The Tuesday Tidbit - Dramatherapy and Autism Spectrum Disorders

Originally published September 22, 2016

Abstract

Children with Autism Spectrum Disorders (ASD) often show deficits in social interactions, communication, vocational abilities, and imagination (Barnhill, Cook, Tebbenkamp & Myles, 2002; D'Amico, Lalonde, & Snow, 2015; Godfrey & Haythorne, 2013; Guli, Semrud-Clikeman, Lerner, & Britton, 2012; Lerner & Mikami, 2012; Loyd, 2013; Olney, 2000; Peter, 2009; Pimpas, 2013). Due to the fact that a lack of social skills can lead to emotional unrest in children with ASD, various social skills interventions are tested (Godfrey & Haythorne, 2013; Loyd, 2013; Pimpas, 2013). Dramatherapy is one such intervention that uses multiple methods and approaches when working to increase social skills and communication in children with ASD.
This paper reviews the literature surrounding Dramatherapy and its effects on children with ASD. The current literature supports Dramatherapy as a viable method to increase social skills, communication, and the use of imaginative play in children with ASD. Further studies are necessary to support the current findings and this paper will discuss suggested future study methods.

Introduction

Autism Spectrum Disorders (ASD) typically relate to impairments in social interactions, communication and imagination (Barnhill, Cook, Tebbenkamp & Myles, 2002; D'Amico, Lalonde, & Snow, 2015; Godfrey & Haythorne, 2013; Guli, Semrud-Clikeman, Lerner, & Britton, 2012; Lerner & Mikami, 2012; Loyd, 2013; Olney, 2000; Peter, 2009; Pimpas 2013). Various approaches and interventions are being devised to help facilitate social growth and development that will enable social communication in children with ASD, increasing their life opportunities (Godfrey & Haythorne, 2013; Loyd, 2013; Pimpas, 2013). A newer form of social skills intervention used with children with ASD is Dramatherapy.

This paper reviews the literature surrounding Dramatherapy and the various types of Dramatherapy methods: Play-drama intervention (PDI), Socio-Dramatic Affective-Relational Intervention (SDARI), Social Emotional NeuroScience Endocrinology (SENSE) Theatre, Mimetics, and Stories in Dramatherapy. The current literature finds a positive trend in social skills and communication development in children with ASD through the use of Dramatherapy. Further studies are necessary to support the current findings, which are based primarily on qualitative studies.

Autism Spectrum Disorders

Autism Spectrum Disorders (ASD) typically relate to impairments in social interactions, communication and imagination (Barnhill et al., 2002; D'Amico et al., 2015; Godfrey & Haythorne, 2013; Guli et al., 2012; Lerner & Mikami, 2012; Loyd, 2013; Olney, 2000; Peter, 2009; Pimpas, 2013). Impairments in social interaction make it challenging for children with ASD to communicate and build meaningful social relationships (D'Amico et al., 2015; Lewis & Banerjee, 2013). In a qualitative study conducted by Muller, Schuler, & Yates (2008), participants with ASD were interviewed about their experience living with ASD. It is important to note that the majority of the participants interviewed were members of autism support groups, or received some type of therapy. This may result in above-average levels of self-awareness, as well as social-awareness. Even still, results showed that "all but one participant reported that intense isolation was a defining feature of his/her experience" (Muller et al., 2008, p. 177). The majority of the participants reported that "initiating social interactions posed a significant challenge" (Muller et al., 2008, p. 179). A variety of communication challenges were described by participants, including "participating in impromptu and/or unstructured dialogue requiring improvised responses, understanding implicit as well as explicit meanings of messages, drawing social and emotional inferences, and interpreting and using gestures and tone of voice" (Muller et al., 2008, p.179).

It is common for individuals with ASD to misinterpret situational nuances and context, as well as facial expressions, tone of voice and common gestures (Lewis & Banerjee, 2013; Muller et al., 2008; Olney, 2000). With a deficit in "Theory of Mind", individuals with ASD often lack the ability to understand anything that occurs outside of their individual self and needs (Lewis & Banerjee, 2013; Olney, 2000). Theory of Mind is "the ability to infer other people's thoughts, beliefs, desires, and intentions and the ability to use this information and predict what they will do next" (Barnhill et al., 2002, p. 116-117). Without this ability, the social challenges among people with ASD become greater. It is difficult for children with ASD to forge strong, supportive relationships with peers, leading to that feeling of isolation and anxiety (Godfrey & Haythorne, 2013). Since these challenges not only affect children with ASD socially, but emotionally as well, it is imperative to find an intervention to assist with their social growth (Kempe & Tissot, 2012).

