booksra-2012

STUDENT RESEARCH AWARD 2012

Book of Students Articles

20 October, 2012

Singapore

SRA 2012 Book of Students Articles

2

Paper revision, planning and implementation are performed by

SPS Council:

Bernard Lim President

Clare Yeo Vice-President

Adrian Toh Honorary Secretary

Ashley Wu Assistant Honorary Secretary

Jason Chan Honorary Treasurer

John Wang Council Member (Membership)

Adrian Koh Council Member (Co-opted, Membership)

Maureen Neihart Council Member (SRP)

Tan Hun Boon Council Member (Public Education)

Anna Leybina Council Member (Public Education)

Julia Lam Council Member (Ezine)

If you have any questions regarding the contents of this book, please do not

hesitate to contact us:

Block 531 Upper Cross Street,

#03-52 Hong Lim Complex,

Singapore 050531

[email protected]


3

Foreword

A key competency of psychologists is their ability to design and measure human thoughts,

feelings and behaviour. The knowledge and skill to do so usually begin as part of the

introductory programmes in psychology, which anchors this discipline in the realm of the

behavioural sciences.

The Student Research Award (formerly known as the Undergraduate Research Award) was

initiated to encourage local research and exchange in psychology. Since its early days when

this award was open only to university students, we have grown to include students from

other local tertiary institutions and even the polytechnics. From the presentations at the event

as well as the contents in this publication, you would agree with me that local interest in

psychology has grown over the years. This is an important development as few have the

opportunity to interact and share their ideas and findings based on local research beyond their

immediate circles. In doing so, we want to improve awareness and standards of student

psychological research as a basic competency for local psychologists-to-be.

This Book of Student Articles therefore complements the Student Research Awards that was

held on 20 October 2012. This is only the second such publication by the SPS and therefore

we are in the early days of promoting awareness of local student psychological research.

Nonetheless, the Book of Student Articles is a fitting recognition of all who have pursued

excellence in their research. I am sure that you will find the diverse research topics a positive

reflection of the local interest in psychology, as well as a source for new research ideas.

Finally, I would like to thank the committee led by Dr Anna Leybina whose dedication and

hard work made the event and this publication a possibility.

Dr Bernard Lim, PPA(G), PhD, C.Psychol, AFBPsS, MSPS, SRP

President

Singapore Psychological Society


4

Contents

Education and Public Service Announcement: An effective intervention to reduce stigma and

social distance against schizophrenia

Yuriati Tju.....................................................................................................................................6

The Effects of Bilateral Eye Movement and Presentation Modality on Memory

Lim Aik Meng..............................................................................................................................11

Teacher Perspectives on the Phenomenology, Causes and Impact of Anxiety in Children and

Young People with Autism Spectrum Disorders: A Qualitative Focus Group Study

Tan Wen-Li Julianne...................................................................................................................18

Placebo Effect: The Role of Personality and Expectation

Goh Sok Hui................................................................................................................................32

Effect of Mandatory Volunteering on Intentions to Volunteer

Shaleni Paneerselvam, Aw Chin Bee, V. Thivya Pillai, & Goh Qian Ci....................................38

Object-substitution Masking with Motion: Effect of Moving Object within Stationary Mask

Peh, Chao Xu, Gillon, Colleen, Lin, Vincent, Wong, Kian Foong and Makhijani, Rahul.........43

Hear No Evil: Can Music Attenuate the Irrelevant Speech Effect?

Soh Wei Jie.................................................................................................................................50

Earmarking and Its Effects on Impulse Buying Reduction

Lee Zhi Qi Glenice, Maxine Wong Rui Shi, Alvin Tay An Ge, Lee Dayang..58

The Effects of Normative Evaluation on Buying Intention

Adam Quek Chin Kiat, Jazreel Tan, Sri Nur Idayu Binte Roslan, Hong Dou............................63

Implementation Intentions & Impulse Buying

Abigail Seng Hui Xin,Lim Joyann, Ng Jing Ying........................................................................67

The Effects of Inoculation and Persuasion Knowledge Training on Resisting Sales Persuasion

Kho Kian Hao, Mubarak Johari.................................................................................................72

The Impact of Academic Stress on Depressive Tendencies Among Singaporean

Undergraduates

Emily D. Burton..........................................................................................................................78

Pilot Study of Public Opinions toward Dementia: Awareness, Knowledge and Attitudes

Ng Li Ting..................................................................................................................................88

Effects of Self-Construal Differences on Cognitive Dissonance Examined by Priming the

Independent and Interdependent Self

Jamie Jia Yan Lee.......................................................................................................................94


5

Association of Adult Attachment Styles and the Big Five Personality Traits in Southeast Asia

Erny Feberina...........................................................................................................................102

Language Background, Non-word Repetition, and Spelling in Bilingual Singaporean Children

Choo Rui Qi..............................................................................................................................110

Motivation and Decision Making Among Young Adults

Amanda Ong Hui Zhong...........................................................................................................115

Executive Functioning and Early Mathematical Ability

Denise Kristen Ng, Maxine Wong, Annabelle Lim, & Gabrielle Lai.......................................121

Understanding the levels of Materialism, Gratitude and Happiness among Asians and

Westerners

Lee Sheue Yee, Nuraishikin Begum..........................................................................................127

Profile and Perceptions of Asian Patients with Irritable Bowel Syndrome

Noradlin Mohamed Yusof................................................................................................................133


6

Education and Public Service Announcement: An effective intervention to reduce stigma

and social distance against schizophrenia

Yuriati Tju

[email protected] James Cook University Australia, Singapore Campus

Previous studies have established media as one of the contributors to schizophrenia

stigma. As media could perpetuate such beliefs, social scientists believed it could also be used

as change agents to reduce those stigmas. The present study examined the effectiveness of

education materials and Public Service Announcement (PSA) video on reducing stigma and

social distance associated with schizophrenia. Information exposure was manipulated through a

knowledge test paired with either schizophrenia PSA (treatment) or environmental PSA

(control). The dependent variables are the ratings of stigmatisation and social distance

measured before and after the information exposure. Consistent with the hypothesis,

participants in the treatment group had greater decrease in stigma following the exposure. No

significant difference was found for ratings of social distance; nonetheless, the 95% confidence

intervals indicated that those on the treatment group had greater decrease than those in the

control group. The findings have implications for the future mental health awareness or stigma

interventions.

Keywords: media, mental illness, schizophrenia, stigma, education, contact

Over the past decade, media has been

acknowledged as the source of public

perceptions of mental illness (Stout, Villegas,

& Jennings, 2004). Frequent exposures to

inaccurate mental illness portrayals in the

media have helped perpetuate stigmatisation

towards individuals with mental illness

(Penn, Chamberlain, & Mueser, 2003; Wahl

& Lefkowits, 1989). The present study is

based on the belief that media could also

serve as change agents to promote knowledge

and to present positive portrayal of mental

illness (Philo, Henderson, & McCracken,

2010).

Studies have established that providing

education materials increases public mental

health literacy and sympathetic understanding

towards people with mental illness (Stout et

al., 2004; Wahl & Lefkowits, 1989), resulting

in enhanced positive attitudes (Nairn,

Coverdale, & Claasen, 2001; Stout et al.,

2004). Filkenstein, Lapshin, and Wasserman

(2008) have also suggested that education

strategies with active participation, achieved

through multiple-choice questions and

immediate feedback for each questions, were

effective in promoting short-term and long-

term positive attitudes towards mental illness

in students.

