Informed written consent was obtained from parents and verbal assent was obtained from all research participants prior to inclusion in the study. The Institutional Review Board of the University of California, Davis approved the study.
Participants included eight children (7 boys, 1 girl) with autism spectrum disorders (six with autism, two with pervasive developmental disorder-not otherwise specified) referred to as SENSE participants, paired with eight typically developing children (4 boys, 4 girls) referred to as peers. The participants ranged in age from 6 to 17 years (Typ = 13.86, SD = 3.49; Aut = 11.30, SD = 3.98). There were no significant differences between the groups based on age
t(13) = 1.31,
Inclusion required the families to attend the majority of 38 rehearsals and six performance dates. SENSE participants required a diagnosis of an ASD based on DSM-IV-TR criteria (APA
) corroborated by the Autism Diagnostic Observation Schedule-Generic; (Lord et al.
). There were no requirements based on age, IQ or gender. The SENSE participants’ were administered the Wechsler Abbreviated Scale of Intelligence, (Wechsler
). IQ scores ranged from 62 to 102 (mean = 82.36, SD = 16.44). The typically developing children did not require an evaluation although parents completed the
Social Communication Questionnaire
(Rutter et al.
a screening tool for autism, and results all fell below clinical levels.
Specific subtests related to social and emotional processing from the NEPSY (Korkman et al.
), a standardized neuropsychological battery of measures for ages 3–16 years, were administered by a licensed psychologist (J.R.G.) pre- and post-treatment and used as dependent variables.
NEPSY Memory for Faces (MF) is a measure of face identification and memory for faces requiring the child to identify persons recently perceived and following a delay.
NEPSY Affect Recognition (AR) is a measure of emotion perception requiring the child to identify different emotional facial expressions.
NEPSY Theory of Mind (TOM) is a measure of TOM requiring the child to apply mental state concepts to interpret and predict self and other behavior.
SENSE Theatre Intervention Procedures
The SENSE Theatre program was expressly designed to target the socioemotional challenges of autism by utilizing well-established behavioral intervention paradigms implemented in combination with theatrical techniques. The approach arose from the SENSE translational research program (B.A.C.) and extensive experience in theatre.
The SENSE participants were paired with typically developing actors who in addition to being co-actors in a musical production, served as the participants’ peer models. These youth actors were conceptualized as master models of verbal and nonverbal communication, socioemotional perception and expression, as well as behavioral and affective control. Under the supervision of the clinical staff (psychologists and behavior specialists), the peer models worked with the SENSE participants to acquire broader skills and individualized target behaviors. The peers also performed the participant’s role on video, which was broadcast on a secure password-protected website, allowing participants to watch, imitate, and practice their roles from home via video modeling.
The SENSE Theatre experience was offered free to the research participants. In March of 2009, all interested actors, with and without autism, were invited to auditions for “Disney’s The Jungle Book” held at Davis Musical Theatre Company (DMTC). Approximately 20 youth with autism expressed an interest in the program, but many families were unable to participate due to scheduling conflicts. The theatre director (J.P.) selected the cast of 37 actors and assigned the eight SENSE participants roles commensurate with their ability.
Approximately 1 week prior to the first rehearsal, the SENSE participants completed diagnostic and neuropsychological procedures at the M.I.N.D. Institute. The rehearsal schedule was based on a general community theatre approach. The musical was broken down into specific scenes. The songs were taught first, followed by basic blocking of places and action, and finally choreography. The rehearsals were initially 1 day per week and gradually progressed to 3 or 4 days per week depending on the child’s role. The rehearsals were 2 h per session. The actual trial lasted 3 months.
Care was taken to provide a supportive social environment and individualized assistance. To enhance social interaction with others, the peers helped the participants through modeling appropriate social behavior, shaping techniques, external reinforcement (e.g., stickers), intrinsic reinforcers (e.g., praise), and in vivo and video peer modeling. Initial support was provided through one-to-one behavioral support, verbal and physical prompting, social reinforcement, redirection techniques, and verbal cues. Each actor’s role was broken down into teachable parts to facilitate learning. Generalization was enhanced through the use of peers, multiple trainers, parent involvement, and video modeling. Once peers established rapport and gained competence in working with the participant on and off the stage, support from team staff was gradually faded.
Video modeling was conducted by peer actors who, in addition to their own parts, learned and performed the SENSE participant’s role on video. For singing or facial gestures, the cameras were framed in a close-up or medium close-up shot. For full-body actions, such as special choreography, the actor’s entire body was videotaped to clearly demonstrate the full actions they were expected to perform.
Selected takes were visually and aurally improved using a digital video editing system (Apple’s Final Cut Pro). The video clips were then compressed for internet publication and posted on a secure website using the video and photo-sharing service “SmugMug” (
). SmugMug account holders are able to create secure password protected galleries that are not accessible by search engines.
Parents of participants were given access to the protected video galleries allowing their children to repeatedly practice the actions recorded on the videos. Depending on their role, participants were encouraged to watch and role play the videos with care providers for 15–30 min daily to aid in the acquisition, maintenance, and generalization of skills. Parents reported consistent video modeling in response to weekly checks by research personnel. The scenes were also brought into the theatre via computer DVDs which allowed on site individual practice.
Cortisol Sampling Protocol
Basal levels of salivary cortisol were collected for six diurnal cycles (3 pre- and 3 post-). Home-based samples were collected by parents upon waking, half an hour after waking, in the afternoon between 1,300 and 1,500 h, and in the evening within a half-hour of bedtime. Our standardized procedures are detailed in previous reports (Corbett et al.
Parents temporarily stored samples in the home refrigerator. Once brought to the lab, samples were stored in a −20°C freezer. Samples were centrifuged at 3,000 rpm for 20 min to separate the aqueous component from mucins and other suspended particles. Salivary concentrations of cortisol were estimated in duplicate using commercial radioimmunoassay kits (Siemens Medical Solutions Diagnostics, Los Angeles, CA). Intra- and inter-assay coefficients of variation were 2.76 and 6.23, respectively.
To evaluate physiological response, the SENSE participants provided salivary samples at the beginning and end of rehearsals; specifically, at the First (1st), Middle (19th), and Last (38th) Rehearsal. In addition, salivary samples were collected at the pre- and post- assessments conducted at the M.I.N.D. Institute.
Oxytocin Collection and Assay
Samples were collected via blood draw by a pediatric phlebotomist at the pre- and post-assessments. Blood was collected on ice and centrifuged at 4°C, 3,300 rpm for 12 min. Plasma was then stored in a −80°C freezer until assay. The assay kit (Assay Designs, Ann Arbor, Michigan) has been validated (Bales et al.
). Analyses were conducted using 0.05% concentration and the coefficient of variation was 4.55%.