DTR 1 (1) pp.

21–39 Intellect Limited 2015

Drama Therapy Review

Volume 1 Number 1
© 2015 Intellect Ltd Article. English language. doi: 10.1386/dtr.1.1.21_1

Miranda D’Amico, Corinne Lalonde and Stephen Snow

Concordia University

Evaluating the efficacy of

drama therapy in teaching
social skills to children with
Autism Spectrum Disorders

Abstract Keywords
This article reviews a year-long study at the Centre for the Arts in Human drama therapy
Development at Concordia University (Montreal, Canada). It analyses the results of autism spectrum
a specialized adaptation of drama therapy for a group of preadolescent children with disorder
high-functioning Autism Spectrum Disorders. The procedure aimed at improving social skills
social skills and problem behaviours. Statistical results of the study are promising in problem behaviours
demonstrating the efficacy of drama therapy in this domain. effective treatment

Introduction
Autism Spectrum Disorders (ASD) are defined as a distinct group of complex
neurodevelopmental conditions that are characterized by pervasive impair-
ments in communication, social interaction skills, restricted and stereo-
typed patterns of behaviours, interests and activities (APA 2013). Although
the term spectrum communicates the variability in the severity of symp-
toms between individuals with these conditions, many children with ASD
experience marked deficits in fundamental social skills that impede peer

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Miranda D’Amico | Corinne Lalonde | Stephen Snow

interactions and relationships (Mitchell et al. 2010). Indeed, several research-

ers have reported that social skill deficits are considered to be the most criti-
cal element in the definition of these disorders (DeRosier et al. 2011; Matson,
Matson and Rivet 2007).
In essence, children with ASD experience challenges in initiating, negotiat-
ing and maintaining social interactions; using and interpreting both nonverbal
and verbal social cues; and sharing affective experiences with others (Barnhill
et al. 2002; DeRosier et al. 2011; Malchiodi 2005). These social skill difficulties
are particularly problematic during adolescence, when peer relationships and
social network affiliations are especially important and increasingly complex.
As the individual with ASD matures, these limitations may lead to increased
incidences of social isolation, peer rejection, bullying, anxiety and depres-
sion over the course of their lives (Mitchell et al. 2010). Thus, it is essential
that these children be provided with effective interventions and support that
address their specific social needs.
Therefore, the purpose of this project was to implement a therapeutic
intervention involving drama therapy to evaluate its efficacy on the social
skills and problem behaviours of a group of preadolescent children with ASD.
Specifically, to provide a therapeutic setting for them to discuss some of the
difficulties they experienced in their social interactions, whereby they had the
opportunity to develop a better understanding of appropriate ways to respond
in social situations. The idea was that by employing drama therapy techniques
in a group context, the children were able to develop and practice social skills,
experience positive social interactions, and manage their problem behaviours
with other individuals who shared similar experiences.

Literature review
Autism Spectrum Disorders
The results of decades of research on individuals with ASD have revealed a
dramatic increase in the prevalence of these conditions (Levy, Kim and Olive
2006). Indeed, the Centre for Disease Control and Prevention (CDC) estimates
that about one in every 68 children in the United States is identified with
ASD, and that males are five times more likely to be diagnosed compared to
females (CDC 2014). As previously stated, social skill limitations are consid-
ered to be one of the defining characteristics of ASD. Research has shown that
social skill difficulties remain an area of vulnerability even for the most cogni-
tively able individuals on the autism spectrum (Reichow and Volkmar 2010).
As early as preschool, children with ASD demonstrate social skill deficits that
distinguish them from their typically developing peers. As these individuals
enter elementary school, they may have substantial relational problems such
as difficulties initiating and maintaining friendships with same-aged peers
(Reichow and Volkmar 2010). In early adolescence, individuals with ASD may
continue to show evidence of the same social difficulties experienced in child-
hood, which places them at risk for rejection and victimization by their peer
group (Barnhill et al. 2002; Chamberlain, Kasari and Rotheram-Fuller 2007;
Rao, Beidel and Murray 2008). This is a troubling reality, especially consider-
ing that the presence of social skill impairments may lead to social isolation,
psychopathology and poor academic achievement (Attwood 2007; DeRosier
et al. 2011; Matson, Matson and Rivet 2007).
Moreover, researchers contend that individuals with ASD do not simply
outgrow their social skills deficits; rather these difficulties persist into their

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 Evaluating the efficacy of drama therapy …

adult life and may continue to negatively impact the individual’s social
functioning (DeRosier et al. 2011; Rao, Beidel and Murray 2008). For these
reasons, this project aimed to address the areas of social difficulty presented
by a group of preadolescent children with high-functioning ASD. These chil-
dren were enrolled in the last two years of elementary school and as such,
were approaching adolescence. The research team believed that social skill
interventions implemented during this critical period would be an appropri-
ate way to prevent or attenuate subsequent social dysfunction among these
individuals. Thus, identifying and implementing effective interventions that
address the social needs of individuals with ASD appears to be important in
overcoming many of the long-term and pervasive limitations associated with
these disorders (DeRosier et al. 2011).