Another strategy to reduce stigma is to

establish contact with people with mental

illness. Indirect contact achieved through

watching video of a person with mental

illness also appeared to be effective in

decreasing stigma (Corrigan, Larson, Sells,

Niessen, & Watson, 2007; Stuart, 2006). A

form of persuasive advertising through video,

defined as Public Service Announcement

(PSA), have been utilized by public health

campaigns to endorse positive attitude change

towards people with mental illness (Gunther

& Thorson, 1992; Stout et al., 2004). Such

videos delivered positive personal narratives

of people with a diagnosed mental illness,

thereby potentially reducing the stigma

against them (Corrigan, 2012). However,

little is known about the effectiveness of this

approach since relevant studies are virtually

non-existent (Corrigan, 2012; Stout et al.,

2004).

The present study seeks to further

understand the influence of information

exposure through education and indirect

contact through PSAs on reducing mental

illness stigma. It was hypothesised that there

will be a significant decrease in the degree of


7

stigmatisation and social distance for

participants who complete the knowledge test

and watch the schizophrenia PSA, as

compared to those who complete the

knowledge test and watch a control video.

Method

Participants

Recruitment was accomplished through

James Cook University Singapore (JCUS)

online research participation system, research

recruitment notice board, and class

announcements in first-year lectures. 82 first-

year psychology students from JCUS,

consisting of 24 males (age range 18-25

years, M= 21.58, SD= 1.84) and 58 females

(age range 18-38 years, M= 20.12, SD= 2.71)

of Chinese (69.51%), Indian (15.85%), Malay

(6.1%), Eurasians (6.1%), and Vietnamese

(2.44%) ethnicity were recruited. They were

alternately assigned to the treatment (68.3%

females, age M= 20.27, SD= 3.64) or control

(73.2% females, age M= 19.97, SD= 1.42)

group according to order of participation with

41 participants in each group.

Materials

The study was a two (treatment/control)

by two (pretest/posttest) mixed factorial

design. Materials include information sheet

and informed consent as an introduction to

the experiment. The independent variables

are information exposure and time of testing,

which is a repeated measurement.

Information exposure was manipulated

through a 15-item Knowledge About

Schizophrenia Test (Compton, Quintero, &

Esterberg, 2007), with immediate feedback

given after each question, paired with

schizophrenia PSA (treatment) or

environmental PSA (control). The videos

were carefully selected and utilized with

permission from the creators.

The dependent variables are the ratings

of social stigmatisation and social distance.

The 12-item stigma measure was derived from

Links Discrimination-Devaluation Scale (Link et al., 1989 as cited in Gaebel, Baumann,

Witte, & Zaeske, 2002), consisting of

statements reflecting acceptance and

stigmatisation against people with mental

illness rated on a five-point scale (1 Strongly Agree, 5 Strongly Disagree). Potential scores range from 12 to 60, with higher score

indicating higher degree of stigmatisation. The

6-item social distance measure was derived

from the Social Distance Scale (Bogardus,

1925 as cited in Gaebel et al., 2002),

questioning participants willingness to interact with individuals diagnosed with schizophrenia

on varying degrees of relationship and

intimacy rated on a four-point scale (1 -

Definitely Not, 4 - Definitely). Potential scores

range from 6 to 24, with higher score

indicating greater social distance. Table 1

indicates the internal reliabilities of the

measurements in the present study.

Table 1.

Internal Reliability of Stigmatisation and Social Distance Measure at Pretest and Posttest

Timing Reliability measure Social Stigmatisation Social Distance

Pretest Cronbachs alpha .662 .604

Inter-item correlation .277 .430

Posttest Cronbachs alpha .833 .638

Inter-item correlation - .448


8

Procedure

The study was conducted in an on-

campus research laboratory. Participants

were introduced to the study and were

instructed to complete the stigmatisation and

social distance questionnaire. Participants

then complete the knowledge test followed

by watching the PSA video. Finally,

participants again completed the

stigmatisation and social distance measures.

No immediate debriefing was done and

research outcomes were sent to participants email addresses provided in the consent

form.

Results

Gain-score analyses were conducted

and scores differences were computed by

subtracting each persons posttest score from the pretest score. Based on the hypotheses, a

gain is a decrease in scores and it should be

negative, indicating that the posttest score

was less than the pretest score. These scores

were analysed in two separate one-way

ANOVA with groups as the between

subjects factor.

Social Stigmatisation. The decrease in

stigma was significantly greater for

participants in the treatment (M = -4.46, SE =

.85, 95% CI [-6.16, -2.76]) than those in the

control condition (M = -.49, SE = .85, 95%

CI [-2.19, 1.21]), F (1, 80) = 10.82, p = .001.

Inspection of the 95% CI also confirmed

similar result which supported the

hypothesis, suggesting that exposure through

the knowledge test paired with the mental

health PSA was effective in decreasing

stigma against individuals with

schizophrenia. Figure 1 shows the mean gain

scores of stigma for control and treatment

group.

Figure 1. Mean gain scores of social stigmatisation in control and treatment group.

Social Distance. There was no

significant difference in social distance scores

for participants in the treatment (M = -1.10,

SE = .31, 95% CI [-1.72, -.48]) and control

condition (M = -.29, SE = .31, 95% CI [-.91,

.33]), F (1, 80) = 3.32, p = .07. Nonetheless,

inspection of the 95% CI indicated that

participants in the treatment condition had

greater decrease in social distance (i.e. the

95% CI excludes zero) than those in the

control condition (i.e. the 95% CI includes

zero, representing zero gain). It offered

partial support for the hypothesis, suggesting

that information exposure through knowledge

test paired with mental health PSA led to

greater decrease in social distance. Figure 2

shows the mean gain scores for social

distance for control and treatment group.

Figure 2. Mean gain scores of social distance in control and treatment group.

Discussion

As hypothesised, exposure through the

knowledge test paired with mental health PSA

was effective in decreasing stigma against

people with schizophrenia. The results,

integrating a balance of point estimation and

range of confidence, also offered support for the

hypothesis, in which those in the treatment group

had greater decrease in social distance as

compared to those in the control group.

The PSA video offered plausibly accurate

portrayal and provided indirect contact with a

person diagnosed with schizophrenia, which

served as the opportunity for participants to

challenge and examine their perceptions and

beliefs of the stereotyped group. However,

improvement in participants readiness to establish social relationships with individuals

with schizophrenia was not strongly evident. No

significant difference was found following the

information exposure on social distance ratings,

suggesting that changes in beliefs about mental

illness might not necessarily be reflected in

behavioural changes (Penn et al., 2003).

Nevertheless, inspection of the 95% CI indicated

that those in the treatment group had greater

decrease in social distance than those in the

control group, and it is reasonable to conclude

that the result provides partial support for the

hypothesis. The lack of a statistically significant

effect on social distance ratings could be due to

inadequacies of the measure, which might have

provided a less-than-accurate reflection of

participants intention for future interaction with individuals diagnosed with schizophrenia.

Several limitations of this study should be

highlighted. First, the sample consisted of only

psychology students. This would limit the

generalisability of the results to the general

population. Second, participants self-reported measures may not necessarily reflect their actual

behaviour and they might have exhibited social

desirability bias. Third, the intervention involved

a combination of education materials and video-

based contact and it is uncertain as to which

component is the strongest contributor to the

decrease in ratings. Nevertheless, it is likely that

the visual stimuli (PSA video) was more

powerful, as participants in the control group

completed the same knowledge test but no

reduction in ratings were evident. Lastly, only

short-term effects were measured and the

stability of attitude changes in the long-term

remains uncertain.

