The emotional understanding of children with Autism Spectrum Disorder. Ronja Neumann. Tilburg University

Transcription

1 1 The emotional understanding of children with Autism Spectrum Disorder Ronja Neumann Tilburg University ANR: Supervisor: Anke Scheeren, Dr. Bachelor thesis Psychology and Health Department Developmental Psychology May, 2016

2 2 Abstract Children with Autism Spectrum Disorder (ASD) have severe emotional impairments. This study examined the differences in emotional understanding between children with ASD and typically developing children (TD). Furthermore, the differences in emotional understanding between the different social behaviors of the ASD group have been researched. For both research questions, the emotional understanding of simple emotions, complex emotions, and of the total score of emotions has been examined. The emotional understanding of 154 children with ASD and of 64 TD children (6-20 years) was assessed using the Kusche Affective Interview-Revised (KAI). Results revealed that children with ASD did score significantly lower on the KAI than TD children regarding simple emotions and regarding the total score of emotions, though no significant difference has been found regarding complex emotions. Furthermore the social behavior, especially active-but-odd behavior and typical behavior, of children with ASD was found to be a positively significant predictor for children s emotional understanding. Children who mostly show active-but-odd or typical behavior appear to have the highest emotional understanding within the ASD group. It seems that although children with ASD do have impairments regarding emotional understanding, their social behavior seems to be an important factor on how severe those impairments are. Implications for clinical practice, limitations of the current study and possible future research questions are discussed. Keywords: Autism Spectrum Disorder, emotional understanding, social subgroups, social interaction style, simple emotions, complex emotions

3 3 According to the DSM-5, Autism Spectrum Disorder (ASD) is a group of lifelong developmental disorders characterized by a number of impairments: difficulties in social interaction and social communication (verbal and nonverbal) as well as behavioral deficits such as a restricted, repetitive range of behaviors, activities or interests, and severe emotional impairments (American Psychiatric Association, 2013). The ability of understanding emotions in oneself and in others is a core part of social interaction and helps individuals to act appropriate in social situations and to adjust the behavior if needed (Gross, 2011). The emotional impairments of children with ASD can have consequences for their social development and social interactions. It therefore is important to examine the emotional understanding of children with ASD and to also consider the relationship between the social interactions and the emotional understanding of children with ASD. Although the main symptoms of ASD are similar, differences in the social behaviors can be seen. Children with ASD can be categorized into three different subgroups of social behavior: the aloof group, the passive group, and the active-but-odd group. The social skills of children of the aloof group are severely impaired. They do not attempt social interactions, neither do they react socially when someone else initiates a social interaction (Wing & Gould, 1979). Past research also indicates that those children have the lowest IQ, poorest language skills, and more severe autistic symptoms compared to the other subgroups (Castelloe & Dawson, 1993). Children of the passive group do not initiate social interactions themselves or spontaneously but do, in contrast to the aloof children, react appropriately when someone else initiates a social situation. Active-but-odd children do, in contrast to the other two groups, make active and spontaneous social contact with others. However, their actions are inappropriate in that particular situation. Their social approaches are one-sided, meaning that they for example continue talking

4 4 about their own particular interests without considering to engage the other person in the conversation. Also, they might seek close physical contact with the conversation partner (Castelloe & Dawson, 1993; Scheeren, Koot, & Begeer, 2012; Wing & Gould, 1979). Lastly, there are also children with typical ASD. These children show social interactions that are appropriate for their age, and the children also anticipate social contact themselves (Wing & Gould, 1979). Past studies on ASD mostly emphasized the emotion recognition of children with ASD, especially in facial expression and bodily movement and mostly focused on simple emotions. Simple emotions are emotions like happiness, sadness, fear, anger, surprise and disgust (Ekman, 1992). This study on the other hand will focus on the emotional understanding of children with ASD concerning simple and complex emotions. In order to understand complex emotions like pride, guilt, surprise, anger or embarrassment, a more advanced understanding of social and interpersonal relations is needed. Complex emotions depend more on the situational outcome than simple emotions, and the underlying cause of the particular complex emotions needs to be considered (Thompson, 1987). Since this study will focus on emotional understanding, it is important to note the difference between emotion recognition and emotional understanding. Emotion recognition is described as the ability to discriminate expressions of emotions in facial, verbal, and bodily expressions in oneself and others (Buitelaar, van der Wees, Swaab-Barneveld, & van der Gaag, 1999). Emotional understanding on the other hand is defined as the ability to interpret and describe one s own and others emotional experiences and is important for children in order to being able to react in social situations (Seja & Russ, 1999). Past findings on emotion recognition and emotional understanding of children with ASD have been mixed. While some earlier studies indicate impairments in recognizing simple emotions, (Hobson, 1986; Philip et al.,