Social Skills Intervention

Various approaches and interventions are being devised to help facilitate social growth and development that will enable social communication in children with ASD, increasing their life opportunities (Godfrey & Haythorne, 2013; Loyd, 2013; Pimpas, 2013). Social skills interventions have existed for over twenty years, however, a recent increase in their interest has led to a "surge in their evaluation" (Lerner & Mikami, 2012, p. 147). Social skills training interventions involve teaching specific social skills including, but not limited to, eye contact and initiating conversation, through behavioral and social learning techniques. Group-based social skills training interventions offer an appealing approach for children with ASD since they provide the opportunity to practice the skills taught in a somewhat natural setting, promoting interactions with other children (Williams White, Keonig, & Scahill, 2006).

While these interventions are great in number, many of the programs have demonstrated inconsistent results and efficacy in addressing these social needs of children with ASD (Guli et al., 2012; Williams White, Keonig, & Scahill, 2006). With the growing body of research related to ASD, it's challenges and it's needs, it is recommended that interventions for ASD "focus on sharing concrete relationships, and break down complex social behaviors into concrete steps" (Guli et al., 2012, p. 37-38). A newer form of social skills intervention used with children with ASD is Dramatherapy.

Dramatherapy

Children with ASD have very literal minds meaning they have deficits in emotional intelligence, Theory of Mind, and the use of metaphor (Godfrey & Haythorne, 2013). In the qualitative study discussed previously, conducted by Muller et al. (2008), several of the participants with ASD recalled watching other children play throughout their childhood and failing to grasp how to join in. While imagination and drama may seem like difficult concepts for children with ASD to grasp, Dramatherapy can offer valuable learning opportunities to such children (Peter, 2003).

Dramatherapy evolved in Britain during the 1960s from "drama in education, theatre in education and remedial drama" (Meldrum, 1994, p. 12). Various definitions of Dramatherapy focus on the creative and expressive process, allowing the use of non-verbal and symbolic expression of emotion (Meldrum, 1994). Dramatherapy uses dramatic processes in order to achieve therapeutic goals. It is "active, experiential, and embodied" (North American Drama Therapy Association, 2014, p. 1).

The goals of Dramatherapy are to assist the development of social skills and expression of feelings in order to reduce anxiety in children with ASD (Corbett, Gunther, Comins, Price, Ryan, Simon, Schupp, & Rios, 2010; Godfrey & Haythorne, 2013; Lewis & Banerjee, 2013; Peter, 2003). Dramatherapy sets out to develop communication skills through creative methods in a safe, structured environment (Corbett et al.; McCarthy & Light, 2001; Wilmer-Barbrook, 2013; Peter, 2003). According to the North American Drama Therapy Association (2014), Dramatherapy offers a space in which participants can tell stories, set and achieve personal goals, express feelings, and solve problems. Participants are able to practice roles they can play in real life, "becoming more flexible and spontaneous in their life choices and interactions" (North American Drama Therapy Association, 2014, p. 1) and gaining the "ability to move from one role to another" (Meldrum, 1994, p. 25).

In addition to the social development goals, Dramatherapy aims to promote self-awareness, as well as the awareness of others' needs, helping children with ASD discover their ability to influence situations and respond to other people's feelings (Goldstein & Winner, 2012; McCarthy & Light, 2001; Peter, 2003; Pimpas, 2013). Within the safe setting Dramatherapy sessions provide, participants are able to achieve behavior changes, skill-building, emotional and physical integration, and personal growth (North American Drama Therapy Association, 2014). Due to the growing research on Dramatherapy, an increasing number of scholars are realizing that it may be an effective method when working with children with ASD (Guli et al., 2012). Dramatherapy offers "special properties regarded by professionals as effective in helping individuals with ASD learn and develop beyond their perceived limitations" (D'Amico et al., 2015, p. 25).