Conclusion

Despite some limitations, results from this

study have shown that media could be used to

reduce mental illness stigma through minimal

resources, while also suggesting an important

practical implications. Mass media producers

should acknowledge the importance of positive

mental illness portrayal in contributing to


10

positive public beliefs and attitudes towards

individuals with mental health issues. Future

mental health campaigns could also utilize

substantial resources in promoting knowledge

and developing PSA videos as the leading

strategy to eliminate, or at least help reduce,

mental illness stigma. Although more research

should be conducted, the outcomes documented

here could be considered as a promising initial

step for future studies in this area.

References

Compton, M. T., Quintero, L., & Esterberg, M.

L. (2007). Assessing knowledge of

schizophrenia: Development and

psychometric properties of a brief,

multiple-choice knowledge test for use

across various samples. Psychiatry

Research, 151, 87-95.

DOI:10.1016/j.psychres.2006.05.019

Corrigan, P. W., Larson, J., Sells, M., Niessen,

N., & Watson, A. C. (2007). Will filmed

presentations of education and contact

diminish mental illness stigma? Community

Mental Health Journal, 43(2), 171-181.

DOI: 10.1007/s10597-006-9061-8

Corrigan, P. W. (2012). Where is the evidence

supporting public service announcements

to eliminate mental illness stigma?

Psychiatric Services, 63(1), 79-82.

Filkenstein, J., Lapshin, O., & Wasserman, E.

(2008). Randomized study of different anti-

stigma media. Patient Education and

Counselling, 71, 204-214. DOI:

10.1016/j.pec.2008.01.002

Gaebel, W., Baumann, A., Witte, A. M., &

Zaeske, H. (2002). Public attitudes towards

people with mental illness in six German

cities: Results of a public survey under

special consideration of schizophrenia.

European Archives of Psychiatry and

Clinical Neuroscience, 252, 278-287.

DOI:10.1007/S00406-002-0393-2

Gunther, A. C., & Thorson, E. (1992).

Perceived persuasive effects of product

commercials and public service

announcements: Third-person effects in

new domains. Communication Research,

19(5), 574-596.

DOI:10.1177/009365092019005002

Link, B. G., Cullen, F. T., Struening, E. L.,

Shrout, P. E., & Dohrenwend, B. P. (1989).

A modified labeling theory approach in the

area of mental disorders: An empirical

assessment. American Sociological Review,

54, 100-123, 1989.

Nairn, R., Coverdale, J., & Claasen, D. (2001).

From source material to news story in New

Zealand print media: A prospective study

of the stigmatizing processes in depicting

mental illness. Australian and New Zealand

Journal of Psychiatry, 35, 654-659.

Penn, D. L., Chamberlain, C., & Mueser, K. T.

(2003). The effects of a documentary film

about schizophrenia on psychiatric stigma.

Schizophrenia Bulletin, 29(2), 383-391.

Philo, G., Henderson, L., & McCracken, K.

(2010). Making Drama out of a Crisis:

Authentic Portrayals of Mental Illness in

TV Drama. Retrieved from

http://www.shift.org.uk/files/media/shift_tv

_research_full.pdf

Stout, P. A., Villegas, J., & Jennings, N. A.

(2004). Images of mental illness in the

media: Identifying gaps in the Research.

Schizophrenia Bulletin, 30(3), 543-561.

Stuart, H. (2006). Reaching out to high-school

youth: The effectiveness of a video-based

antistigma program. Canadian Journal of

Psychiatry, 51(10), 647-653.

Wahl, O. F., & Lefkowits, J. Y. (1989). Impact

of a television film on attitudes toward

mental illness. American Journal of

Community Psychology, 17(4), 521-528.


11

The Effects of Bilateral Eye Movement and Presentation Modality

on Memory

Lim Aik Meng

[email protected]

SIM University

The effects of presentation modality (visual and aural) and eye movement (bilateral and central

fixation) on memory were investigated using a mixed factorial design. The participants were

140 SIM University undergraduates. A two-way factorial ANOVA revealed no main effects of

presentation modality and eye movement on the proportion of falsely-recognised critical lures.

No interaction effect was found as well. Significant main effects of presentation modality and

eye movement were found on the proportion of remember judgements of correctly-recognised words. However, no corresponding interaction effect was found. The additional

contextual information provided by visual presentation and facilitated by bilateral eye

movements appeared to help participants in remembering details of presented words but not in

rejecting non-presented critical lures. Therefore, the distinctiveness heuristic appeared to be

utilised only for remembering presented words in this sample. The non-utilisation of the

distinctiveness heuristic in the rejection of non-presented critical lures warrants future

investigation.

Keywords: bilateral eye movement, presentation modality, memory, DRM paradigm

One consistent finding using the DRM

paradigm (Roediger & McDermott, 1995)

demonstrated that false memory was reduced

when words presentation mode was visual

rather than auditory (Gallo, McDermott, Percer

& Roediger, 2001; Kellogg, 2001; Pierce,

Gallo, Weiss & Schacter, 2005; Smith & Hunt,

1998). This was explained by the

distinctiveness heuristic monitoring process

whereby participants retrieve distinctive

detailed information during the testing phase,

helping them assess memory accuracy before

recall and recognition (Gallo et al. 2001).

Kelloggs (2001) study demonstrated that by visualising the orthographic features of aurally-

presented words during study, the modality

effect was eliminated, suggesting that while

phonological and semantic codes were

activated by both modalities, an orthographic

code was activated by visual presentation only.

Participants were also more likely to make

remember judgments on visually-presented words than aurally-presented words, suggesting

that visually-presented words were more

distinctive (Pierce et al., 2005). A remember judgement was made if the participant had

some recollection of presentation details such

as the image of the word while a know

judgement was made if no details were

remember (Rajaram, 1993).

Some studies had shown that by

performing thirty seconds of bilateral saccadic

eye movement, false memory was reduced and

true memory was improved. (Christman,

Garvey, Propper & Phaneuf, 2003; Christman,

Propper & Dion, 2004; Parker & Dagnall,

2007; Parker, Relph & Dagnall, 2008).

Participants were also more likely to remember

details of correctly-recognised words and less

likely to remember details for falsely-

recognised critical lures (Parker et al., 2008).

One finding suggested that bilateral eye

movement lead to enhanced recollection of

contextual information (Parker et al., 2008 -

Experiment 2). Such enhanced recollection

helped in true recognition by providing

distinctive details of the presented word. The

reduction in false recognition could be due to a

recollection-based monitoring strategy (Parker

et. al, 2008), whereby the retrieved contextual

information allows participants to discriminate

between presented and non-presented word

items. The absence of distinct information

allowed participants to reject non-presented

critical lures and reduce false memory.


12

Although presentation modality and

bilateral eye movement were both found to

affect memory in the DRM paradigm, no

current research investigated the combined

roles of both variables. As past research

suggested a post-retrieval monitoring strategy

determining the reduction of false memory and

remembering in both factors, we would expect

an interaction effect. Visually-presented words

being more distinctive should provide more

contextual information than aurally-presented

words. There would therefore be a magnifying

effect after bilateral eye movement as it

enhances recollection of contextual

information, where false memory will be

reduced more for visually-presented words than

for aurally-presented words. There would also

be a magnifying effect in remember

judgments, whereby after bilateral eye

movements, the increment of remember judgments on correctly-recognised words

should be more for visually-presented than

aurally-presented words.