Social skill interventions

The literature reveals that social skill interventions employed with children
with ASD typically attempt to break down complex social behaviours into
stages determined by chronological and developmental age levels (Cappadocia
and Weiss 2011). These behaviours often include getting acquainted, making
friends, engaging in conversation, developing empathy and self-regulation
skills, as well as conflict management (Cappadocia and Weiss 2011). To accom-
plish this, researchers have traditionally used behavioural and social-learning
strategies in both individual and group social skill training programmes with
children with ASD. Some of the most popular techniques include using writ-
ten scripts, such as ‘Social stories’ (Gray 1998), that explain the nuances of
common social situations (i.e. such as making new friends at school and join-
ing in group games) while providing assistance for how to act in these circum-
stances; teaching theory of mind and other interpersonal perspective-taking
skills through explicit and systematic instruction (Ozonoff and Miller 1995);
training pivotal behaviours and responses (i.e. responding to multiple social
cues) through instruction, modelling and reinforcement (Koegel, Koegel
and Schreibman 1991); and finally using the principles of Applied Behaviour
Analysis (ABA) to teach functional skills in order to improve various socially
acceptable behaviours (Smith and Eikeseth 2011).
Barry and colleagues (2003) examined the efficacy of a group social skills
intervention with four 6–9-year-old children with high-functioning ASD.
A curriculum was developed and implemented to teach specific social skills
during an eight-week group programme in an outpatient clinic. The compo-
nents of these sessions included warm-up activities that promoted interac-
tions among the group members; a didactic component during which new
skills were taught using specific social scripts (i.e. a script for greeting); role
play and active practice of newly acquired skills while using the scripts (i.e.
act out with puppets); and an assessment period wherein each child engaged
in two five-minute play sessions with typically developing peers to assess
the generalization of the skills previously learned. Overall, this intervention
was effective in increasing the social behaviours of children with ASD when
targeted skills (i.e. greeting, play, composite initiating and composite respond-
ing skills) were measured during interactions with trained typical peers (Barry
et al. 2003). In another study, DeRosier and colleagues (2011) investigated
the effectiveness of a group social skills intervention known as Social Skills
Group Intervention-High-Functioning Autism (S.S.GRIN-HFA) on the social
behaviours of 55 8–12-year-old children with high-functioning ASD. This

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Miranda D’Amico | Corinne Lalonde | Stephen Snow

fifteen-session group programme included didactic instruction combined with

active practice (i.e. role-playing and modelling) of a variety of social skills. In
particular, three modules were used and focused on social abilities related to
communication (i.e. verbal and nonverbal); working with others (i.e. perspec-
tive taking and cooperation); and friendship skills (i.e. social problem-solving)
that were developed and reinforced over a period of several sessions to facili-
tate learning both within and outside of the programme.
The authors investigated the effectiveness of the treatment condition
(S.S.GRIN-HFA) on the social skills outcomes by comparing these with the
outcomes observed in a group of 8–12-year-old children participating in the
control condition (S.S.GRIN) designed for same-aged typically develop-
ing peers (DeRosier et al. 2011). An analysis of the Social Responsiveness
Scale (SRS; Constantino and Gruber 2005) and the Social Self-Efficacy Scale
(Ollendick and Schmidt 1987) revealed more positive changes for children
who participated in the S.S.GRIN-HFA compared to those in the control
condition. Indeed, the children in the treatment condition significantly
improved in areas of social awareness, motivation for social interaction,
social communication skills and unusual mannerisms associated with ASD
(DeRosier et al. 2011).
These studies provide support in using group social skill interventions to
improve a variety of interpersonal skills (i.e. engaging in conversations, read-
ing and interpreting body language and making friends) among children and
adolescents with high-functioning ASD. In addition, it has been reported that
these interventions are an effective way of helping these individuals form
friendships by teaching them social skills in groups (Epp 2008). As the body
of work in social skill interventions has grown considerably over the last few
decades, there has also been a corresponding increased interest in therapeu-
tic interventions that involve creative arts therapies aimed at addressing the
social difficulties experienced by children with ASD. Several researchers have
reported that creative arts therapies are particularly appropriate as some chil-
dren with ASD are concrete and visual thinkers (Epp 2008). In this sense,
creative arts therapies offer these individuals the opportunity to solve social
problems visually; indeed, they may learn to deal with their social skill limi-
tations, feelings of social anxiety and over arousal in social situations while
developing strategies to manage their problem behaviours in the therapeutic
setting (Epp 2008).