5 5 2010; Schlitt et al., 2014) others have not found such impairments (Capps, Yirmiya, & Sigman, 1992; Castelli, 2005). Research by Losh and Capps (2006) indicates that children with ASD are able to discuss simple emotions, though they have difficulties understanding emotional experiences. In their study, children with ASD were less able to understand the causes of the emotion they felt. Furthermore, they used different strategies to interpret those emotions. Studies on complex emotions however have shown more consistent findings, suggesting that children with ASD have difficulties understanding and recognizing various complex emotions in facial expressions, in photos of the eyes, as well as in pictures (Baron-Cohen, Wheelwright, Spong, Scahill, & Lawson, 2001; Bauminger, 2004; Begeer et al., 2008; Capps et al., 1992; Golan, Baron-Cohen & Gola, 2008). Because previous studies have yielded inconsistent results and not examined all components of emotional competence of children with ASD, it is important to further study their emotional understanding. The ability to understand emotions seems to be connected to the Theory of Mind (ToM). ToM is described as the ability to ascribe mental states to oneself and to others. A lack of ToM leads to difficulties identifying how others feel and difficulties understanding someone else s thinking (Rajendran & Mitchell, 2007). There is evidence that children with ASD do have a lack of ToM (Baron-Cohen, 2000; Baron-Cohen, Leslie, & Frith, 1985). Furthermore, ToM is related to the development of emotional understanding and might lead to difficulties understanding emotions, especially complex emotions (Begeer et al., 2008). In addition to ToM, the social interactions of children are an important factor for their emotional understanding. Children with ASD have severe emotional impairments, showing less facial expressions and body language, and they have problems sharing emotional states (APA, 2013). These deficits can have a severe impact on their social life. Studying their emotional understanding is important because

6 6 recognition and knowledge of emotions are core parts of social interactions. They signalize us if we have to change or adjust our current behavior and help us to respond appropriately in social situations (Gross, 2011). Different emotional content can lead to different interpretations of social situations. The ability to describe and reflect on experienced emotion is crucial for social actions throughout life (Salovey, 2003; Losh & Capps, 2006). Emotion recognition, emotion knowledge, and the emotional content seem to play a role in children s social interactions. Since children with ASD differ in their social behaviors, they might as well differ in their ability to understand emotions. Therefore, this study will examine the differences between children with ASD who show different social behaviors. Various previous studies point out that TD children who had better emotional understanding were more popular among their peers and had better academic results. Being able to understand emotions in oneself and in others makes a child smarter and more able to socially interact with their peers (Sprung, Münch, Harris, Ebesutani, & Hofmann, 2015; Seja & Russ, 1999). More social interactions in turn might lead to more verbal interactions with peers, enabling the children to better understand what others think and feel. Children who mostly show typical social behavior have the most appropriate social interaction style, less severe ASD symptoms, and a higher IQ compared to children who mostly show one of the other social behaviors (Scheeren, Koot, & Begeer, 2012). This in turn might lead to a more advanced emotional understanding of children who mostly display typical behavior. If emotional understanding is indeed impaired in children with ASD, it might be explained by impairments in ToM and in social interactions. Getting more knowledge of their ability to understand simple and complex emotions, a better understanding of why children with ASD have difficulties reacting appropriately in social situations might be achieved. By doing so, interventions could focus more on the improvement of their academic, emotional, and social