The objective of this study was to

determine the combined effects of presentation

modality and eye movement in generating false

memory and their effects in determining

remember judgments of correctly-recognised words. It was hypothesised that there will be a

main effect of presentation modality, a main

effect of eye movement and an interaction

effect between eye movement and presentation

modality on the proportion of falsely

recognised critical lures (Figure 1) as well as

on the proportion of remember judgements of correctly recognised words (Figure 2)

Figure 1. Graphical representation of hypotheses on the proportion of falsely recognised

critical lures.

Visual Aural

PRESENTATION MODALITY

MEAN Eye Movement Conditions

Central Fixation

Bilateral


13

Figure 2. Graphical representation of hypotheses on the proportion of remember judgements of correctly recognised words.

Method

Participants

140 SIM University undergraduates

were awarded module credit for their

participation in this experiment. The final

data analysis consisted of 124 participants

(48 males and 76 females) as 16 participants

were excluded for not following

instructions.

Design

A 2x2 mixed-participants factorial

design was employed in this experimental

study. The two independent variables were

(1) presentation modality (visual or aural)

and (2) eye movement (bilateral or central

fixation). The presentation modality and eye

movement variables were manipulated

within-participants and between-participants

respectively. The dependent variables were

the proportion of falsely-recognised critical

lures and the proportion of remember judgements of correctly-recognised

presented words.

Materials and Procedure

Participants were tested in 4

different experimental groups. All groups

were presented with eight aural followed by

eight visual word lists or vice versa. The

sixteen word lists were taken from

published norms (Stadler, Roediger &

McDermott, 1999) (Appendix A). Next,

each group underwent one of the eye

movement conditions for 30 seconds. For

the bilateral eye movement conditions,

participants used their eyes to follow the dot

as it flashed (500ms) left and right on the

screen. For the central fixation conditions,

participants were instructed to stare at the

central flashing (500ms) black dot. Lastly,

participants were provided with word

recognition test booklets containing 128

words (Appendix B) where they indicate if a

word was old (presented) or new (not

presented). If a word was indicated as old,

participants were to make remember or know judgments.

Visual Aural

PRESENTATION MODALITY

MEAN Eye Movement Conditions

Central Fixation

Bilateral


14

Proportion of Falsely-recognised Critical Lures

Table 1

Means and Standard Deviations of Proportion of Falsely Recognised Critical Lures

(N = 124)

IV: Presentation Modality

Visual Aural

Total

M SD M SD M SD

IV: Eye Movement Bilateral .67 .21 .68 .23 .67 .22

Central Fixation .60 .26 .62 .24 .61 .25

Total .64 .24 .65 .24

Table 2

Analysis of Variance for Proportion of Falsely Recognised Critical Lures

Sphericity Assumed

Error

Source

df

F

2

P

df

MSE

Mixed participants

Presentation Modality (PM) 1 .29


15

Table 4

Analysis of Variance for Proportion of Remember Judgements of Correctly Recognised Words

Sphericity Assumed

Error

Source

df

F

2

P

df

MSE

Mixed participants

Presentation Modality (PM) 1 11.70**

.09


16

information was common to both visually

and aurally presented words, resulting in no

difference in the proportion of remember judgements for visually and aurally

presented words.

An interesting finding was that the

main effects of eye movement and

presentation modality were found for

remember judgements of correctly-recognised words but not for falsely-

recognised critical lures. In previous studies

(Parker et al., 2008; Pierce et al., 2005), it

was assumed that a monitoring process

would be utilised both in rejecting critical

lures and in remembering presented words.

However, this study cast doubt on this

assumption as it appeared that the

distinctiveness heuristic was only utilised

for remembering presented words but not

for rejecting non-presented critical lures.

The reason why the distinctiveness heuristic

was not employed in the rejection of non-

presented critical lures warrants further

investigation.

There were some limitations to the

results of this study. Previous studies

investigating the effect of eye movement on

memory tested the participants individually

but this study tested the participants in

groups (Parker & Dagnall, 2007). Mental

fatigue which had been shown to be

detrimental to cognitive functioning such as

attention (Boksem, Meijman & Lorist,

2005) may be another limitation as most

participants took the experiment after

working in the day (Boksem & Tops, 2008).

As previous studies were predominantly

based on western samples, there may be

subtle cultural differences in the way local

samples respond to the DRM paradigm. One

study using Taiwanese and American

samples found that the specific critical lure

falsely recalled in the DRM Paradigm were

culturally influenced (Lee, Chiang & Hung,

2008).

Conclusion

The additional contextual

information provided by visual presentation

and facilitated by bilateral eye movements

appeared to help participants in

remembering details of presented words.

However, the additional information did not

appear to help participants in rejecting non-

presented critical lures. Hence, the

distinctiveness heuristic appeared to be

utilised for remembering presented words

but not for rejecting non-presented critical

lures. Further research to determine the

reasons why the distinctiveness heuristic

was not utilised in the rejection of non-

presented critical lures in this sample is

warranted.

References

Boksem, M. A. S., & Tops, M. (2008).

Mental fatigue: Costs and benefits.

Brain Research Reviews, 59, 125-139.

doi:10.1016/j.brainresrev.2008.07.001

Boksem, M. A. S., Meijman, T. F., &

Lorist, M. M. (2005). Effects of mental

fatigue on attention: An ERP study.

Cognitive Brain Research, 25, 107-116.

doi:10.1016/j.cogbrainres.2005.04.011

Christman, S. D., Garvey, K. J., Propper, R.

E., & Phaneuf, K. A. (2003). Bilateral

eye movements enhance the retrieval of

episodic memories. Neuropsychology,

17, 221-229. doi: 10.1037/0894-

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18

Teacher Perspectives on the Phenomenology, Causes and Impact of Anxiety

in Children and Young People with Autism Spectrum Disorders:

A Qualitative Focus Group Study

Tan Wen-Li Julianne

[email protected]

National University of Singapore

While a plethora of research on comorbid psychopathology in autism spectrum disorders (ASDs) exists, there is a knowledge gap regarding the everyday nature of the experience of

anxiety in autism, and how autism-specific factors may play a role in this increased prevalence

of anxiety. Assessment of anxiety in ASD has also largely utilised measures developed for

typically developing children, and parents have been the main informants, raising limitations

with regard to creating a holistic picture of anxiety in ASD. As such, this exploratory study

reports on a series of focus groups with teachers from Special Education schools in Singapore

regarding the anxiety difficulties of their low-functioning students with ASD. Taken together,

the teachers views were strikingly consistent across groups and provided a unique constellation of findings regarding triggers and signs of anxiety, as well as management/coping strategies.

These findings provide ecological validity to recently proposed theoretical models of anxiety in

ASD, and also suggest the broadening of theoretical conceptualisations for a more complete

view of anxiety across the entire ASD spectrum.

