Autism: Puppets could be a useful tool to help young children to improve social engagement and attention

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A new study by researchers at the Yale Child Study Center demonstrates that puppets can attract and hold the attention of children with autism spectrum disorder (ASD), raising the potential for developing more engaging therapies that strengthen social engagement and facilitate learning.

The study, published in the journal Autism Research, is the first to test anecdotal evidence that children with ASD, like most youngsters, pay attention to puppets.

In a series of experiments, the researchers examined the visual attention patterns of young children with ASD, alongside a control group of typically developing children, in response to a video depicting a lively interaction between Violet, a brightly colored puppet, and a human counterpart.

They found that the attention patterns of children with ASD were similar to those of children in the control group when Violet spoke, with both sets of children spending a similar proportion of time watching her face and exhibiting a strong preference for the talking puppet over the listening person.

“Children with autism are less likely to attend to and to engage emotionally with their social partners, which limits their exposure to a host of important learning opportunities and experiences. In the present study, we found that while children with autism paid less attention than typically developing peers when an interactive partner was human, their attention was largely typical when the interactive partner was Violet, the puppet,” said study coauthor Katarzyna Chawarska, the Emily Fraser Beede Professor of Child Psychiatry at Yale School of Medicine, and director of the National Institutes of Health Autism Center of Excellence at the Yale Child Study Center.

“Our findings highlight the attentional and affective advantages of puppets which, hopefully, can be harnessed to augment the therapeutic efforts in children with ASD.”

The researchers created the experiment in collaboration with Cheryl Henson ’84 B.A., who is a daughter of celebrated puppeteer Jim Henson and president of the Jim Henson Foundation.

“For many years, I’ve observed how puppets can engage children with ASD in meaningful ways, often establishing an uncommonly emotional connection,” said Henson, who was a puppet builder on “The Muppet Show” and worked with “Sesame Street” in the 1990s, among other productions.

“I was thrilled when the Yale Child Study Center expressed interest in conducting the first-ever clinical research exploring how puppets are seen by kids with ASD.

“The findings lend scholarly weight to our anecdotal experiences and suggest that puppets could be a powerful tool to help children with ASD improve their social engagement, which is very exciting.”

For the study, participants were seated in a dark soundproof room in front of a widescreen LED monitor, and then shown an 86-second video created by Henson and the staff of the Jim Henson Foundation in partnership with the researchers.

Researchers used eye-tracker software to monitor the children’s visual attention as they watched the video of Violet in playful conversation with a woman named “Z.” Violet is soft, furry, and colorful. She has moving hands, head, and mouth and was voiced by a professional puppeteer. During the video, the puppet and human took turns speaking and played with a ball. They’d occasionally look into the camera.

The study showed that children with ASD paid less attention to Z’s face throughout the video. Unlike the typically developing children, they demonstrated no preference for Z while she spoke to Violet. The children with ASD often looked at Z’s body or the ball instead of her face, according to the study.

In contrast, Violet elicited more typical patterns of attention among the children with ASD, the study found. There was no evidence that the perceptually salient puppet monopolized the children’s attention, Chawarska noted.

When Violet spoke, their visual patterns were very similar to those of the children without ASD and both groups showed a pronounced preference for the speaking puppet over the listening human. Importantly, the study found that the attentional benefit of the puppet was similar in children with less and more severe symptoms.

The findings suggest that puppets could become an entry point for teaching children with ASD about salient social cues and encourage them to engage in social exchanges.

They could provide a bridge to therapeutic efforts aimed at improving understanding of human social cues for all children with ASD, regardless of their level of impairment, Chawarska said. Further research should examine directly the feasibility and efficacy of introducing puppets to augment the existing therapeutic approaches, she said.

Funding: The study was supported in part by Cheryl Henson and the National Institute of Mental Health.


Because empathetic responding to displays of sadness or pain increased systematically with the introduction of treatment across all participants, we can conclude that the treatment was effective for this group of students. Similarly, because Josh’s empathetic responding to displays of affect in three response categories increased systematically with the introduction of treatment, we can conclude that the treatment was effective for Josh.

We can also conclude that the treatment was effective in promoting generalized empathetic responding. Specifically, empathetic responding generalized from training to nontraining probe stimuli, increasing systematically with the introduction of treatment with the training stimuli across all 4 participants and all three response categories.

In addition, empathetic responding to actual people in a nontraining setting increased systematically with the introduction of treatment with the training stimuli in the training setting for 2 participants. Finally, a group of teachers scored empathy more frequently during videotaped treatment sessions than during baseline sessions.

Collectively, our results indicate that children with autism as young as 4 years old can learn to demonstrate socially relevant empathy skills in pretend-play settings, and that these skills can generalize to pretend-play vignettes and toys not targeted during training. It is important to note that these skills can also generalize to interactions with real people in nontraining settings, although generalization from pretend play to real life may be limited.