7 7 skills. Improved interventions are from great importance due to the rising prevalence of ASD. Previous research indicates that the prevalence of ASD has increased throughout the last years. While in 2008 one in every 88 children at the age of eight was diagnosed with ASD, this number rose up to one in every 68 children in 2010 (Baio, 2012; Baio, 2014; Nicholas et al., 2009; Matson, 2011). This increase in prevalence implies an increase on both the use of interventions and the spending on interventions. In 2006 the lifetime cost of an individual with ASD without an intellectual disorder was 1.36 million in the United States (Buescher, Ciday, Knapp, & Mandell, 2014). However, using more efficient interventions, those costs might be reduced leading to an overall decreased spending on health care for ASD children. Previous research indicates that after a cognitive behavioral intervention, children with ASD improved in their emotional understanding and in their social interactions. First of all, they improved in their ability to understand both simple and complex emotions. When asked to provide an example of a time they felt a simple emotion, all children were able to do so after the intervention, while before treatment only 60% were able to do so. Regarding complex emotion, after treatment 53 % of the children could provide an example of a time they felt five or more of the six complex emotions, while before treatment only 27% could do so. The children also improved in their social interactions, especially in their prosocial behavior. They had a greater interest in initiating social contact with others, made more eye contact, and were more able to share experiences with others (Bauminger, 2002). Also, a meta-analysis of 19 studies or experiments on emotional understanding revealed medium to large effect sizes (Sprung et al., 2015). Thus, it seems that emotional knowledge and social interactions could actually be improved through interventions. With more knowledge of how children with ASD differ in their emotional understanding, the better interventions can be developed. Wanting the most effective interventions for each child,

8 8 the individual differences and needs of every child need to be taken into account. These needs might differ within the ASD group, depending on which social behavior a child mostly shows. More knowledge of the differences between these different social behaviors might help to make interventions more effective and well-fitted for each child. That in turn will lead to a decrease in costs being spent on ASD interventions and care. Due to the importance of more profound knowledge, the mixed results of previous studies, and the lack of literature on the differences in emotional understanding within the ASD group, two research questions are conducted. The first research question is if there is a difference in emotional understanding between children with ASD and TD children. Furthermore, within the ASD group, the differences in emotional understanding between children who show mostly aloof, active-but-odd, passive, or typical behavior will be examined. The first hypothesis of this study is that children with ASD have less emotional understanding compared to TD children. Less emotional understanding of the ASD group is expected regarding simple emotions, complex emotions, and regarding the total score of emotions. The total score is the score of both simple emotions and complex emotions together. Furthermore, looking specifically at the ASD group, and taking into account the differences in social interaction style of the children, the following hypothesis is composed: the more typical social behavior children shows, the better the child s emotional understanding of simple emotions, of complex emotions, and of the total score of emotions. Method Participants The participants of the ASD group were recruited via a specialized school for normally intelligent children (IQ > 70) with ASD. Children with ASD with an IQ > 70 are referred to as

9 9 children with high functioning Autism Spectrum Disorder (HFASD). The diagnosis of ASD has been done by a psychiatrist or psychologist, according to the DSM-IV-TR criteria, prior and independent to this study. The sample of the TD children was recruited via public primary and secondary schools. The initial participants of this study were 287 Dutch children, 73 of the control group and 214 of the ASD group. The control group consisted of 62 boys and 11 girls, and the ASD group of 183 boys and 31 girls. However, not all of the participants were included in the analyses. For the ASD group, the following inclusion criteria were used for the data analyses: 1) The child has completed the Kusche Affective Interview (KAI) and there is no missing data. The KAI is a questionnaire to examine an individual s emotional understanding. 2) The Peabody Picture Vocabulary Test (PPVT) has been filled out completely and correctly, and the child s verbal IQ is > 70. The PPVT is a test that assesses receptive vocabulary (Dunn and Dunn, 2004). For this study, the Dutch version of the PPVT was used. For the control group, the following inclusion criteria were used: 1) The child has completed the interview and there is no missing data 2) the child s score on the social responsiveness scale (SRS) is < 70 and 3) the PPVT has been filled out completely and correctly. The SRS is a questionnaire that assesses autistic traits (Constantino & Gruber, 2007). An overview of the final sample is presented in table 1. Table 1 Final sample mean age and number of participants Group N Boys (N) Girls (N) Age (M) Age (SD) TD ASD Total