Keywords: Autism Spectrum Disorders (ASD), anxiety, comorbid psychopathology, qualitative

methodology, focus groups, teachers, special education

Autism Spectrum Disorders (ASD)

are complex neurodevelopmental conditions

which share a triad of impairments in the

core domains of reciprocal social

interaction, communication and stereotyped

behaviours and interests (American

Psychiatric Association, 1994). Despite a

plethora of ASD-related research, however,

what is less noted is that ASDs are further

compounded by comorbid psychiatric

psychopathology, especially anxiety

disorders. Various types of anxiety are so

frequently exhibited in children with ASDs

that the DSM-IV highlights anxiety-related

behaviours as an associated feature of autism (American Psychiatric Association,

1994, p.68). This significant overlap

between anxiety and ASD has also been

empirically established, with various meta-

analyses and prevalence studies (van

Steensel, Bgels, & Perrin, 2011; Brereton,

Tonge, & Einfeld, 2006) reporting high

rates of comorbidity between anxiety

disorders and ASD (from 39.6%-49%).

Proposed hypothetical model and

theories about the links between anxiety

and ASD

It has been proposed that many of the core

symptoms of ASD can lead to stressful

experiences that promote anxiety, likening

anxiety to a downstream consequence of ASD. In turn, anxiety may also be a

mediator or a moderator of ASD symptom

severity (Wood & Gadow, 2010). The

hypothetical model proposed by Wood &

Gadow (2010; see Figure 1) consists of two

parts first; the contributions of ASD-related specific stressors (such as social

confusion and rejection, prevention of

preferred repetitive behaviours and aversive

sensory experiences) are thought to lead to

anxiety (conceptualised as social anxiety

and other forms of negative affectivity), and

second, the increased experiences of anxiety

are hypothesized to further impact the

individuals ASD related behaviours resulting in increases in avoidance or autism

symptoms, other problem behaviours and

distress that arise from anxiety (Figure 1).

Figure 1. Hypothetical model of clinical anxiety in autism spectrum disorders (Wood &

Gadow, 2010)

Current research limitations Despite the presence of these

hypotheses on the theoretical relationships

and factors between anxiety and ASD, they

have received little empirical validation in

terms of obtaining an accurate

representation of how anxiety might

manifest itself in children with ASD, on a

behavioural, cognitive and physical level,

and gaining a working knowledge of what

triggers of anxiety exist on an everyday

basis.

Specifically, one limitation of

current research arises from the use of

clinic-based samples in a majority of studies

that have examined anxiety in children and

adolescents with ASD. According to White

et al. (2009), it is unlikely that clinic-based

samples are representative of all children

with ASD in various important respects,

such as the level of behaviour disturbance or

the degree of parental investment, therefore

highlighting the need for non-clinical,

community- and school-based samples to

evaluate the presence of anxiety in the

broader ASD population.

In addition, existing studies that

examined the phenomenology of anxiety in

ASD (i.e. Strang et al., 2011) have primarily

used parent-report measures that have been

designed for typically developing youth and

their manifestations of psychopathology,

such as the Spence Childrens Anxiety Scale (SCAS; Spence, 1993), that have not

been validated for use with the ASD

population.

As such, given the limitations of

quantitative methodologies using

standardized scales designed for typically

developing children, a qualitative approach

may be useful because it would generate

targeted data regarding the actual

experience of anxiety in ASD and not

merely on what the measure is asking. It is

for this reason that this study uses a

qualitative, bottom-up approach, to allow for a fluid exploration of the atypical

manifestation of anxiety in naturalistic

settings and to obtain a more ecologically

valid picture of the anxiety difficulties of

children with ASD.

Teachers perspectives on anxiety in children with ASD

As in Ozsivadjian, Knott and

Magiati (2012), a large bulk of the existing

body of literature on anxiety and ASD has


20

been conducted with parents (for reviews,

see White et al., 2009; van Steensel et al.,

2011). While parents are knowledgeable

informants, teachers perspectives are also valuable in obtaining a holistic picture of

childrens experiences, as they are able to yield information about school-specific

triggers and presentation of anxiety, given

that schools are a much more complex

environment than the home, with additional

performance-based and social demands, and

other factors that are not as easy to control

as in the home, such as the level of noise

and activity in the childs surroundings (Howlin, 1997).

The present study: rationale and

research aims

Using a qualitative methodology and

obtaining teachers perspectives, the aims of this exploratory study is to add to an

increasing body of knowledge via:

(i) Developing a constellation of findings that holistically describe the nature of

anxiety in lower-functioning children

with ASD, and establishing a ranking of

the most common triggers and signs of

anxiety, and the strategies used by

children, teachers and schools to cope

and manage with anxiety;

(ii) Identifying ASD-specific factors implicated in the development and

maintenance of anxiety in this

population, with particular emphasis in

school-related experiences; and

(iii) Providing ecologically valid empirical support (or disputes) to

recently proposed hypothetical

theoretical models of anxiety in ASD

(Wood & Gadow, 2010)

It also aimed to explore the nature of

anxiety in a population of children ASD

who are lower functioning, as this group of

children has been largely ignored in studies

of psychiatric comorbidity in ASD and most

published studies have focused on children

with high-functioning autism or Aspergers syndrome.

Method

Data collection approach

The key objective of this exploratory

study was to elicit a rich variety of views

from each group of participants, regarding

the focused topic of anxiety difficulties in

children with ASD, and this objective was

well-suited to the qualitative, bottom-up methodological approach of focus groups.

Focus groups are planned discussion

sessions that are organised to explore a

particular topic of interest (Krueger &

Casey, 1988), encourage engagement

between participants, and draw out

reflections that would have otherwise not

been obtained via individual interviews or

questionnaires, allowing us to capture a

picture of anxiety in ASD that is as

ecologically valid and complete as possible.

Participants

Teacher-participants were recruited through

their school administrations and signed up

for focus group slots if they were willing to

participate. In total, five teacher focus

groups were conducted, across four

different Special Education schools in

Singapore with educational programmes for

students with ASD and IQ levels of less

than 70. Therefore, dialogue focused mainly

on lower-functioning children with ASD,

from 6-14 years of age. Descriptive

information about the teachers was obtained

via a demographic questionnaire (Appendix

A) and this information is summarised in

Table 1.

Procedure Focus groups were organised by school, so

that the teachers involved in each group had

a shared knowledge of current students on

which to base their discussion. The teachers

met in groups of 2 to 5 participants for 1-1.5

hours, and all sessions were audio recorded,


21

with participants permission. The topic guide was loosely based on the similar

study on parent focus groups by Ozsivadjian

et al. (2012), and is presented in detail in

Table 2. The facilitator(s) took care to let

the discussion develop freely and strive for

minimal interference, unless it was

necessary to clarify issues, or encourage

teachers to further reflect on issues they

might have overlooked. Another goal of

facilitation was to ensure that each

participant had equal opportunities to

express their views.

Data analysis

Audio recordings of the sessions

were transcribed verbatim. These five focus

group transcripts constituted the data for

analysis, and were analysed using the

qualitative procedure of thematic analysis

(Vaughn et al., 1996). Firstly, key themes

were identified within the data that related

to the categories used in the topic guide and

the transcripts were reviewed to identify

consistently emerging sub-themes within

each of the predefined categories that

surfaced in the discussion. Secondly,

specific units of information (phrases and

sentences) were coded according to

category and sub-theme headings. Efforts

were made to ensure that category and sub-

theme headings could parsimoniously

accommodate all the relevant units of

information. Thirdly, these codes and

categories were reviewed with another

researcher as a check for clarity and

agreement, and transcripts were double-

coded between the author and two other

researchers who were blind to the authors codes. A minimum of 91% agreement was

reached, reflecting the strong consistency in

approach, and reliable interpretation of the

data.