According to Wilmer-Barbrook (2013), typical Dramatherapy sessions begin with an icebreaker game in order to help learners focus and encourage eye contact, flexibility of thought, spontaneity and use of gestures. Immediately following the icebreaker is the physical warm-up exercises to stimulate the imagination. The main part of the drama therapy session could be improvisation, role-play, story, myth, or movement work. The main portion always explores group and/or individual themes, allowing opportunities for experimenting with social interaction (North American Drama Therapy Association, 2014; Wilmer-Barbrook, 2013).

Wilmer-Barbrook (2013) examined the structure and process of Dramatherapy in a group setting of children with ASD. At the conclusion of this study, evaluation sheets were collected and analyzed using Microsoft Excel in order to see the final outcomes and effect the Dramatherapy sessions had on all group participants. Results showed "a 31% increase in self-confidence and self-esteem, a 24% increase in social skills and ability to cooperate, a 23% increase in the ability to express emotions and a 17% increase in communication skills" (Wilmer-Barbrook, 2013, p. 52). A crucial aspect of Dramatherapy is the trust that forms and grows over the course of the academic year, allowing students to feel safe, share things, and make mistakes while finding that communication can be fun (Wilmer-Barbrook, 2013). Building off of this knowledge, it would be beneficial to take a more detailed look at the relationship between participants and leader in a group Dramatherapy session and how much that truly impacts the outcome and effectiveness of the sessions themselves.

While drama provides a wonderful opportunity for children to perform and play, there is much more it can provide when used as a learning medium (Kempe & Tissot, 2012). In a qualitative study conducted by Kempe & Tissot (2012), a class of twelve students with moderate to severe learning difficulties, two with autism, was examined. The class as a whole had very limited experience with drama. This study took the form of a case study, with multiple observations taking place. During each session, notes were taken which were later elaborated when the leader consulted with the teaching assistants regarding specific engagement and progress. This resulted in a more detailed, collaborative reflection journal. In addition to this teacher journal, feedback was obtained from the students and other staff for further data. While engagement in imaginary worlds is often difficult for individuals with ASD, this study suggests that drama can provide a forum for supporting this skill. Through the use of drama, the process of interacting and co-creating a safe space enables the children with ASD to practice social skills (Kempe & Tissot, 2012). An important aspect to note within this study is that only two of the twelve participants were diagnosed with ASD. The remaining participants were typically developing children. This is both a limitation and a benefit, depending on what one wishes to research. It strongly supports that the interaction and cooperation with typically developing peers in a drama setting aids children with ASD in developing social skills. However, if the main focus is on Dramatherapy and its effectiveness on its own, the use of typically developing peers could skew the results. Any growth seen in the children with ASD could not be solely attributed to Dramatherapy itself, but to the work and interaction with the typically developing peers.

This is a common finding among Dramatherapy research. The goal of many Dramatherapy programs is to develop "increased confidence and self-esteem, improved sense of self and how to relate to others, increased opportunities to develop creativity and imaginative thinking, improved cooperation and turn-taking, greater social and communication skills, improved skills to work effectively alone and with others, and improved mental health" (Godfrey & Haythorne, 2013, p.23). The research focusing on Dramatherapy and autism is overwhelmingly positive, as are the opinions from both drama therapists and participants with ASD. 

Andersen-Warren (2013) examined responses to a questionnaire circulated by drama therapists in order to determine the effectiveness of Dramatherapy in children and adolescents with ASD. The main approach to this study was qualitative, but some quantitative information was provided, making it an exploratory mixed-methods research design. The study focused on the settings in which drama therapists provide their services, the assessment and the outcome measures used to evaluate, the range of difficulties drama therapists experience, and the range of Dramatherapy interventions employed. The questionnaire had both open and closed questions about practice and methods drama therapists used with children with ASD. This questionnaire was provided as an email attachment, making it easy to complete and return, but also raising questions of validity. After all questionnaires were completed, they were evaluated to find patterns. One such pattern was the overwhelming belief that the dramatic structure allows the practice to be adapted and adjusted to meet the specific needs of the children with ASD, while employing a multitude of diverse approaches (Andersen-Warren, 2013). In addition to the question of validity, a possible limitation to this study is the number of participants. Since the participant size is small, it is difficult to generalize the findings. However, the findings can still be representative. In order to build upon this research, a larger scale study would need to occur, including children with ASD who come from varying backgrounds (Andersen-Warren, 2013).