10 10 Measures Wing Subgroups Questionnaire (WSQ). To assess the social behavior of the ASD group the WSQ, a parent or teacher questionnaire, was used and translated into Dutch. The questionnaire contains 13 statements regarding the ASD subtypes and 13 statements regarding the social behavior of the child. In this study, the parents filled in the questionnaire and were asked to describe to what extent the statements fit the child s behavior ( When my child is with unfamiliar adults or children he readily approaches others to interact and responds easily to others. His manner of interacting is generally appropriate (not awkward or unusual) (Castelloe & Dawson, 1993). In order to score the children s behavior, a 7 point Likert scale ranging from 0 (never) to 6 (always) was used. Normally, the children are assigned to the social subtype on which they score the highest scale score. The higher the score, the more the child displays that particular behavior. For example, a child who gets the highest scale score on active-but-odd behavior will be assigned to the active-but-odd social subtype of ASD. The scale scores of the other behaviors are not considered, meaning that in this example, only the score on active-butodd behavior matters, not considering how high or how low the child scores on passive, typical, or aloof behavior. However, this study used a continuous scale to classify the children s social behavior. That way, all scale scores, not only the highest, were considered. The children were not only assigned one specific subtype, but were given a scale score on each of the social behaviors. Therefore they got four individual scores on the four different behaviors: a score for the amount of active-but-odd behavior shown, one for aloof behavior, one for passive behavior, and one for typical behavior. An overview of the WSQ raw scores and ranges is shown in table 2. Internal consistency of the WSQ has already been assessed in previous studies and was moderate to good (Castelloe & Dawson, 1993; O Brien, 1996). Moreover, a previous study

11 11 reported a Cronbach s alpha of.84 for the active-but-odd group,.69 for the aloof subgroup,.73 for the passive subgroup, and.86 for the typical subgroup (Scheeren, Begeer, & Koot, 2012). Table 2 Descriptive statistics of the WSQ raw scores for the predictors Mean SD Range Passive Active-but-odd Aloof Typical Kusche Affective Interview-Revised (KAI-R). For this study the KAI-R, developed by Kusche, Beilke, and Greenberg (1988), was used. The KAI-R is a semi-structured interview to examine emotional understanding of individuals (with and without ASD) using open ended questions. The KAI-R consists of three questions, however only two of them were used for this study. The children were first asked to tell the interviewer if they ever felt a particular emotion. If the answer to the first question was yes, they were asked to provide an example of an experience where this emotion was felt in order to get to know more about the participant s ability to understand their own emotions: tell me about a time when you felt. If the answer to the first question was no, the children were asked to provide an example of an experience where someone else has felt the particular emotion. That way the children s ability to understand emotions and emotional experiences in others was assessed ( tell me about a time when someone else felt ). The emotions asked for were four simple emotions (happiness, sadness, anger, fear) and four complex emotions (shame, guilt, jealousy, pride). Eventually, the children were asked 16 questions, since they were asked to answer the two questions of the KAI for the four simple and for the four complex emotions.

12 12 The first question had two possible answers: (1) yes, and (2) no. The second question was an open question. The examples for the second questions were classified into different categories: appropriate, ambiguous, not appropriate, and no example given/participant states not to know the meaning of the emotion. For giving an appropriate example the score 2 was given, for an ambiguous example the score 1, and for a not appropriate example, when no example was given, or if the child did not understand the emotion, the score 0 was given. In order to score the KAI-R, the children were given three scores: 1) a total score of simple emotions, being the score they got when asked to remember a situation in which they felt happy, sad, angry, or scared, 2) a total score of complex emotions, meaning the score they received when asked to remember a situation in which they felt ashamed, guilty, jealous, or proud, and 3) a total score of emotions, being the sum of the score on simple emotions plus the score on complex emotions. The maximum score for simple emotions was 8 and the maximum for complex emotions was 8 as well. Therefore, the maximum score for the total score of the KAI-R was 16. That was the case if a child gave an appropriate answer on the four simple emotions and on the four complex emotions. The higher the score on the KAI-R, the better the child s emotional understanding. Procedure After receiving informed consent of both the parents and the children (if older than 12) each child was tested individually at school. All interviews were videotaped and transcribed, and coded by students who were blind to the clinical diagnosis of the children. Data-analyses First of all, an independent sample t-test is conducted in order to compare the score on emotional understanding between children with ASD and TD children. The score on the KAI-R for simple emotions, complex emotions, and the total score of emotions is individually compared