Table 1.

Characteristics of teacher-participants in the present study

Characteristics Participants (n = 15) Total

Gender Female 14

Male 1

Age

24 years old 3

25 35 years old 4

36 46 years old 5

47 years old 3

Role

Teacher 12

Senior teacher/Department

Head 2

Psychologist 1

Qualifications (in psychology/

special education)

Bachelors Degree 5

Diploma 7

Postgraduate 3

Specialist Training Courses 14

Years of teaching experience

(overall)

Mean: 10.4 years;

Range: 1-30 years

Years of teaching experience

with students with ASD

Mean: 5.9 years;

Range: 1-14 years


22

Table 2.

Focus Group Topic Guide

Topic Question

Triggers of anxiety 1. What are some situations in which your students with ASD become anxious?

Signs of anxiety:

- Behavioural - Cognitive - Somatic

How easily is anxiety

recognised?

2. How do you know/how can you tell when your students are

anxious?

a. What are the behavioural signs that your students are anxious?

b. Do they report any thoughts associated with their anxiety?

c. Do your students have somatic problems associated with their anxiety?

3. Do you think that someone who didnt know your student well know that they were getting anxious? Why/why not?

Strategies and anxiety

management

4. What strategies are used when your students are anxious?

a. What strategies do you use in the classroom to manage your students anxiety?

b. What strategies do you observe the students using to cope with their anxiety, if any? Are there any strategies

that seem to work more/less well?

c. c. Does the school have any strategies/interventions to manage anxiety?

Comparisons between

typically developing

children and children

with ASD in

mainstream schools

5. What is different about your students anxiety compared to anxiety of children without ASD?

6. Do children with ASD attending mainstream schools

experience similar or different types of anxiety difficulties

compared to their peers in special schools? (If teachers have had

experience teaching in mainstream schools)

Impact of anxiety 7. What do you think is the impact of childrens with ASD anxiety in:

a. Their life in school and learning? b. His/her classmates c. The progress of your teaching

8. Do your students avoid any situations/people/settings because

of their anxiety? Do they seek reassurance from you or others

about their anxieties?

Parent-related issues 9. How well do parents work with teachers in communicating and managing their childs anxiety?

Results

Overall, the focus groups generated

rich information and a number of themes

relating to anxiety in low-functioning

children with ASD in the school setting

emerged that were highly consistent across

focus groups. This consistency is reflected

in the data below in the No. of interviews


23

column, which indicates the number of

groups in which the same themes were

mentioned at least one. Percentages of total

responses have also been calculated to

reflect the distribution and proportion of the

themes that emerged across focus groups, to

shed light on which may be considered

more common or more relevant for the ASD

population. These percentages were

calculated by first coding taking the number

of units/sets of comments emitted in

response to each theme and dividing it by

the total number of units emitted in response

to the category to which that theme

belonged. For example, 40 units/sets of

comments were related to changes as

triggers of anxiety, out of a total of 118

units/sets of comments, which therefore

yielded a 33.9% response rate of comments

about triggers of anxiety relating to change

(Table 3). This approach to summarizing the

data alongside qualitative presentations has

been used in other studies employing

similar methodology, such as Frederickson,

Dunsmuir, Lang, & Monsen (2004), and is

useful in showing the consistency of data

and proportion of responses given that are

associated with each specific theme.

Analysis of the focus group

transcripts is reported in the tables below,

alongside illustrations of the codes within

categories. A more in-depth examination of

resultant themes and codes are included in

Appendix B, C and D.

Table 3.

Triggers of anxiety Types of triggers Number of responses

(%)

Number of focus

groups Examples

Change

40 (33.9%) 5

Disruption of routine, change of

location or route, new person,

new environment

Aversive sensory

experiences 23 (19.5%) 5 Loud noises, visual overload

Performance

demands and high

expectations 13 (11.0%) 5

Receiving negative feedback,

answering a question wrongly,

pressure to behave normally

Social/Communica

tion challenges 14 (11.8%) 4

Difficulty initiating interaction,

bullying, teasing, not

understanding someone elses intentions

Specific fears and

worries 13 (11.0%) 4 Of a specific location, e.g. the

library, of a person

Being prevented

from engaging in

stereotyped

repetitive

behaviours and

interests/activities

11 (9.3%) 4

Not being allowed to touch a

preferred object, or watch a

television scene on repeat

Delayed reactions

to earlier

experiences of

anxiety

4 (3.4%) 3

No immediate trigger, childs behaviour is instead an effect of

a trigger from home, from the

day/night before

Triggers of anxiety Within the school setting and according to

teachers experiences, a variety of key themes emerged within this category of

triggers of anxiety (see Table 3). All of the

responses given in the focus groups could

be classified as triggers relating to change;

performance-related triggers; triggers

concerning sensory issues; triggers arising

from social and communication deficits;

specific fears and worries; being disrupted

from engaging in fixations and obsessions;

and triggers from home or a past event that

only manifested after a delay.

Table 4.

Presentation of anxiety

Signs of anxiety

Behavioural: Number of

responses (%)

Number of

interviews Examples

Challenging

behaviours 38 (27.9%) 5

Temper tantrums, hitting,

screaming, aggression, crying,

jumping

- Arousal

(increase in

behaviours) 9 (6.6%) 3

Intensified behaviours, like

hitting themselves more, or

singing faster and more loudly

than usual

Avoidance/escape 21 (15.4%) 5

Running away, avoiding

trigger, zoning out

Sensory behaviours

18 (13.2%) 5

Self-stimulatory behaviours i.e.

tapping, flapping, biting shirt

collar

Repetitive behaviours 11 (8.1%) 4

Asking questions repeatedly,

checking behaviours

Anxious facial

expressions and body

language

11 (8.1%) 4 Frowning, looking tense

Other socially

inappropriate or out-

of-context behaviours

1 (0.7%) 1 Laughing, even though

inappropriate for the situation

Total = 80%

Expressing thoughts and emotions

Verbal

15 (11.0%) 5

Telling teachers their

feelings or identifying

the source of anxiety

Non-verbal

7 (5.2%) 4

Using picture cards,

gestures and drawing to

indicate thoughts and

feelings

Total = 16.2%

Somatic/Physical

Toileting

2 (1.5%) 2

Increased levels of

bowel movement and

urination

Other physical/somatic

signs of anxiety 3 (2.2%) 3

Sweaty palms, overall

body muscle tension,

stomach aches

Total = 3.7%

Presentation/Signs of anxiety

Indicators/signs of anxiety were

separated into three main categories, before

being sub-divided into specific codes (see

Table 4). These categories comprise of

behavioural signs of anxiety, the expression

of thoughts and emotions on the childs part, and also somatic/physical indicators of

anxiety according to cognitive behavioural

models of anxiety (Lang, 1968; Beidel &

Turner, 2005).

Strategies to manage anxiety

Strategies of coping with anxiety were

categorised into child, teacher, and school,

depending on who initiated the use of each

strategy (see Tables 5, 6 and 7).

Table 5.