In another study conducted by Loyd (2013), children with autism were examined through their participation in drama education. The aim of this case study was to identify outcomes for the participants and examine relevant teaching approaches that facilitate these outcomes. The study gathered information about ten students, ages 16-18, who attended a school for children with autism. The study lasted thirty-four weeks and involved observations, interviews, questionnaires, and documentation. At the conclusion of the study, questionnaires were collected and evaluated, revealing that drama was an activity the students enjoyed. The fact that all participants were able to reflect back on what they liked and disliked about drama suggests that even students who struggle to communicate verbally, are able to communicate their thoughts and feelings about an activity. Emotional engagement in an activity seems to encourage the ability to recall events and feelings elated to that activity (Loyd, 2013). It is important to note that the methods of communication throughout the interview process varied. Some participants were fully verbal, while others were nonverbal. Some varying methods included widget literacy symbols, photographs and video footage from different drama sessions. The benefit to having access to these different methods is that each child was able to participate fully in the interview process, regardless of their verbal communication ability. However, there are also certain disadvantages to this approach. Those children with difficulty communicating verbally required questions be repeated multiple times, as well as prompting. These same children are also limited with the pictures available to them when describing their experience and expressing their thoughts and feelings. These issues did not seem to hinder this particular study a great deal, but it is worth noting. The responses were thoroughly compared and contrasted to other responses and questions throughout the interview, as well as observation data. This, in turn, created a strong picture for analysis, helping assist the interpretation of views expressed by those students with limited to no verbal communication (Loyd, 2013).

This study is not the only study that reveals positive support for Dramatherapy from participants with ASD. The interviews conducted by Muller et al. (2008) affirmed that individuals with ASD enjoy participating in drama related activities. "Some tried to explain their attraction to theatre- including the writing of dramatic scripts, improvisational theatre classes, voice workshops, or role playing games. In the words of one, 'by doing (improvisational theatre), you realize that it's actually possible to be spontaneous, to just go with an impulse'" (Muller et al., 2008, p. 185).

In addition to the positive opinions of those involved in Dramatherapy, there is further research that supports the use of Dramatherapy while working with children with ASD. As seen in the studies mentioned above, "drama is capable of motivating even hard to reach children and developing their essential creativity at the core of their difficulties" (Peter, 2009, p. 15-16). D'Amico et al. (2015) examined the efficacy of Dramatherapy using Social Skills Improvement System- Rating Scales (SSIS-RS) forms. This yearlong study implemented a Dramatherapy intervention with six ten to twelve year old children with ASD who were on a waiting list to receive social skills training and interventions at a nearby social service center. Children and parents completed SSIS-RS forms both pre- and post-intervention. The scale used with the SSIS-RS is "a norm-referenced instrument that provides a comprehensive analysis of children's social skills and problem behaviors in reference to typically developing peers" (D'Amico et al., 2015, p. 28). Children completing this form were asked to rate forty-six social skill items across seven different subscales. These subscales included "communication, cooperation, assertion, responsibility, empathy, engagement, and self-control" (D'Amico et al., 2015, p. 29). In addition, they were asked to rate twenty-nine problem behavior items across four separate subscales including "externalizing, bullying, hyperactivity/inattention and internalizing" (D'Amico et al., 2015, p. 29). The parents completed a similar form containing the same social skill items and problem behaviors, rating based on how often their children displayed the behaviors.

Based on the results of the SSIS-RS, therapeutic activities and sessions were designed around each individual child's needs. These therapeutic sessions were conducted one day a week for seventy-five minutes each, over the course of twenty-one weeks. Dramatherapy activities were used to address areas of social difficulty determined by the SSIS-RS. Each Dramatherapy technique centered on "making connections among the group members, while discovering commonalities and shared interests, and encouraging self-expression" (D'Amico et al., 2015, p. 30). Active listening and communication skills were also practiced through the natural discussion that took place during each session, building cooperation and cohesion. Once the children were comfortable with each other, the sessions moved toward activities to help the children develop skills in "reading body language, facial expressions and vocal intonations" (D'Amico et al., 2015, p. 30-31). Using acting and characters, the participants were able to improvise scenes of conflict, enhancing "problem-solving and communication skills while developing empathy among the group members" (D'Amico et al., 2015, p. 31).