13 13 between ASD children and TD children. Secondly, in order to examine the differences in emotional understanding between children with ASD who show different social behaviors, three sets of standard multiple regression analyses are done. First of all, with the simple score as the dependent variable, then the complex score as the dependent variable, and lastly the total score as the dependent variable. The same predictors are used in all three analyses, being passive behavior, active-but-odd behavior, aloof behavior, and typical behavior. In the following section the predictor active-but-odd is simply named active. The scores on the social behaviors are viewed as a dimensional variable. In all three regression analyses the predictors are added to the model using the enter method, meaning that they are added simultaneously and not one by one. This method is appropriate because of the small number of predictors in this study. Since it is still unknown which one of the predictors best predicts the score of the KAI-R, all of the predictors need to be added to the analyses, not excluding any variables like it might happen using the stepwise method. Lastly, in order to rule out that the results are explained by differences in the VIQ of the children, three additional hierarchical multiple regression analyses are done using the same predictor variables (passive, active, aloof, typical), but three different outcome variables. First, the total score of simple emotions is used as the outcome variable, then the total score of complex emotions and lastly the total score of emotions. Using the enter method, the regression analysis leads to two models in each of the analyses. Model 1 consisting of only the covariate VIQ and Model 2 consisting of the covariate VIQ and the predictors active, aloof, passive, and typical. Results

14 14 Due to the fact that only participants who were given a simple score, a complex score, and a total score, not all of the initial participants were taken into analyses. The number of participants in each condition (simple score, complex score, and total score) are presented in table 3. Table 3 Number of participants per condition taken into analyses Group Simple score Complex score Total score TD ASD N Group differences between ASD group and TD group Three independent t-tests were conducted in order to compare the ASD group and the TD group regarding the score on simple emotion, on complex emotion, and regarding the total score on the KAI-R. As predicted, regarding simple emotions, the ASD group (M = 6.10, SD = 1.58) scored significantly lower on the KAI-R compared to the TD group (M = 6.7, SD = 1.12), t(163) = 2.96, p =.004, d =.42. The effect size suggested a small to moderate practical significance. The results of the independent t-tests suggest that children with ASD had less emotional understanding regarding simple emotions. They were significantly less able to provide an example of a time they themselves, or of a time someone else has felt a particular simple emotion. Looking at the effects of the two groups on the complex score of emotion, the following results were found: no significant difference has been found between children with ASD (M = 6.04, SD = 1.63) and the TD children (M = 6.53, SD = 1.62), t(187) = 1.91, p =.058, d =.3. This effect size indicated a small practical significance. It can be suggested that having ASD did not have an effect on the score of the KAI-R regarding complex emotions. However,

15 15 the results showed a certain trend towards significance (p <.10), suggesting that this result was close to being statistically significant. Lastly, an independent t-test of the total score on the KAI- R was conducted. Comparing the ASD group (M = 12.22, SD = 2.66) and the TD group (M = 13.08, SD = 2.43), a significant effect has been found, t(184) = 2.44, p =.016, d =.4. It can be suggested that children with ASD performed significantly worse on the KAI. The effect size suggested a small to moderate practical significance. The previous results indicate that, as predicted, children with ASD in this particular sample had less emotional understanding than TD children. They had less emotional understanding regarding simple emotions and regarding the total score of emotions. However, unlike predicted, concerning complex emotions, children of the ASD group did not significantly differ from TD children in emotional understanding. Regression Analyses In order to predict the total score of simple emotions, the total score of complex emotions, and the total score of the KAI-R, three standard multiple regression analyses were conducted. In order to do so, the ASD social behaviors were viewed as a dimensional variable. The predictor variables were the level of active, passive, aloof, or typical behavior. The outcome variable was the simple score in the first analysis, the complex score in the second analysis, and the total score in the third analysis. A summary of the correlations between the predictors and the simple score, the complex score, and the total score is presented in table 3. Simple Score. Table 3 shows a significant positive correlation between the level of active behavior and the simple score. However, correlations of the other predictors revealed nonsignificant correlations with the simple score. In order to predict the influence of the predictors on the simple score of emotion, a standard multiple regression analysis using the enter method was done. The four predictors did not explain a significant amount of the variance of the total