Child-initiated strategies for coping with anxiety

Childrens strategies

Number of

responses (%)

Number of

interviews

Examples

Challenging

behaviours (fight)

7 (12.5%) 2 Physical struggle, fighting with

teachers

Avoidance (flight) 12 (21.4%) 5 Running away from the trigger,

requesting for timeout periods,

covering ears or eyes

Seeking help or

reassurance

11 (19.6%) 5 Approaching teachers for help or

comfort

Repetitive

behaviours and

actions

9 (16.1%) 3 Echolalia, checking behaviours,

repeating songs or verbal scripts

- Self-

reassurance

7 (12.5%) 3 Verbally calming themselves, i.e. its gonna be okay repeatedly

Sensory behaviours 6 (10.7%) 4 Tapping, flapping, making funny

sounds, biting shirt collar

Use of previously

taught strategies

4 (7.1%) 3 Engaging in coping techniques that had

been previously taught, i.e.

independently requesting for time out,

counting

Discussion

The teacher focus groups generated

a holistic, clinically relevant picture of

comorbid ASD and anxiety in the school

context, for a predominantly low-

functioning group of children and young

people aged 6 to 18 years old, lending some

theoretical evidence towards ASD-specific

and non-specific signs and triggers of

anxiety and generating a number of

implications towards the clinical assessment

of anxiety in children and young people

with ASD.

Specifically, the most consistently

reported triggers were changes and

disruption of routines, sensory issues,

performance/expectations,

social/communication difficulties, specific

fears and worries and being prevented from

engaging in stereotyped interests and

activities. With respect to signs of anxiety,

behavioural signs were most significant and

observable, especially challenging

behaviours, avoidance/escape, sensory

behaviours, repetitive behaviours, and

anxious facial expressions (though most

teachers said experience with the child was

required to recognise this). This

constellation of findings obtained in this

study mirrors that of Ozsivadjian et al.s (2012) research with parental accounts of

higher-functioning children and young

people with ASD, and further extends it

with teacher perspectives and lower-

functioning children.


26

Table 6.

Teacher-initiated strategies of managing students anxiety

Teachers strategies

Number of

responses (%)

Number of

interviews

Examples

Timely intervention

22 (24.4%) 5

Taking action at appropriate times,

i.e. choosing the right time to

approach the child and calm him or

her down, prevention, preparing the

child for an anticipated event

Teaching self-calming

strategies

14 (15.6%) 5

Teaching students coping techniques

like breathing and counting exercises,

or how to recognise and better

regulate their feelings related to

anxiety using assorted

scrapbooks/collections of pictures and

drawings of different thoughts and

feelings, use of social stories

Removal/Timeout

11 (12.2%) 4

Removing the trigger of anxiety, or

removing the child from the anxiety-

inducing situation

Distraction 7 (7.8%) 4

Distracting the child with a preferred

object or activity

Exposure

7 (7.8%) 3

Gradually exposing the child to

known trigger of anxiety with the aim

of overcoming anxious feelings,

reinforcing progress

Supervision without

interference or

intervention

6 (6.7%) 4

Do nothing, i.e. allowing the childs anxious behaviour to run its course

without interfering

Offering verbal prompts

6 (6.7%) 4

Asking the child you need help? to encourage them to express their needs

better

Seeking additional help

6 (6.7%) 5

Calling for external help, i.e. other

teachers, teaching assistants, or

school psychologists

Other preventative

strategies 10 (11.1%) 5

Maintaining a calm classroom

atmosphere, use of visual aides,

providing high levels of structure

ASD-specific Triggers and Signs of

Anxiety

Teachers identified the ASD-specific

triggers of changes (unpredictability,

disruptions to routine), aversive sensory

experiences, social difficulties related to

communication and being prevented from

engaging in stereotyped interests and

activities. These triggers reflect common

ASD-related difficulties in sensory

sensitivities, communication difficulties and

perspective taking, as well as inflexibility

and the insistence of sameness in terms of

processing style (Tantam, 2012; Spiker,

Enjey Lin, Van Dyke, & Wood, 2011;

Wood & Gadow, 2010).

One key theme that appeared across

groups regarding ASD-specific signs of

anxiety were the childrens difficulty in communicating anxiety clearly via verbal

means, especially during times of

heightened distress. While this difficulty


27

might also apply to typically developing

children, it may be even more significant for

children with ASD given their existing

challenges with language, social

communication, and understanding and

expressing thoughts and emotions. This

meant that teachers often had to make

inferences about triggers and their students dominant emotions via behavioural signals

and prior knowledge about their students idiosyncrasies. Teachers also consistently

gave comments concerning sensory and

repetitive behaviours as indicators of

anxiety, which referred to a range of

behaviours such as echolalia, repetitive

flapping, persistent checking behaviours and

reassurance-seeking behaviours, which

sometimes occurred regularly but grew

more intense during periods of anxiety.

Additionally, the qualitative focus

group results suggest that it might be

important to note how non-ASD-specific

triggers may be presented in ASD-specific

ways. For example, though high

expectations and performance demands do

not appear to be triggers of anxiety specific

to ASD, the nature of the comments

provided by the teachers show that the high

levels of performance/task-based anxiety

exhibited by their students may be

associated with perfectionism and

manifested in terms of obsessive

behaviours, such as intense levels of

repetitive questioning and checking,

requiring a teacher to guide the students work at every step, as the students would

often react with high levels of anxiety,

negative affectivity and challenging

behaviour to simple performance feedback

such as the marking of a cross on a

worksheet. According to the teachers in the

focus groups, these behaviours were

frequently and consistently observed in their

students with ASD, but might not be

observed in the general population in a

similar form or intensity. As such, in

developing an understanding of the atypical

presentation of anxiety in children with

ASD and in using standardized, non-ASD

specific questionnaires and checklists for

assessment, care should be taken to ensure

that details like these are not lost to

categorical simplicity.

Table 7.

School-initiated strategies to manage students anxiety

Relevance to Wood & Gadows theoretical model

The findings from this study largely

provide some ecological validity to Wood

and Gadows (2010) theoretical model specifically, teachers identified consistent

and frequently emerging themes relating to

aversive sensory experiences, prevention of

stereotyped/repetitive behaviours and

social/communication challenges, which

appear to map directly onto similar

categories in Wood & Gadows (2010) model (see Figure 1 in Introduction).

Teachers in the focus groups also identified

School strategies Number of

responses (%)

Number of

interviews

Examples

Structural facilities 7 (50%) 3

Calm-down rooms, multi-sensory rooms,

creating manageable spaces in the classroom

Special programs or

curriculum 5 (35.7%) 2

Targeted intervention sessions to tackle

anxiety difficulties, teaching and reinforcing

coping techniques as part of the curriculum

Ensuring familiarity

and structure in every

day school life

2 (14.3%) 2

Keeping a low teacher-student ratio, ensuring

that students are familiar with teacher-

chaperones on school outings


28

similar effects of ASD-related stressors namely arousal, challenging behaviour, and

also commented on the pervasive impact on

their students lives and learning, all of which map onto Wood and Gadows proposed effect factors of increased autism

symptom severity, behavioural problems,

and personal distress/reduced quality of life.