Drama-based interventions in a non-drama therapy framework

Outside the field of drama therapy, several researchers have found posi-
tive effects of drama as a tool for the social development of individuals with
ASD. Corbett and colleagues (2011) investigated the efficacy of the inter-
vention programme, the Social Emotional NeuroScience Endocrinology
(SENSE) Theatre with eight individuals with ASD and eight typically devel-
oping children. The purpose of this intervention was to improve upon
social and emotional functioning while reducing stress among the 6–17-
year-old participants. The SENSE programme used a behavioural interven-
tion paradigm in combination with theatrical techniques, video modelling
and social skills training. The programme incorporated a musical based on
Disney’s The Jungle Book, which was segmented into specific components
and rehearsed over two hours for a period of three months. Each partici-
pant was paired with a typically developing child who served as the child’s

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peer model (Corbett et al. 2011). The results revealed that the children with
ASD showed improvements in social perception skills in response to the
treatment. The authors also noted increased empathy, social referencing and
communication among the typically developing children toward the chil-
dren with ASD at the end of the intervention phase. The study also demon-
strated that the therapeutic process with drama and theatre activities led
to a reduction in anxiety and stress among the participants involved in the
SENSE programme (Corbett et al. 2011).
In addition, Lerner, Mikami and Levine (2011) evaluated an interven-
tion called Socio-Dramatic Affective-Relational Intervention (SDARI), a
group-based programme with three components: (1) a performance-based
social skills curriculum with affectively engaging improvisation games and
dramatic training, (2) a focus on building relationships between the children
and staff members to reinforce social interaction, and (3) use of age-appropri-
ate motivators so that participants continue to use the skills in other settings.
Seventeen individuals aged 11–17-years-old with Asperger’s syndrome partic-
ipated in the study. The SDARI intervention used in this study, known as the
‘Spotlight Summer’ programme, was conducted for five hours over the course
of six weeks. The SDARI curriculum included activities based on variations
of dramatic improvisation-based games (i.e. ‘Gibberish Game’, ‘Working
Together Day’ and ‘Emotion Ball’) that focus on training participants to
attend to specific nonverbal reciprocal interaction cues (Lerner, Mikami and
Levine 2011). The authors found that the individuals participating in SDARI
displayed gains in social assertion and the ability to detect emotions from
baseline to the end of the programme relative to the individuals who did not
participate in the SDARI programme (Lerner, Mikami and Levine 2011). In
addition, the treatment group continued to show maintenance in gains rela-
tive to the comparison group when data were considered from baseline to six
weeks post-treatment in social assertion and the ability to detect emotions, as
well as a reduction in social problems.

Drama therapy as an effective intervention

for individuals with ASD
Creative arts therapies such as drama therapy have special properties
regarded by professionals as effective in helping individuals with ASD learn
and develop beyond their perceived limitations and as such, are regarded
as viable treatment methods with this particular population (Martin 2009).
But, what are the unique aspects of drama therapy, per se, as differentiated
from other drama-based interventions, which make it particularly effective
for individuals with ASD? According to the North American Drama Therapy
Association (NADTA 2014), drama therapy is the use of drama and theatre
processes to achieve therapeutic goals. It is an active process that provides
a unique context for participants to share their stories, solve problems and
express their thoughts and feelings (NADTA 2014). Several scholars in the
field have emphasized the potential that drama therapy has for helping
children with ASD. They argue that drama can help build social compe-
tence by teaching these children to better understand social narratives that
arise from interactions with others (Tytherleigh and Karkou 2010). Other
researchers have argued that drama therapy may also be useful in develop-
ing make-believe and imaginative activity, shared meaning, flexible think-
ing and sensitivity to others among children with ASD (Malchiodi 2005).

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Miranda D’Amico | Corinne Lalonde | Stephen Snow

1. See Dramatherapy, Particularly noteworthy in this regard is the recent Special Edition of the
Special issue on
Dramatherapy and
British Journal of Dramatherapy1 (2013) on the practice of drama therapy
Autistic Spectrum with individuals with ASD. Several authors in this issue produce significant
Disorder (35: 1, 2013), research to demonstrate the efficacy of drama therapy in this domain. Many
for a wide-ranging
integration of drama of these studies were also focused on children with ASD. Several of these
therapy literature and authors also looked at the unique properties in drama therapy that make it a
practice. particularly effective intervention for children and young people with ASD.
Frequently, they focused on four major components of drama therapy: (1)
dramatic projection; (2) dramatic reality; (3) role-playing; and (4) storytelling.
The idea of projecting inner experience onto an outer media is ‘at the heart
of all Dramatherapy’ (Jones 1996: 147). Whether projecting the self into a
fairy-tale character or a puppet or a spontaneously created story, the power
of projection is an undeniable factor in the efficacy of drama therapy. As
Andersen-Warren writes:

Dramatic projection used as a form of expression, is an extremely valu-

able tool for dramatherapists who support the ASD client in projecting
their fears or anxieties onto something concrete, so that they may ‘see’ it
from a safe distance which we call an ‘aesthetic distance’.
(Andersen-Warren 2013: 9)

This was very true for our project as will be demonstrated, shortly.
Another important and dynamic construct of drama therapy practice is
what is called dramatic reality. It is a concept, although sometimes expressed
in different terms, that is common to all drama therapy. It designates the
special, liminal, ‘as if’, reality of the drama therapy process. Pendzik goes so
far as to state that ‘the use of dramatic reality for therapeutic purposes can be
considered as the unique contribution of drama therapy to the field of psycho-
therapy’ (2012: 198). It seems to also be very relevant in practice with individ-
uals with ASD. In the ‘Conclusion’ to her article on the use of dramatic reality
as ‘a path for emotional awareness in autism’, Pimpas writes: ‘the concept of
dramatic reality could enhance […] the meaning of self and emotional aware-
ness as well as the link of appropriate cause to a given emotion which is
impaired in autism’ (2013: 62). This was exactly like the experience of the
participants in our project when they worked in the extended dramatization
of an imaginary world, which they collectively created under the guidance of
the drama therapists.
The use of story and storytelling in drama therapy is also of vital impor-
tance. A small-scale study by drama therapists Tytherleigh and Karkou (2010)
examined six weekly sessions of drama therapy with two 11-year-old children
with ASD with the purpose of providing opportunities to build relationships.
The drama therapy sessions were conducted at a school for children with
learning difficulties, wherein, the group met weekly for 30 to 40 minutes. The
authors used a developmental approach based on the embodiment, projec-
tion, role model (EPR) commonly used in drama therapy with people with
learning difficulties. EPR, as developed by Sue Jennings, is a quintessential
model in drama therapy as it combines the three dynamic constructs in its
name. It has been used in many drama therapy training programmes over
the past two decades (Jennings 2012: 177). The sessions began with a story-
telling exercise called ‘Story of the Circle Dance’, used to encourage feelings
of togetherness among group members. This was followed by a group game
with balls to develop social awareness, and then developmental movement

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activities between adult and child to develop trust. The results revealed that
both participants developed symbolic communication, relationships with
group members and the research team, eye contact, spontaneity and creativity.
These changes were also observed outside the sessions in the child’s natural
environment; parents’ reports indicated that their child was more outgo-
ing, was engaging in more social and role-play activities, had an increased
tendency to approach others, and was able to communicate better with others
(Tytherleigh and Karkou 2010).
Role-playing is another core process in drama therapy. This has been
particularly emphasized in the role method developed by Robert Landy who
states ‘Drama therapy is distinct among other forms of psychotherapy in that
it proceeds through role’ (1993:45). It is also a core process that is highly rele-
vant in developing social skills with children and young people with ASD.
Wilmer-Barbrook’s study of adolescents with Asperger’s clearly demonstrates
the value of role-playing to improving social skills:

The elements of an actor’s and audience’s role are both a mirror and
essential component for successful social interaction, where one person
listens, observes the other’s communications and then offers verbal
interaction and feedback when there is a pause. Thus the learners in
their role as the actors and audience can practice developing techniques
for social understanding and successful communication.
(Wilmer-Barbrook 2013: 48)

This is an essentialized expression of the value of role-playing and was a

vital part of the 21-week drama therapy process with the boys at our Centre.
All of these core components of drama therapy are especially affirmed in the
approach developed by Chasen and eloquently delineated in his book, Social
Skills, Emotional Growth, and Drama Therapy: Inspiring Connection on the Autism
Spectrum (Chasen 2011). Chasen utilizes myriad drama and play techniques
involving projective play, improvisation, set-building, movie-making and
stand-up comedy, to name a few. In the 30 sessions described in his book, the
author delineates the implementation of his ‘Process Reflective Enactment’
approach to drama therapy for children with autism. In the end, it may all boil
down to the validity of the creation of a genuine playspace (Johnson 1998) for
the participants. Like dramatic reality, the playspace is a construct of entering a
very different dimension of experience. Likewise, according to drama therapy
theory, one that is absolutely necessary for transformation to take place. As
Chasen writes:

The joyous, exhilarating, intriguing and liberating feeling of fun prompts

a desire to engage and sustain play, the foundation of human develop-
ment, beckoning us to explore and interact with objects and concepts
that project, reflect and expand the essence of who we are. Socialization,
especially from a child’s perspective, makes a more positive impact if
the encounter is fun and playful.
(Chasen 2011: 21)

Chasen confirms the enormous value of the drama therapy playspace for chil-
dren with ASD. All of these studies reveal that drama therapy has unique
properties as an intervention and can be very effective in improving the social
and emotional skills of young people with ASD.