16 16 score of simple emotions (F (4, 141) = 1.82, p =.129, R 2 =.05, R 2 Adjusted =.02). Unlike predicted, the level of active behavior contributed significantly to the variance in the total score of simple emotions. Therefore, it can be suggested that children who showed more active behavior had more emotional understanding. Moreover, the level of active behavior made the strongest and significant unique contribution to explaining the simple score of emotion, controlled for the variance of the other predictors. This indicates that a higher score on active behavior was associated with a higher score on the KAI regarding simple emotions. For an overview of the standard multiple regression analysis see table 5. Complex Score. As it can be seen in table 4, the level of typical behavior was positively and significantly correlated with the complex score of emotions, being the only significant correlation. Additionally, a standard multiple regression analysis was done using the complex score as the dependent variable and adding the predictors all at once using the enter method. The results indicate that the four predictors together did not explain a significant portion of the variance of the total score of complex emotions, though a trend in significance can be seen (F (4, 125) = 2.22, p =.071, R 2 =.07, R 2 Adjusted =.04). As predicted, the level of typical behavior uniquely contributed significantly to the variance in the total score of complex emotions. Moreover, typical behavior significantly predicted the score of complex emotions. This signifies that the higher the participants scored on typical behavior, the higher the participants score on the KAI-R when it came to questions regarding complex emotions. Total score. No significant correlations were found between the predictors and the total score of emotions. An overview of the correlations is presented in table 3. In this analysis, the total score of emotions was the dependent variable and the four predictors active, passive, typical, and aloof were added simultaneously with the enter method. The following conclusions

17 17 can be made. It can be concluded that the four predictors together explained a significant proportion of the total variance of the total score (F (4, 123) = 2.51, p =.046, r 2 =.08, R 2 Adjusted =.05). As predicted, children who scored higher on the level of typical behavior scored significantly higher on the total score of the KAI-R. Therefore, children who showed mostly typical behavior seem to have had a better emotional understanding. However, unlike predicted, the level of active behavior had a significant and positive contribution to the variance in the total score of the KAI-R. Therefore, it can be suggested that the more typical behavior or the more active behavior a child showed, the higher the child s emotional understanding. An overview of the standard multiple regression analyses is presented in table 5. Control analysis In order to control for possible influences of VIQ on the scores of the KAI, additional hierarchical multiple regression analyses were conducted. After controlling for VIQ, active behavior was still the best and significant predictor of the simple score, typical behavior still the best and significant predictor of the complex score, and active and typical behavior still the best and significant predictors of the total score (see table 6). This signifies that the previous findings cannot be explained by differences in VIQ. Table 4 Pearson correlations between the simple score, complex score and total score and the ASD social behaviors Simple score Complex score Total score N = 146 N = 154 N = 154 r sig. r sig. r sig. Passive

18 18 Active.19.02* Aloof Typical * *p <.05 Table 5 Outcome of standard multiple regression analyses Predictor Dependent Simple score Complex score Total score B SE B SE B SE Passive Active * * Aloof Typical * * *p <.05 Table 6 Outcome of standard multiple regression analyses controlled for VIQ Predictor Dependent Simple score Complex score Total score B SE B SE B SE VIQ * * * Passive Active * * Aloof

