff (Nigro-Bruzzi & Sturmey, 2010), safe guarding behaviours by staff for students with multiple physical disabilities (Nabeyama & Sturmey, 2010), task engagement in adolescents with HFA (Palmen & Didden, 2012), and even assertive conversation skills in adolescents with autism

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(McGee et al., 1984). It is encouraging that McGee et al. (1984) were able to teach assertive conversational skills to relatively delayed adolescents with autism. It could be anticipated that children and youth with AS and HFA may also benefit from BST of more complex assertive communication behaviours. Method Research Question Will Behavioural Skills Training be an effective teaching method for assertive communication skills in children with Aspergers syndrome and comorbid depression and anxiety in an inpatient pediatric mental health hospital? Participants Three or four adolescent males or females, aged 13 to 16 years old, diagnosed with AS by the British Columbia Autism Assessment Network, will participate in this study. The Autism Diagnostic Interview Revised (Le Couteur et al., 2003) and the Autism Diagnostic Observation Schedule (Lord et al. 2001) are used to determine autism diagnosis in British Columbia. Medical records and collateral information reports, including psycho-educational and socio-emotional reports will be reviewed to establish that potential participants have average IQ scores and especially, average language scores. Patients without recent evaluations will be assessed using the Kaufman Brief Intelligence Test-Second Edition (Kaufman and Kaufman, 2005) to determine eligibility for this study. Patients with below average IQ and language scores will be deemed ineligible. Each participant will meet DSM-IV (APA, 1994) criteria for clinical depression, anxiety or both, as assessed by psychiatrists at the inpatient pediatric mental health hospital to which the participants are admitted. Children and adolescents residing on Vancouver Island, British Columbia are eligible for admission to the Ledger House inpatient mental health hospital

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for support for a variety of mental health issues, including diagnostic clarification, medication review, and suicidal ideation stabilization. Referrals come from community physicians and psychiatrists and are assessed by a multidisciplinary intake team to determine appropriateness of admission. Appropriateness is defined based on community reports of current severity of risk to the patient and stakeholders in the community. Only patients with current or emerging mental health crises are admitted to hospital, therefore, the participants in this study will have demonstrated significant need for mental health services by their behaviour in their communities. Specifically, participants will have demonstrated or experienced some or all of the following behaviours: significant maladaptive parent-child interactions, aggressive outbursts, threats, demands, severe rigidity with regard to personal wants and needs, intolerance of the requests and demands of others, truancy, school suspensions and expulsions, bullying from peers, inability to make and maintain friendships with peers, and suicidal ideation or attempts, all of which could stem, at least in part, from a lack of assertive communication skills. Patients will be given the choice of whether or not to participate in this study and may still take part in BST for assertive communication skill development regardless of their participation in the study. Setting This study will take place on the adolescent unit of an inpatient pediatric mental health hospital. Initial assessments (baseline) and intervention (BST) will occur in a quiet meeting room equipped with a one-way mirror. Patient rooms and meeting rooms will be used for follow up and to support maintenance and generalization. Measurement Dependent variable. Assertive communication skills include behaviours that function to meet the needs of the individual while honestly and clearly expressing their needs in a manner

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that is safe and respectful for the listener. Non-verbal behaviours such as posture and facial expressions and verbal behaviours like tone of voice and the actual words chosen to deliver the message are all components of assertive communication (Wolpe & Lazarus, 1966). Assertive communication is not aggressive nor is it passive in nature. It does not intimidate or abuse the listener. It does not function to meet the speakers needs by going behind the listeners back. Assertive communication is open, direct and confident. The need for assertive communication often occurs most during episodes of interpersonal conflict. The specific behaviours being taught in this study include objectively labeling the behaviours of others, labeling what the participant thinks about what has been observed, labeling how the participant feels about what has been observed and finally asking the listener for what the participant wants related to the situation. This quartet of behaviours combine to form a script of assertive communication that can be used in times of interpersonal conflict to effectively express the thoughts, feelings and wants of the individual while maintaining respect and safety for the listener. When faced with a challenging interpersonal situation the participants will be assessed based on their performance of the following script: When I see or hearI thinkI feeland I want Statements of objective observation will avoid using the pronoun you to decrease defensiveness on the part of the listener (e.g.: When I hear you call me names). Instead, the experimenter will model and encourage statements like, When I hear someone call me names or When I see that unflattering pictures have been posted online Statements of what the participant thinks must refer to their ideas or stories about the situation (e.g.: I think that shows a lack of respect. or I think there is a difference of opinion. or I think it was done to hurt my feelings.). Statements of how the participant feels must refer to specific emotional states (e.g.: I feel angry. or I feel hurt and frustrated.). Finally, statements of what the participant wants must be phrased using