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Miranda D’Amico | Corinne Lalonde | Stephen Snow

Therapeutic intervention
Problem statement
In light of the review provided above, it is clear that effective interventions
are required to meet the needs of children with ASD to become socially
competent individuals, especially as they enter adolescence. In this sense, it is
important to address the social skill deficits of these individuals at this stage
of their development in order to attenuate subsequent dysfunction. Thus, the
aim of this project was to provide a therapeutic intervention that involved
drama therapy as a creative modality to address specific areas of social diffi-
culty and problem behaviours presented by a group of preadolescent chil-
dren with high-functioning ASD. The objectives of the intervention were to
offer various drama-based activities and group processes whereby the chil-
dren were able to develop and practice their social skills and manage their
problem behaviours with similar others. The following section provides details
of the project’s methods, including a report of the participants, the interven-
tion setting, research team members, as well as the measures and procedures
included in the therapeutic interventions with these individuals.

Methods
Participants
The participants in the drama therapy intervention were six 10–12-year-old
children (M = 10.5 years old) diagnosed with an ASD (i.e. Asperger’s syndrome
or High-Functioning Autism and Pervasive Developmental Disorder Not
Otherwise Specified). The participants were considered to be high-functioning
individuals on the spectrum, and as such, they had adequate to good language
skills and were within the ordinary bounds of cognitive development, yet they
had been identified as having social skill difficulties. The children and their
families were on a waiting list for social skill interventions at a social service
centre. Therefore, one of the benefits of this project is that it provided the
children with therapeutic interventions that addressed their social difficulties
while they remained on the waiting list for additional services.
The sample consisted of six male participants attending either regular or
adapted programmes. One child was enrolled in seventh grade, while the
other children were between the 4th and 6th grades. All participants were
screened and interviewed prior to the commencement of the project, and those
children with a history of emotional and behavioural disorders or aggressive
behaviours were excluded from the study. This research project was given
ethical approval by the University Research Office.

Measures
Parents and children were asked to complete the Parent and Student Forms
of the Social Skills Improvement System-Rating Scales (SSIS-RS; Gresham
and Elliott 2008). This scale is a norm-referenced instrument that provides
a comprehensive analysis of children’s social skills and problem behaviours
in reference to typically developing peers, information that was critical to the
planning of therapeutic goals and in the evaluation of the therapeutic inter-
ventions at the end of the project. The SSIS-RS is a revised version of the
SSRS (Gresham and Elliott 1990), a rating scale that has been widely used in
the autism literature as a tool to identify the social and problem behaviours
that were targeted in various interventions. The SSIS-RS was standardized

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using a sample of 4,700 children ensuring that their representative sample

was based on appropriate gender, ethnic, socio-economic and geographic
representations for normative purposes (Gresham and Elliot 2008). The SSRS
has also been used in several studies to examine the efficacy of a variety of
treatment programmes, including social-emotional interventions (Bauminger
2002), social skill interventions with an art therapy component (Epp 2008),
and social skills training to teach theory of mind to children and adolescents
with ASD (Ozonoff and Miller 1995). The research team selected the revised
SSIS-RS as it has several additional features, including updated national
norms, four additional subscales (Communication, Engagement, Bullying
and Autism Spectrum), improved psychometric properties, and scoring and
reporting software (Gresham et al. 2011).