Results of the post-intervention SSIS-RS showed "statistically significant improvements in engagement, coupled with decreased externalizing, hyperactivity in attention and Autism Spectrum behaviors" (D'Amico et al., 2015, p. 32). Parents noted both statistically significant changes in social skills and problem behavior, as well as reductions in hyperactivity and inattention. Children also noted a reduction in hyperactivity and inattention. According to D'Amico et al (2015), this study shows that Dramatherapy could be an effective method of helping individuals with ASD and other communication deficits engage with others and manage problem behaviors. The study's results "affirm that social skills can be taught and problem behaviors can be managed in group therapeutic settings that meet the social and behavioral needs of children with high-functioning ASD" (D'Amico et al., 2015, p. 35).

The strength of Dramatherapy seems to lie in its diversity (Andersen-Warren, 2013). Multiple subsets of Dramatherapy allow for each child with ASD to work with a model best suited for their own personal needs and approaches.

Play-drama intervention (PDI)

Much of Dramatherapy is built upon Play-drama intervention (PDI) which offers a structured, developmental approach in order to support and expedite the participants' ability to make believe (Peter, 2003). According to Peter (2003), Drama can offer vital social play opportunities and the potential for exploration through pretend. Through pretend play, children with ASD can experiment with their understanding of social situations, exploring their feelings that coincide with those situations. Play-drama intervention gives children with ASD the opportunity to participate more meaningfully in a social world by offering a structured approach to developing their understanding. The security provided by the structure helps liberate the children, allowing them to make creative choices and decisions while gradually expanding their boundaries in the world of pretend and, eventually, their real life experiences. Drama is able to provoke real emotional responses in children, giving them the chance to learn about their feelings, responses and consequences of certain actions and reactions (Peter, 2003). Play-drama intervention helps promote a thinking that many children with autism tend to lack. This thinking can then be modified through the active engagement that play-drama intervention provides (Sherratt & Peter, 2012).

Socio-Dramatic Affective-Relational Intervention (SDARI)

According to Lerner, Mikami & Levine (2010), Socio-Dramatic Affective-Relational Intervention (SDARI), formerly known as Drama-based Social Pragmatic Intervention, is a group-based intervention with three separate components. These components include a unique performance-based social skills curriculum, a focus on child-child and child-staff relationships, and the use of other age-appropriate motivators. The SDARI curriculum uses affectively-driven, relational techniques similar to those in other interventions for children with ASD. The curriculum prioritizes social engagement over behavioral accuracy. The activities are based loosely on improvisation games used in drama. These activities are meant to encourage participants to use their personal interests pro-socially, motivating participation and replicating the complexities of social interactions one may find in the real world, in a non-threatening environment (Lerner et al., 2010).

The study by Lerner et al. (2010), investigated the effects of SDARI over the course of a summer intervention. Seventeen youth with Autism, ages 11-17, participated. Nine of these participants received SDARI intervention while eight children, equivalent to the intervention group in age and diagnosis, did not. The focus of this study was on the change in social aspects over the course of the summer, not the overall group differences. Participants met for five hours a week over the course of six weeks during the summer of 2007. This equaled 147 hours of group treatment over 29 sessions. There were seven groups of about five to nine participants with three staff members per group. In order to obtain information on the effectiveness of the program, parent and child reports of social functioning were collected at three week intervals starting six-weeks prior to SDARI intervention and ending six-weeks post-intervention. Hierarchical Linear Modeling (HLM) was used to estimate any growth trends between the groups in order to assess treatment outcomes and post-treatment maintenance (Lerner et al., 2010).

Lerner et al. (2010) found that participants who received SDARI demonstrated gains in social assertion and the ability to accurately detect emotions in adult voices in comparison to the group who did not receive the intervention. However, the intervention group did not show any gains relative to the comparison group on other measures of social skills, internalizing and externalizing symptoms, or non-verbal cue reading ability. These results suggest that SDARI may be an effective intervention in addressing some areas of developing social skills as part of a continuum of care for children with ASD (Lerner et al., 2010).