TEACHING ASSERTIVE COMMUNICATION SKILLS active language. For example, the listener would have specific actions to perform if the

participant said, I want to be treated respectfully. or I want my lunch money returned. or I want the unflattering pictures removed from the website. A statement like, I want you not to do that. does not give the listener a specific action to perform and could be misunderstood. Measurement procedures. Assertive communication skills will be measured by calculating the percentage of steps completed correctly during a whole-task presentation task analysis as participants respond to hypothetical, scripted interpersonal conflict scenarios. Participants will initially meet with the experimenter to review up to nine interpersonal conflict scenarios and demonstrate how he or she might respond in that situation. Similarly to the Bornstein, Bellack, and Hersen (1977) study, the experimenter will issue instructions such as, Today we are going to think and talk about how we respond when someone does or says something that bothers us. Im going to read you some scenarios one at a time and I want you to tell me how you would respond if it were happening to you. The experimenter will then read one interpersonal conflict scenario at a time and prompt the participant to respond. An example of a scenario is as follows: A friend posts an unflattering picture of you on their Facebook wall even after you asked them not to. How would you respond assertively? Observations will be recorded on self-graphing task analysis data sheets (see Appendix) for each scenario by the experimenter. The experimenter will score the response for each step in the task analysis as correct or incorrect as per the instructions on the data sheet. Sessions will last approximately 10 to 15 minutes and will be videotaped and scored retrospectively by a trained nave observer for inter-observer agreement. After BST sessions, probe data will be recorded at least three times per week by the experimenter similarly to above except the participant will only respond to one interpersonal conflict scenario delivered by the experimenter. Probes will be videotaped and retrospectively

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scored by a trained nave observer for inter-observer agreement. Follow-up probes will be scored exactly the same way except the content for the interpersonal conflict scenarios will be drawn directly from the participants life. Follow-up probes will also be videotaped and scored retrospectively similarly to baseline and intervention conditions. Inter-observer agreement procedures. Trained nave observers will score approximately 33% of all videotaped sessions in all conditions. Inter-observer agreement will be calculated by dividing the number of agreements by the number of agreement plus disagreements and then multiplying by 100. Implementation fidelity. It is expected that there will be a very low risk of any intervention implementation issues because the experimenter will be the only person delivering the intervention. The experimenter is considered an expert performer of assertive communication behaviours. Research Design A non-concurrent multiple baseline design across participants will be used to determine the effects of BST on the development of assertive communication skills in adolescents with AS and comorbid depression and anxiety. This study will be comprised of three conditions: baseline, treatment and follow-up. The unpredictability of referrals of suitable participants in this setting requires a non-concurrent research design. A multiple baseline design is appropriate for this study because the intervention will likely be impossible to reverse. As Watson and Workman (1981) suggest, each participant will be randomly assigned to a pre-determined baseline length of three, five, seven, or nine data points. Behavioural Skills Training would then be implemented after completion of assigned number of baseline data points. Should a participant not produce stable responding by the end of their predetermined assignment, Watson and Workman (1981)

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recommend dropping the participant from the research. This scenario is highly unlikely to occur in this study considering the participants will probably begin the study with very poor assertive communication skills and therefore have very stable, though very low, data scores. Research Procedures Preliminary start-up procedures. In addition to participant recruitment, obtaining consent and an ethics review, a list of at least 25 fictional, but relevant interpersonal conflict scenarios will be developed to ensure that there are enough novel scenarios for participants to respond to during baseline and intervention. For the follow-up condition, the experimenter will develop at least three patient-specific scenarios directly related to conflict in the participants life from information gathered through interviews with the participant, the participants family, and community stakeholders. Baseline procedures. This condition will begin exactly as stated previously. The experimenter will invite participants to respond to a randomly assigned number of interpersonal conflict scenarios after being oriented to the process. The experimenter will record data on task analysis data sheets on a clipboard. This condition should only last 10 or 15 minutes. The experimenter will refrain from giving feedback to the participants for their responses, other than to thank them for their response. Intervention procedures. BST involves providing instruction, modeling, rehearsal and giving feedback. The experimenter will offer definitions of assertive, aggressive and passive communication behaviour and compare and contrast each with the other. Visual representations of each style of communicating will be highlighted and emphasized while the experimenter explains each one. A diagram of the structured assertive communication phrase (When I see or hearI thinkI feeland I want) will be displayed and each step will be explained and