Procedures
Prior to the start of the intervention, the parents and children were asked to
provide consent and complete several forms in two separate rooms. Specifically,
the student oral consent form was read aloud, which described the purpose of
the project and asked the children for their assent to participate in the drama
therapy group. In turn, the children gave their verbal assent and proceeded
to complete the SSIS-RS student form for 8–12-year-olds. This rating scale
contains 46 social skill items across seven subscales (i.e. Communication,
Cooperation, Assertion, Responsibility, Empathy, Engagement and Self-
Control), and 29 problem behaviour items across four subscales (i.e.
Externalizing, Bullying, Hyperactivity/Inattention and Internalizing). The chil-
dren were asked to rate the items based on a 4-point scale that determined
how true a particular sentence was for that individual (i.e. Not True, Little True,
A lot True and Very True) (Gresham and Elliott 2008). The children completed
the forms with the assistance of graduate students who addressed any of the
questions that they had about the items on the rating scale.
At the same time, the parents were in another room with several research
team members completing the measures required for this project. The parent
consent form was read aloud and all participants were given the opportu-
nity to ask questions or obtain clarifications about the goals of the project.
Following this, the parents were asked to complete the parent form of the
SSIS-RS. The parent version consists of 46 social skill items across seven
subscales (i.e. Communication, Cooperation, Assertion, Responsibility,
Empathy, Engagement and Self-Control) and 33 problem behaviour items
across five subscales (i.e. Externalizing, Bullying, Hyperactivity/Inattention,
Internalizing and Autism Spectrum). The parents rated these items accord-
ing to how often their children displayed the behaviours on a 4-point scale
(i.e. Never, Seldom, Often and Almost Always), as well as the importance of the
items in relation to their children’s development on a 3-point scale (i.e. Not
Important, Important and Critical) (Gresham and Elliott 2008).
Once this information was collected, the scores were calculated using the
SSIS-RS ASSIST software program (Gresham and Elliott 2008), a computer-
based scoring system that provides a model framework to base the individ-
ual and group therapeutic goals. In particular, the SSIS-RS ASSIST program
calculates the scores obtained from the items to indicate the children’s
performance relative to the norm group (M = 100, SD = 15) (Gresham and
Elliott 2008). The subscales that showed below average scores for social skills
and above average scores for problem behaviours were the areas targeted

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Miranda D’Amico | Corinne Lalonde | Stephen Snow

in the therapeutic intervention. The SSIS-RS ASSIST program also revealed

whether the children had a performance or acquisition deficit on a particular
subscale. Specifically, performance deficits signify that the child could use the
skill but does so infrequently, while acquisition deficits denote that the child
does not sufficiently know the skill or how to use it appropriately (Gresham
and Elliott 2008).
In light of this, the therapists consulted the model framework and used
different therapeutic activities to address the children’s performance or
acquisition deficits across the social skill domains, while also addressing any
competing behaviours that were identified as above average on the problem
behaviour subscales. For instance, the SSIS-RS scores revealed that some of
the children exhibited below average scores on the assertion subscale, wherein,
it was determined that they had performance difficulties in asking for help
when needed and telling others when there was a problem. The model frame-
work suggested that the therapists use direct instruction to increase the chil-
dren’s practice and performance of the desired behaviours, such as asking for
help, on this subscale (Gresham and Elliott 2008). At the end of the interven-
tion, the SSIS-RS was re-administered to both parents and children to deter-
mine the efficacy of the therapeutic intervention in addressing the behaviours
targeted over the course of the project.
The therapeutic sessions were conducted one day per week for 21 weeks.
The children met on Saturday mornings for 75 minutes and during each
session, they participated in drama therapy activities to address areas of social
difficulty that were determined by the results obtained on the SSIS-RS forms.
In particular, it was determined on the SSIS-RS forms that the six children in
the drama therapy group scored below average on six social skills subscales
(i.e. communication, cooperation, assertion, responsibility, empathy, engage-
ment), and above average on the internalizing problem behaviour subscale.
Using the model framework provided in the SSIS-RS manual, the thera-
pists employed various drama therapy techniques and training strategies to
increase student practice and performance of the desired social behaviours. For
instance, scores on the empathy subscale of the SSIS-RS forms indicated that
children experienced performance and acquisition difficulties with emotion
identification and recognition. To foster these skills, the children worked on
emotional expression (i.e., sad, happy, angry etc.) through improvisational
scenes and projection techniques in several group activities.
The drama therapy techniques centred on making connections among the
group members, while discovering commonalities and shared interests, and
encouraging self-expression. Through their discussions with one another, the
children practised active listening and communication skills. Moreover, the
therapists created a variety of opportunities for the children to cooperate and
build cohesion among the group members. For instance, in the first semester
(November to December), the therapists chose a tribal theme for the group
that established a dramatic reality in which the children were encouraged to
select a role within their tribe, create a fictional tribal history and design a
tribal headdress to represent their individual roles. In this process, additional
therapeutic goals included developing self-identity as well as creating a sense
of community among the group members. Here is where the power of role
play in drama therapy was particularly cogent as their role-playing afforded
them the opportunity to explore new identities (Landy 1986, 1993).
Once the children became more at ease with one another, the thera-
pists employed activities to help the children develop skills for reading body