Dolls and puppets (rather than actual people) were used for this study because typical peers and other people were not readily available for teaching in this setting, as is frequently the case when teaching students with autism. Teaching through pretend-play vignettes allowed us to address empathy skills without involving other people and allowed easy repetition of trials when needed.

Because we did not conduct a component analysis to separate the effects of individual treatment package components, we cannot say how much influence the pretend-play component had over responding. Nevertheless, given the limited generalization to actual people observed for both Luke and Ali, teaching with actual people (e.g., peers, siblings) would likely be a more effective strategy to promote generalization from pretend play to real life.

In fact, when treatment was introduced briefly with an actual person in the nontraining setting, both Luke and Ali quickly emitted the target responses. This procedure would more closely resemble those of previous studies (e.g., Gena et al., 1996; Reeve et al., 2007) that demonstrated the effectiveness of components of our treatment package (e.g., modeling, prompting, reinforcement) in teaching other complex social skills.

The types of responses displayed by the participants during baseline supported our hypothesis that deficits in empathy and perspective taking may not indicate the absence of necessary responses but rather an inability to distinguish the conditions under which a specific response (e.g., offering assistance, demonstrating interest) would be appropriate. During baseline, the few responses displayed were often inappropriate for the given vignette category but appropriate for another (e.g., laughing when the puppet was sad). Therefore, it may be most effective to teach responding separately for different response categories, as occurred in the present study.

Multiple-exemplar training (Stokes & Baer, 1977), in addition to training with complex stimulus compounds for each response category, might have been responsible for the generalization observed to nontraining probe stimuli, people, and settings, because the children learned to attend and respond to a variety of motor and vocal discriminative stimuli for each response category.

One can speculate about whether the responses demonstrated by the participants in this study were general enough to be considered empathetic. We presented multiple stimulus compounds in training for the sadness or pain category, and for Josh, we taught empathy responses across a variety of response categories but did not specifically investigate how many exemplars would be required to produce a generalized empathy repertoire.

It seems likely that this number differs across individuals, but that training with multiple exemplars should eventually produce a class of responses one could reasonably label as empathetic.

Future researchers may also consider presenting motor and vocal elements of the stimulus compounds separately to determine whether empathetic responding would occur to one element without the presence of the other. We made the decision to present both elements together in an attempt to present the most salient discriminative stimuli possible to our beginning empathy responders. Certainly a more sophisticated generalized empathy repertoire would include responses to motor or vocal displays of affect in isolation.

Differences in generalized responding to Person 1 and Person 2 observed for several of the participants in the nontraining setting may have been due to familiarity with each of the teachers. Person 1 acted as the prompter in the training setting (but never presented vignettes), whereas Person 2 was a completely unfamiliar teacher. Introduction of training with Person 2 in the nontraining setting, as occurred with Person 1, may have resulted in similar increases in empathetic responding, but this training was not conducted because of time limitations.

One limitation of the study was the cumbersome nature of the treatment package. Language Master scripts were used because they did not require the participants to have reading skills or to interact with the prompter (i.e., when given vocal prompts) before responding to the dolls and puppets. Language Master scripts are also useful because of the ease with which they can be faded.

In this case, however, given all of the other treatment components involved, using vocal prompts may have simplified the procedure. This change, in addition to teaching with actual people instead of dolls and puppets might produce a more manageable treatment package.

An additional limitation of this study is the nature of the raters in the social validity assessment. The raters, although not directly involved with the study, were teachers at the behavioral intervention program and so had familiarity with a variety of individuals with autism. Their knowledge of autism and behavioral techniques used to teach complex social skills may have affected their ratings of empathy shown in the videotaped segments. A group of raters inexperienced with autism might have produced a more convincing demonstration of social validity.

Future studies may also compare ratings of empathy demonstrated toward puppets and dolls to ratings of empathy demonstrated toward actual people. It is plausible that responses deemed empathetic in a pretend-play situation may not appear as genuine in interactions with people. It would also be informative to assess parent and caregiver ratings of empathy demonstrated in unstructured home and community settings.

Empathy is a socially relevant skill for children with autism because it enhances their ability to engage in other critical prosocial behaviors (Rheingold & Hay, 1980). Children with autism who demonstrate appropriate concern and interest when others are sad, excited, or frustrated will likely increase their future interaction with peers and family members.

This may be especially important for children like Josh who are making the transition from special education classrooms to typical classrooms. The results of this study support the conclusions of previous research that behavior-analytic techniques are effective in improving complex social skills such as empathy for children with autism. This seems an important step toward ameliorating an often noted but rarely treated deficit in children with autism.

reference link: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2649842/


Original Research: “Puppets facilitate attention to social cues in children with ASD” by Katarzyna Chawarska et al. Autism Research

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