19 19 Typical * * *p <.05 Discussion The purpose of this study was to examine the differences in emotional understanding of both simple and complex emotions of children with ASD. Additionally, the differences in emotional understanding of simple and complex emotions regarding the different social behaviors within the ASD group have been examined. As expected, children with ASD had significantly less emotional understanding than TD children regarding the total score of emotions, and regarding simple emotions. However, counter the expectations, children with ASD did not have significantly less emotional understanding of complex emotions. Furthermore, looking at the differences between the different social behaviors within the ASD group, the following results have been found: First of all, unlike expected, children with ASD who showed mostly active-but-odd behavior had significantly more emotional understanding of simple emotions. Second, as expected, children who showed mostly typical behavior had significantly more emotional understanding of complex emotions. Third, children who showed mostly typical behavior and children who mostly showed active-but-odd behavior had significantly more emotional understanding regarding the total score of emotions. First of all, the results of the total score of emotions will be discussed. As expected, children with ASD did have significantly less emotional understanding regarding the total score of emotions. When asked questions concerning both simple and complex emotions, children with ASD had less understanding of the emotions. This result signifies that, looking at both of the emotions, they seem to have impairments in emotional understanding. They were less able to provide an example of a time they themselves, or of a time when someone else has, felt a

20 20 particular simple and a particular complex emotion. There are a few possible explanations for this finding. First of all, it can be explained by the trend in significance that has been found in the total score of complex emotions. ASD did have an impact on the children s emotional understanding, though it was just not significant. With adjustments in the methodology or analyses, that will be discussed later on, significant results might have been found. Secondly, simple emotions did actually yield significant results and therefore seem to have a higher impact on the emotional understanding than complex emotions. Thus, looking at all types of emotions together, we can conclude that children with ASD do indeed have impairments in emotional understanding. As expected, compared to TD children, children with ASD displayed less emotional understanding of simple emotions. They were less able to give an example of a time they, or of a time when someone else, felt a particular simple emotion like happiness or sadness. This finding is in line with previous findings regarding the understanding of simple emotions (Philip et al., 2010; Schlitt et al., 2014; Hobson, 1986). After the examination of the results of the total score of emotions and of the simple score of emotions, the results of complex emotions will be discussed in the following. In contrast to the expectations, children with ASD did not perform significantly worse than the TD children in terms of complex emotions. Surprisingly, it seems that they do not have less emotional understanding of complex emotions than TD children. They were not less able to give an example of a time they, or of a time when someone else, felt a particular complex emotion like jealousy or pride. The current finding on complex emotions contradicts most previous studies of complex emotions in children with ASD (Bauminger, 2004; Begeer et al., 2008; Golan, Baron-Cohen & Gola, 2008; Capps et al., 1992). Since children with ASD did

21 21 actually have more difficulties in understanding simple emotions, it is surprising that this result has not been found for complex emotions, since it was expected that understanding complex emotions would be even more difficult to understand than simple emotions. A few possible explanations for this finding will be pointed out in the following section. Although the results of complex emotions were not significant, a trend in significance was found. This signifies that the current finding was just not significant, but with adjustments in the analyses significant results might have been found. A possible adjustment that might have led to significant results is the range of age of the participants in this study. The age of the children of the current study ranged from 6-20 years old. This range is quite big and therefore, the results might be due to the participant s differences in age. An independent sample t-test was conducted in order to examine the influence of age on emotional understanding within the ASD group. From those results it can be concluded that within the ASD group, children older than 12 years old did have a significantly better emotional understanding compared to children younger than 12 years old. They had a significantly better emotional understanding regarding simple emotions, t(144)= -2.68, p = 0.008, complex emotions, t(128) = -2.47, p = 0.008, and regarding the total score of emotions, t(126) = -2.76, p = The current results indicate that children with ASD are just as able to understand complex emotions as TD children. This might also be explained due to the fact that the VIQ of children with ASD did not significantly differ from the VIQ of TD children, t(212) = 0.69, p = In order to get to know more about the emotional understanding of children with ASD regarding complex emotion, it might be interesting to replicate this study with children who do differ significantly in their VIQ. That way the influence of VIQ on emotional understanding can be examined. This could be done by comparing children