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language, facial expressions and vocal intonations. As the children embod-

ied the personas of their tribal characters, the therapists used vocal exercises
to practise word enunciations, tone and volume. Furthermore, the children
participated in improvised scenes of conflict among the tribe members. The
purpose of these activities was to enhance the children’s problem-solving and
communication skills while developing empathy among the group members.
Finally, the therapists used various activities to develop nonverbal communi-
cation abilities. For instance, by combining charades with gibberish, children
were encouraged to vary their vocal inflexion (i.e. tempo, quality and pitch),
use gestures, body language and facial expressions to communicate specific
actions to the other group members, who in turn, provided observations and
interpretations of the child’s communicative behaviours during the scenes.
In the Spring semester (January to April), the children were encouraged
to create a new dramatic reality for the drama therapy group, in the form of a
creature from another planet. ‘The Alien’, was used to develop several skills
such as engagement, self-awareness and self-control. Based on the discovery
of an article outlining an innovative projective approach (Kempe and Tissot
2012), the two drama therapists adapted the ‘Alien’ in a way that, through
the use of projective explorations with this creature, the children shared their
understanding and challenges of being on the autism spectrum and what it
means to be ‘different’, like the ‘alien’ creature.
All four drama therapy processes, previously mentioned, were evidenced
in developing the improvisational scenes with the ‘Alien’ figure (a cardboard
cut-out animated by the two therapists). On a weekly basis, it was a kind of
extended dramatization (Landy 1986) wherein the children acted out differ-
ent social issues, such as being bullied at school, and worked on improving
their ability to exert self-control. Role-playing was very present. The drama
therapists used gibberish for the voice of the ‘Alien’ and the participants,
subsequently, served as ‘translators’: giving the boys the opportunity to
empathize with the ‘Alien’ and to project their own ideas about how he felt.
The boys even helped the ‘Alien’ to write postcards back to his parents on
another planet. The therapists, as the parents, wrote letters back the follow-
ing week and this created a collaborative narrative dialogue. It allowed for
deeper reflection on the part of the boys through engaging in storytelling in
this unique way. It enhanced their engagement in creative expression and
projection. The drama therapists used these and other cooperative activities to
help the children improve their social functioning and work through personal
issues, while providing them with opportunities for behavioural practice that
enhanced their self-esteem and well-being over the course of the interven-
tion. In fact, from this experience, the two drama therapists created a whole
adaptive approach to working in a unique projective format with this popula-
tion (Rae and Powell 2013), hopefully, soon to be published. It is important
to note as well that these two drama therapists in this term did intentionally
plan the weekly sessions using each skill from the SSIS as a theme for the
two subsequent weeks. They planned the activities and interventions with this
in mind. It is also important to emphasize from the clinical perspective how
valuable entering this dramatic reality of the ‘Alien’s’ world was for these boys
with ASD. It was a powerful opportunity to explore their vulnerabilities and
psychological issues in a safe playspace. It brought the practice of their social
skills to life through ‘living’, each session, in this fictional world. Entering this
dramatic reality made their healing and growth experiences, in the words of
one of the therapists, more ‘accessible’, ‘palatable’ and ‘motivating’. This is

31
Miranda D’Amico | Corinne Lalonde | Stephen Snow

likely a validation of the unique properties of the use of drama therapy with
this population. At the heart of it, is the dynamic experience of dramatic projec-
tion, which, through the role-playing and storytelling in this unique dramatic
reality, offered this preadolescent group of boys the opportunity for collabora-
tion and to genuinely improve their social skills.

Results
Efficacy of the therapeutic interventions
The children and parents completed the SSIS-RS forms at pre- and post-in-
tervention to determine the efficacy of the therapeutic interventions on the
targeted behaviours over the course of 21 weeks. The results of the SSIS-RS
social skill and problem behaviour scales were analysed according to the
respondent (Student Form and Parent Form) using paired sample t-tests. As
can be seen in Table 1, the overall mean difference scores of the social skills
and problem behaviours on the Student Form was not statistically significant
between pre- and post-test. In examining the results obtained on the parent
form, there was a statistically significant difference in the overall mean differ-
ence scores (M = 0.55, SD = 0.52), t(5) = 2.57, p = 0.05.
The pre-to post-test scores of the social skill and problem behaviour
subscales on the SSIS-RS Student Form are provided in Table 2. The results
obtained on this form demonstrates a statistically significant difference in the
mean score on the hyperactivity/inattention subscale (M = 4.33, SD = 3.82),
t(5) = 2.77, p < 0.05, while the bullying subscale approached significance.
There were no statistically significant changes in mean scores on the social
skill subscales between pre- and post-test on the student form.
Finally, Table 3 provides a summary of the results obtained on the SSIS-RS
parent form. There was a statistically significant difference in the mean scores
on the engagement subscale (M = −2.00, SD = 1.41), t(5) = −3.46, p < 0.05,
while the mean difference score on self-control and responsibility approached
significance. Moreover, the results revealed statistically significant changes in
the mean scores on the externalizing behaviours (M = 4.00, SD = 3.22), t(5) =
3.03, p < 0.05, hyperactivity/inattention (M = 2.83, SD = 1.83), t(5) = 3.78, p <
0.05, and the Autism Spectrum problem behaviour subscales (M = 5.00, SD =
3.46), t(5) = 3.53, p < 0.05.

