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STUDENT RESEARCH AWARD 2012
Book of Students Articles
20 October, 2012
Singapore
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SRA 2012 Book of Students Articles
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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
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SRA 2012 Book of Students Articles
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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
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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
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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
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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
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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
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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.
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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
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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.
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The Effects of Bilateral Eye Movement and Presentation Modality
on Memory
Lim Aik Meng
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.
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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
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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
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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
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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
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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-
4105.17.2.221
Christman, S. D., Propper, R. E., & Dion,
A. (2004).Increased interhemispheric
interaction is associated with decreased
false memories in a verbal converging
semantic associates paradigm. Brain &
Cognition, 56, 313-319. doi:
10.1016/j.bandc.2004.08.005
Gallo, D. A., McDermott, K. B., Percer, J.
M., & Roediger, H. L., III (2001).
Modality effects in false recall and false
recognition. Journal of Experimental
Psychology: Learning, Memory, and
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Cognition, 27, 339-353.
doi:10.1037/0278-7393.27.2.339
Kellogg, R. T. (2001). Presentation
modality and mode of recall in verbal
false memory. Journal of Experimental
Psychology:Learning,Memory,and
Cognition, 27, 913-919. doi:
10.1037/0278-7393.27.4.913
Lee, Y. S., Chiang, W. C, & Hung, H. C.
(2008). Lexical association and false
memory for words in two
cultures. Journal of Psycholinguistic
Research, 37, 49-58. doi:
10.1007/s10936-007-9058-7
Parker, A., & Dagnall, N. (2007). Effects of
bilateral eye movements on gist based
false recognition in the DRM paradigm.
Brain and Cognition, 63, 221-225.
doi: 10.1016/j.bandc.2006.08.005
Parker, A., Relph, S., & Dagnall, N. (2008).
Effects of bilateral eye movements on
the retrieval of item, associative, and
contextual
information. Neuropsychology, 22, 136-
145. doi:10.1037/0894-4105.22.1.136
Pierce, B. H., Gallo, D. A., Weiss, J. A., &
Schacter, D. L. (2005). The modality
effect in false recognition: Evidence for
test-based monitoring. Memory &
Cognition, 33,
1407-1413. doi: 10.3758/BF03193373
Rajaram,S. (1993). Remembering and
knowing: Two means of access to the
personal past. Memory & Cognition, 21,
89-102. doi: 10.3758/BF03211168
Roediger, H. L., III, & McDermott, K. B.
(1995). Creating false memories:
Remembering words not present in lists.
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Learning, Memory, and Cognition, 21,
803-814. doi: 10.1037/0278-
7393.21.4.803
Smith, R. E., & Hunt, R. (1998).
Presentation modality affects false
memory. Psychonomic Bulletin &
Review, 5, 710-715. doi:
10.3758/BF03208850
Stadler, M. A., Roediger, H. L., III, &
McDermott, K. B. (1999). Norm for
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Memory & Cognition,27,494-500.
doi: 10.3758/BF03211543
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SRA 2012 Book of Students Articles
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
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
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SRA 2012 Book of Students Articles
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,
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SRA 2012 Book of Students Articles
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
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SRA 2012 Book of Students Articles
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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
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SRA 2012 Book of Students Articles
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.
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SRA 2012 Book of Students Articles
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
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SRA 2012 Book of Students Articles
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
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SRA 2012 Book of Students Articles
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
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SRA 2012 Book of Students Articles
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
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SRA 2012 Book of Students Articles
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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