However, Wood and Gadows heavy social component of the proposed

theoretical model (two out of four ASD-

related stressors; see Figure 1 in

Introduction) did not fit entirely well with

the focus group reports. For example, while

the teachers did comment on peer rejection

and victimization related to autism

symptoms, these descriptions were strictly

limited to their knowledge of a few higher

functioning students that had transferred out

of the Special Education schools to

mainstream schools. Furthermore, though

Wood and Gadow highlighted the

unpredictability of social encounters as an

ASD-related stressor, the teachers in the

focus group reports highlighted changes and

unpredictability across all aspects of life as

potential stressors, in addition to

unpredictability arising from social-

communication challenges. In addition,

Wood and Gadow have proposed that ASD

symptoms could potentially generate stress

for individuals when symptom expression,

in the form of inappropriate repetitive

behaviours for example, is in conflict with

social expectations and demands, and it is

this pressure for social conformity that

brings about anxiety (Wood & Gadow,

2010). While this was also discussed to

some extent in the focus groups, the

teachers felt that anxiety provoked by high

expectations and demands was also

extremely relevant to school-based task

performance and an obsessive need to

complete tasks just right. Greenaway & Howlin (2010) further support this concept,

and demonstrated that dysfunctional

attitudes and perfectionism, which is related

to cognitive inflexibility, is pertinent to

children with ASD.

As such, while the focus group

findings do provide some ecological validity

for almost all the factors proposed by Wood

and Gadow (2010), the focus group findings

also suggest that there is a need to expand

Wood and Gadows theoretical conceptualisation of anxiety to include

ASD-specific triggers of anxiety like

changes, and to widen the scope of high

expectations and demands from social

expectations alone, to include task-based

performance anxiety and perfectionism.

Alternatively, the potential inclusion of

these additional factors may also imply that

Wood and Gadows (2010) model may serve as a better fit for high-functioning

children rather than low-functioning

children, and that it could possibly be

expanded to explore and include factors

relevant to the experience and

phenomenology of anxiety in ASD across

the entire spectrum of functioning and

severity.

Limitations Before expanding on the

implications of the findings, it is first

important to note that they need to be

interpreted in light of certain limitations.

One limitation is the small sample size,

which may not be representative enough of

the entire teacher population of ASD

schools. Secondly, as this was an

exploratory study into teachers perspectives about ASD and anxiety, there

was a lack of detailed information about the

students themselves, such as demographics,

verbal ability, level of cognitive functioning

and adaptive skills. However, based on the

admission criteria of each of the schools, as

well as the teachers descriptions of their students during the discussions, it is likely

that the findings of this study can be

tentatively generalized to children in the

lower-functioning end of the ASD

spectrum. Furthermore, although the sample


29

might be limited in terms of size and

representativeness, the qualitative study

carried out provided rich, detailed

information that cannot be obtained via

large qualitative studies, and efforts were

made to recruit teachers from a range of

schools, rather than just one school, and the

teachers that participated came from diverse

backgrounds in terms of years of experience

and educational qualifications.

Implications for assessing anxiety in

children and youth with ASD

Having demonstrated some evidence

towards an atypical presentation of anxiety

in ASD that is markedly different in terms

of triggers and signs of anxiety, the present

findings provide further insight into the

inadequacies of using standardized

measures of anxiety that have been

developed for the general population with

children with ASD. As such, these findings,

along with Ozsivadjian et al. (2012), point

towards the usefulness of the development

of an autism-specific or an autism-sensitive

assessment measure/procedure at the very

least, and it remains possible that a number

of anxiety difficulties have not been

adequately identified and assessed.

Implications for clinical practice

These focus group findings also

provide ecological evidence for the use of

cognitive-behavioural therapy (CBT)

programs for this population of low-

functioning children and young people with

ASD, but with ASD-specific modifications

(Davis, May, & Whiting, 2011; Lang,

Regester, Lauderdale, Ashbaugh, & Haring,

2010). Specifically, potential ASD

modifications that could work with children

with lower levels of functioning would de-

emphasize the traditional mechanism of

creating a change in cognition, and step up

focus on behaviour modifications instead, as

the focus group findings regarding signs of

anxiety show that anxiety in this population

is largely expressed behaviourally. In

addition, special attention should be paid to

increasing the use of structured, simple

visual aids and tools, as well as strategies to

help students better identify their emotions

and prepare themselves in order to cope in

complex social scenarios. At the same time,

environmental modifications are very

important and need to be made to reduce

levels of anxiety in everyday life, such as

attempts to introduce a certain amount of

structure to avoid unnecessary changes or

disruptions to routine, and reducing the

childs exposure to frequent aversive sensory experiences as well as allowing

some limited time for the children to engage

in their repetitive behaviours and interests

(Howlin, 1997)

Implications for educators and schools

Besides shedding light on the nature

of anxiety in children and young people

with ASD, these teachers focus groups also provided a vivid and detailed picture of the

challenges that Special Education schools

currently face when it comes to

understanding and managing anxiety in their

students.

Firstly, it was observed via the

nature of the teachers quotes, examples and discussions that most of them had some

trouble disentangling frustration and anger

from anxiety in their students. Most used

broader terms like upset or referred to behavioural issues, and often required

clarification from the facilitators of the

focus groups to ensure that the groups were

on topic (anxiety) and did not veer off into

another emotion that is related but distinct

from anxiety, such as anger. For example,

one teacher stated we dont use words like anxiety, just that they are having a bad day,

or not feeling too good. From a practical standpoint, this is understandable as it could

be easier for teachers to use layman terms.

However, it is possible that a concerted

effort to identify and understand anxiety

would be beneficial for themselves as

educators, and for their students as well. By


30

being able to more effectively recognise it

in their students, instead of casting their

students behaviour off as merely being

upset or having a bad day, teachers and schools might be able to gain a more

holistic view of the conditions that afflict

their students, and implement more targeted

coping strategies and treatment options

instead.

Recommendations for future research

Given these additional findings

towards the atypical presentation of anxiety

as observed in the ASD population, the

collective literature could be used to pilot

ASD-specific assessments of anxiety and

explore whether reported rates or types of

anxiety are different when such tools are

used as compared to traditional existing

scales for typically developing children.

Future research could also focus on

replicating the study with larger groups, as

well as with teachers from Special

Education schools with a higher-functioning

student body, or with children with ASD in

mainstream schools, in order to yield a more

descriptive foundational basis across the

educational landscape and autism spectrum.

Summary and Conclusions

In sum, besides being the first of its

kind to tap into the differential views and

experiences of teachers, as a supplement to

parent informants, this study has provided a

holistic picture of anxiety and ASD in the

Special Education school setting in

Singapore, with a special focus on children

and young people on the lower functioning

end of the autism spectrum. By harvesting

rich, detailed perspectives and data via a

qualitative focus group methodology, the

findings reflected consistent patterns of

themes and frequencies regarding triggers,

indicators and strategies for coping with

anxiety, and has lent ecological validity to

existing hypothesized models of anxiety in

ASD, while also suggesting the addition of

the significant themes of unexpected

changes and task-based performance

anxiety as ASD-related stressors and

triggers of anxiety, and a broadening of

Wood & Gadows (2010) theoretical model to include factors relating to low

functioning children with ASD.

By contributing towards a better

theoretical understanding of anxiety

difficulties ASD, it is also hoped that a

clearer, more holistic picture of anxiety can

in turn play a significant role in the

development of better assessment and

measurement techniques that will either be

targeted at, or specific to the ASD

population. This can then potentially

enhance the way clinical practitioners and

educators manage these additional

difficulties that pervade the daily wellbeing

of children with ASD and their families,

thereby contributing to a necessary and

significant advancement in the way that

anxiety is theoretically conceptualised,

assessed, treated and managed across the

range of professional settings.

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