In a similar study, Guli et al. (2012) placed eighteen participants in a treatment group to compare with a clinical control group of sixteen participants. The treatment group received the Social Competence Intervention Program (SCIP), an innovative creative drama-based group intervention based largely off of SDARI. Both observational data and interview data were consistent, showing positive changes in the treatment group's interpersonal relationships, understanding of nonverbal cues, empathy and self-control. Post-treatment showed "generalized improvements in positive interactions and decreased solitary play" (Guli et al., 2012, p. 42). Lerner & Mikami (2012) found that the results of the use of SDARI in children with ASD and communication hindrances indicated an increase in reciprocated friendship nominations and social skills. Those children who participated in SDARI liked and interacted more with each other even after just one session (Lerner & Mikami, 2012).

Social Emotional NeuroScience Endocrinology (SENSE) Theatre

Social Emotional NeuroScience Endocrinology (SENSE) Theatre is a theatrical intervention program "designed to improve socioemotional functioning and reduce stress in children with autism spectrum disorder (ASD)" (Corbett et al., 2010, p.505). According to the program creator, Blythe Corbett, "SENSE Theatre allows us to bridge science and art in a unique intervention program for children with autism" (Wetzel, 2011, p.1). In the pilot investigation study of SENSE Theatre conducted by Corbett et al. (2010), eight children with ASD were partnered with eight typically developing peers who served as models. Social skills training with children with ASD usually involves a variety of techniques. Much of human learning occurs from watching and imitating others. Children with Autism who possess the ability to imitate are able to learn from observation as well. Including typically developing peers in a social skills intervention, such as SENSE Theatre, can facilitate social functioning and play behavior in those children with ASD. In this particular study, the eight children with ASD (seven boys and one girl), were each paired with a typically developing peer. Throughout the thirty-eight rehearsals and six performances, various measures took place to evaluate progress. Subtests were administered by a licensed psychologist pre- and post-treatment, and used as dependent variables. In addition, parent questionnaires were administered and collected. Throughout the SENSE Theatre program, care was taken to provide a supportive social environment and individualized assistance.

While the parent report measures showed no significant changes, the neuropsychological measures indicated statistically significant differences between pre- and post-treatment measures for face identification and Theory of Mind skills, as well as in social perception (Corbett et al., 2010).

Mimetics

A method similar to the modeling that SENSE Theatre provides is known as Mimetics. Mimetics uses an interactive communication process that is based on copying and imitation (Trowsdale & Hayhow, 2013). According to Trowsdale and Hayhow (2013), Mimetics draws upon children's personal interpretations, feelings and ideas in order to engage them emotionally and imaginatively through physicality. This communal process creates a collective experience. Imitative play is emphasized through a range of physically-based, non-verbal communications.

Trowsdale and Hayhow (2013) evaluated Mimetics and its effect on engaging young children with learning disabilities and struggles in communication and socialization, specifically children with autism. Children were selected from a larger group to participate in case studies investigating how Mimetics might generate change. A Likert scale was used to record "perceived change in relation to aspects of creative learning as a result of the experience of Mimetics" (Trowsdale & Hayhow, 2013, p. 76). In addition to the Likert scale recording, photographing and filming took place throughout the various Mimetics sessions in order to support any observation notes conducted by the teachers (Trowsdale & Hayhow, 2013).

At the conclusion of the study, Trowsdale & Hayhow (2013), found that Mimetics has a significant value for children with various learning disabilities. Significant changes were recorded in "children's level of engagement with each other and with learning, in problem-solving, taking risks, thinking in new and imaginative ways, as well as in children's readiness to reflect on their behavior and progress in learning" (Trowsdale & Hayhow, 2013, p. 78). Trowsdale & Hayhow (2013) found that Mimetics allowed for one particular child with autism to break away from the stereotype of autism and display multiple versions of himself. It is strongly felt that through sustained Mimetics experiences, children with learning disabilities, such as autism, might continue to develop their multiple capabilities (Trowsdale & Hayhow, 2013).

Stories of Dramatherapy

The use of stories in social skills intervention is another form of Dramatherapy. The aim of using stories in Dramatherapy is to not only teach, practice and improve social skills and functioning of children with ASD, but to offer an imaginative frame in which to process material (Lewis & Banerjee, 2013). Using stories and storytelling within a Dramatherapy session gives participants the freedom to create and expand their imagination, confidence, and social understanding. Often times, the drama therapist will provide the group with a theme to start them off. From there, the drama therapist will be present for support and encouragement, allowing the participants to fill out their stories, invent characters, and work toward an open forum where the participating children feel comfortable sharing the stories and characters they create (Wharam, 2013).