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highlighted. Next, the participant will listen to the experimenter read two or three interpersonal scenario out loud. The experimenter will model each of the structured assertive communication phrases germane to the presented scenarios. Finally, the participant will role-play and rehearse several scenarios of their choosing while the experimenter provides feedback for correct and incorrect responding. Descriptive praise will be given for correct responding and informational feedback with modeling will be given for incorrect responding. The intervention condition will end after five scenarios have been presented and practiced or when the participant asks to end the session. Follow-up procedures. As stated previously, follow-up probes will include individualized interpersonal conflict scenarios based on the participants current struggles in life. The experimenter will meet with the participant exactly as in baseline and intervention conditions and present the scenario. The participant will respond and the experimenter will record data. Follow-up sessions will occur during the participants last week of admission. With any and all successful responses, the experimenter will encourage and support the participant to use their assertive communication skills with the individuals with which they currently have some degree of interpersonal conflict. This last point will not be part of the experiment but is considered good clinical practice. Anticipated Results The anticipated results for this study are illustrated in Figure 1. It is expected that participants will score very poorly during baseline and that if any of them score above 0% it will be for the final I want step in the assertive communication script. After BST, participants are expected to substantially improve their performance with scores ranging from 75% to 100% correct. In the follow-up condition, some participants might have an initial drop-off in

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performance potentially due to the length of time between the last intervention probe and their last week of their hospital stay. However, it would be expected that overall, follow-up probes would be consistently successful due to the formulaic nature of the assertive communication script and the exposure of multiple scenarios throughout intervention.

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Figure 1. Percentage of steps of assertive communication script completed correctly during whole task presentation task analysis when participants respond to hypothetical scripted interpersonal conflict scenarios.

TEACHING ASSERTIVE COMMUNICATION SKILLS References

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Le Couteur, A., Lord, C., & Rutter, M. (2003). The Autism Diagnostic Interview-Revised (ADIR). Los Angeles, CA: Western Psychological Services. Lord, C., Rutter, M., DiLavore, P. D., & Risi, S. (2001). Autism diagnostic observation schedule. Los Angeles, CA: Western Psychological Services. Macintosh, K., & Dissanayake, C. (2006). Social skills and problem behaviours in school aged children with high-functioning autism and aspergers disorder. Journal of Autism and Developmental Disorders, 36, 1065-1076. DOI 10.1007/s10803-006-0139-5 Mazzone, L., Ruta, L., & Reale, L. (2012). Psychiatric comorbidities in asperger syndrome and high functioning autism: Diagnostic challenges. Annals of General Psychiatry, 11, 1-13. doi:10.1186/1744-859X-11-16 McGee, G. G., Krantz, P. J., & McClannahan, L. E. (1984). Conversational skills for autistic adolescents: Teaching assertiveness in naturalistic game settings. Journal of Autism and Developmental Disorders, 14, 319-330. Meyer, J. A., Mundy, P. C., Van Hecke, A. V., & Durocher, J. S. (2006). Social attribution processes and comorbid psychiatric symptoms in children with asperger syndrome. Autism, 10, 383-402. Nabeyama, B. & Sturmey, P. (2010). Using behaviour skills training to promote safe and correct staff guarding and ambulation distance of students with multiple physical disabilities. Journal of Applied Behavior Analysis, 43, 341-345. Nigro-Bruzzi, D. & Sturmey, P. (2010). The effects of behavioural skills training on mand training by staff and unprompted vocal mands by children. Journal of Applied Behavior Analysis, 43, 757-761.

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Palmen, A., & Didden, R. (2012). Task engagement in young adults with high-functioning autism spectrum disorders: Generalization effects of behavioural skills training. Research in Autism Spectrum Disorders, 6, 1377-1388. Rao, P. A., Beidel, D. C., & Murray, M. J. (2008). Social skills interventions for children with aspergers syndrome or high-functioning autism: A review and recommendations. Journal of Autism and Developmental Disorders, 38, 353-361. DOI 10.1007/s10803-007-0402-4 Sukhodolsky, D., Scahill, L., Gadow, K., Arnold, L., Aman, M., McDougle, C., & ... Vitiello, B. (2008). Parent-rated anxiety symptoms in children with pervasive developmental disorders: Frequency and association with core autism symptoms and cognitive functioning. Journal Of Abnormal Child Psychology, 36, 117-128. DOI 10.1007/s10802007-9165-9 Watson, P. J., & Workman, E. A. (1981). The non-concurrent multiple baseline acrossindividuals design: An extension of the traditional multiple baseline design. Journal of Behaviour Therapy & Experimental Psychiatry, 12, 257-259. Whitehouse, A. J., Durkin, K., Jacquet, E., & Ziatas, K. (2009). Friendship, loneliness and depression in adolescents with aspergers syndrome. Journal of Adolescence, 32, 309322. Wolpe, J. & Lazarus, A. A. (1966). Behaviour therapy techniques. New York: Pergamon Press.