22 22 with HFASD with children with low-functioning ASD (LFASD). It can be concluded that children with ASD performed better than expected in understanding complex emotions. Alongside the examination of the differences in emotional understanding between children with ASD and TD children, this study also examined the differences in emotional understanding between the different social behaviors of ASD. A child s social interaction style seems to be an important factor to understand one s own emotions and to understand emotions of others. In contrast to the expectation, children who showed mostly active-but-odd behavior had the most emotional understanding of simple emotions. This result might be explained by the social interaction style of children who mostly show active-but-odd behavior. These children do make social contact with others, but their actions are inappropriate to the particular situation. However, since they do indeed socially interact with others, regardless of the inappropriateness, they might consequently develop a better understanding of how and of what others think or feel. Social interaction, though in a strange, inappropriate way, seems to be an important factor of understanding emotions in others and in oneself. Looking at the complex emotions, children who showed mostly typical behavior had, as expected, a better emotional understanding of complex emotions. One explanation of this finding might be due to the similarities of children with typical ASD and the TD children. Children who display mostly typical behavior have the most appropriate and most advanced social interactions compared to those who mostly show active-but-odd, passive, or aloof behavior (Wing & Gould, 1979). Furthermore, children who mainly show typical behavior also have less severe symptoms, a higher IQ, and better verbal language skills than children who mainly show one of the other behaviors (Scheeren, Koot, & Begeer, 2012; Castelloe & Dawson, 1993). Taking these factors into account, the more typical behavior children with ASD display, the more they seem to be

23 23 similar to TD children, who in fact had a better emotional understanding of simple emotions than children with ASD. The current study has a few strong points. First of all, the study had a big sample size, with a total of 218 children taken into final analyses. Furthermore, after controlling for VIQ, it is assumable that the current results cannot be explained by differences in VIQ. Despite its strengths, the current study also has some limitations. First of all, it is important to notice that the children of this study were all diagnosed with HFASD. For future research, it might be interesting to examine the differences in emotional understanding between children with LFASD and HFASD. Additionally, it might be useful to study the differences between children with LFASD and children who are not diagnosed with ASD but who do have a mental retardation. Since children who mostly show active-but-odd behavior and those who mainly show typical behavior have the highest IQ scores, further research needs to control for possible influences of IQ on emotional understanding. Another limitation of this study is the wide range of age of the participants, ranging from 6-20 years old. An independent sample t-test revealed that within the ASD group, the ability to understand emotions seems to vary for different ages. Children younger than 12 years old had less emotional understanding than children who were older than 12 years old. It can be suggested that with using a smaller range of age, more significant results might have been found. Future research should therefore especially focus on the emotional understanding of children under the age of 12. The current study could for example be replicated, though only with participants under the age of 12. Especially the nonsignificant results of the emotional understanding of complex emotions might be explained by the variety in age. The results of this study reveal various implications for the clinical practice. Apparently, the social interaction style of children with ASD appears to have an important impact on how

24 24 well they understand both simple and complex emotions. It has to be noted that with the high and rising prevalence of ASD, effective interventions are needed in order to provide the best possible help for children with ASD. Emotional understanding, being linked to the ability to interact socially, could possibly explain the difficulties in social interactions of children with ASD. With this knowledge, interventions can focus on not only improving emotional understanding but on improving the children s social interaction skills as well. There is evidence that a cognitive behavioral intervention on both these factors is effective. After the intervention, the children had a better emotional understanding of simple and complex emotions. Furthermore, they improved in terms of their social interactions. They improved in initiating social contact with other children, in making eye contact, and in sharing experiences with others (Bauminger, 2002). Since emotional understanding and social interactions of children with ASD seem to be connected, interventions should be multidisciplinary, focusing on both of these factors. Cognitive behavior interventions might be especially useful for children who mostly show passive or aloof behavior, in order to improve their social interactions. These children might have more active interactions with others after treatment and that in turn might lead to an increasing emotional understanding. All in all, this study provides evidence that children with ASD have less emotional understanding compared to TD children. Additionally, the social interaction style of children with ASD seems to be an important predictor of how well children understand emotions of themselves, and of others. With this study, more profound knowledge of ASD and of the differences within the ASD has been achieved. With this knowledge, interventions can be made more effective leading to an increase in costs. With a wide range of age in this study, future

25 25 research should specifically focus on the emotional understanding of children with ASD regarding different ages.

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