A ten week study conducted by Lewis & Banerjee (2013) evaluated the use of stories in Dramatherapy to assess how it may help to guide and grow Theory of Mind and imagination in children with ASD. The qualitative study took place in a non-maintained, co-educational, special school for children with speech-language, social communication, and learning difficulties. Three children were identified to partake in the three-part intervention beginning with an initial individual meeting, followed by ten group Dramatherapy sessions, each sixty minutes in length, and concluding with one final individual session. At the first meeting, a Theory of Mind test and projective storytelling exercise took place. The projective storytelling exercise was used to establish a "language of storytelling and an atmosphere of imaginative play" (Lewis & Banerjee, 2013, p. 33).

The ten group sessions used a similar format each week, which involved a welcome, warm-up, a main storytelling activity, reflection and goodbye. Each session offered a wide array of storytelling methods as well as various Dramatherapy approaches. Throughout each session, themes were followed, developed, and explored. At the conclusion of the ten-week sessions, a final individual session occurred in which each of the participants met with the researcher. The data from these individual meetings, the group sessions, and additional input given to the researcher by parents, teachers and caregivers, was used to find "meanings, concepts, characteristics, metaphors, and descriptions relating to the area of investigation (Lewis & Banerjee, 2013, p. 33-34).
Results suggested that the use of stories in Dramatherapy "presents a real and exciting set of possibilities for engaging young people with ASD in a positive therapeutic pathway that is likely to benefit their emotional psychological and social development" (Lewis & Banerjee, 2013, p. 38).

What happens next?

While there is limited research evidence for the use of Dramatherapy (Cassidy, Turnbull, & Gumley, 2014), the current available research positively supports Dramatherapy as a therapeutic intervention for children with ASD. However, "drama as a learning medium is still under-used in specialist settings and with children with learning difficulties" (Peter, 2009, p. 9). Much of the literature based around Dramatherapy is qualitative in nature, making it difficult for the method to be fully accepted by the professional world. In order to gain the support of professional educators, therapists and researchers, Dramatherapy needs to undergo more quantitative analysis studies. It is difficult to dispute numbers, charts, and data that show a positive trend. This will allow the "literature to move forward from describing experience and models to developing a theory that will underpin change (Cassidy, Turnbull, & Gumley, 2014, p. 354). The qualitative reviews have laid a solid base off of which future research can build.

It is difficult to work with multiple groups in a comparative format since ASD reflects in every child differently. Finding children with comparable social skill deficiencies and diagnoses may prove challenging. Instead, the single-group pretest-posttest study design seems best suited for further investigation on the effects Dramatherapy has on children with ASD and their social skills and communication. In this research design, "a single group of subjects is given a pretest, then the treatment, then the posttest. The results are determined by comparing the pretest score to the posttest score" (McMillan, 2004, p. 217). Since Autism Spectrum Disorders are such individualized disorders, assessing the child's individual growth seems the strongest approach for an initial research study method.

It is important to consider the possible threats to internal validity when approaching this type of study. According to McMillan (2004), since no comparison subjects exist, it is possible that extraneous events take place that effect the growth seen in any of the subjects. Another possibility is that maturation takes place throughout the course of the intervention. If a child matures throughout the study, the results may show a positive increase in social skills and communication that are the result of the child's growth, not necessarily the Dramatherapy intervention (McMillan, 2004).

While these possible hindrances to validity are present, a single-group pretest-posttest study will continue to add to the growing body of literature related to this subject. Dramatherapy could be a very effective method of social skills and communication intervention for children with ASD. It is important to continue research, both qualitatively and quantitatively, to determine the scope of its effectiveness.

References

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Corbett, B., Gunther, J., Comins, D., Price, J., Ryan, N., Simon, D., Schupp, C., Rios, T. (2010). Brief report: Theatre as therapy for children with Autism Spectrum Disorder. Journal of Autism and Developmental Disorders, 41, 505-511. doi: 10.1007/s10803-010-1064-1

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