Discussion
In examining the efficacy of the therapeutic intervention using drama ther-
apy, the SSIS-RS results showed statistically significant improvements in
engagement, coupled with decreased externalizing, hyperactivity, inatten-
tion and Autism Spectrum behaviours at the end of the project. Several other

SSIS-RS M SD T Df P

Student Pre-Post-test 1.10 1.80 1.50 5 0.19

Parent Pre-Post-test 0.55 0.52 2.57 5   0.05*

Note: M = mean; SD = standard deviation; Df = degrees of freedom.

*p = .05
Table 1: Overall mean difference scores on SSIS-RS student and parent forms (N = 6).

32
 Evaluating the efficacy of drama therapy …

Behaviours M SD T Df P

Social skills

Communication Pre-Post-test 0.00 2.75 0.00 5 1.00

Cooperation Pre-Post-test 1.00 4.33 0.56 5 0.59
Assertion Pre-Post-test −0.73 3.86 −0.73 5 0.49
Responsibility Pre-Post-test 0.00 3.22 0.00 5 1.00
Empathy Pre-Post-test −1.00 2.96 −0.82 5 0.44
Engagement Pre-Post-test 1.50 4.08 0.89 5 0.41
Self-Control Pre-Post-test 1.00 6.32 0.38 5 0.71

Problem Behaviours

Externalizing Pre-Post-test 1.50 5.99 0.61 5 0.56

Bullying Pre-Post-test 1.00 1.09 2.23 5 0.07
Hyperactivity/Inattention Pre-Post 4.33 3.82 2.77 5   0.03*
Internalizing Pre-Post-test 4.00 4.93 1.98 5 0.10

Note: M = mean; SD = standard deviation; Df = degrees of freedom.

*p < .05

Table 2: Mean difference scores on SSIS-RS social skill and problem behaviour subscales student form (N = 6).

Behaviours M SD T Df P

Social skills

Communication Pre-Post-test −0.66 3.01 −0.54 5 0.61

Cooperation Pre-Post-test −1.16 2.04 −1.40 5 0.22
Assertion Pre-Post-test −0.16 2.92 −0.13 5 0.89
Responsibility Pre-Post-test −2.00 2.36 −2.07 5 0.09
Empathy Pre-Post-test 0.83 2.40 0.85 5 0.43
Engagement Pre-Post-test −2.00 1.41 −3.46 5 0.01*
Self-Control Pre-Post-test −2.50 2.58 −2.36 5 0.06

Problem Behaviours

Externalizing Pre-Post-test 4.00 3.22 3.03 5 0.02*

Bullying Pre-Post-test 0.33 0.51 1.58 5 0.17
Hyperactivity/Inattention Pre-Post 2.83 1.83 3.78 5 0.01*
Internalizing Pre-Post-test 2.16 2.71 1.95 5 0.10
Autism Spectrum Pre-Post-test 5.00 3.46 3.53 5 0.01*

Note: M = mean; SD = standard deviation; Df = degrees of freedom

*p < .05

Table 3: Mean difference scores on SSIS-RS social skill and problem behaviour subscales parent form (N = 6).

33
Miranda D’Amico | Corinne Lalonde | Stephen Snow

social skills and problem behaviours (i.e. self-control, and bullying) showed
improvement between pre- and post-test, although the measurements were
not statistically significant. Most importantly, the results of this project add to
the limited yet growing body of evidence in support of using drama therapy in
group therapeutic interventions to teach social skills and to manage problem
behaviours with children with high-functioning ASD.
Several interesting patterns emerged from the findings on the SSIS-RS
student and parent forms. To begin, both children and parents reported
reductions in hyperactivity and inattention, a problem behaviour subscale that
had one of the highest frequency ratings on the SSIS-RS at pre-test. Indeed, it
was noted that the children had difficulties dealing with certain issues such as
temper tantrums, fidgeting behaviours and inattention. Perhaps the therapeu-
tic group processes were particularly effective in addressing these competing
behaviours; indeed, through the drama therapy methods previously described,
involving role-playing, storytelling and projective techniques, the children
had the opportunity to manage their problem behaviours, while increasing
their capacity to focus their attention on a collaborative project with the other
group members.
Also, the participants were given the opportunity to express themselves
through dramatic media and share their emotions and thoughts with one
another, which may have been helpful to manage their feelings and reduce
the likelihood of outbursts. These behavioural improvements have important
educational implications. Indeed, problem behaviours such as hyperactiv-
ity and inattention may negatively impact these children’s ability to concen-
trate on school tasks, pay attention to teacher instructions, and finish their
assignments. Taken together, these behaviours can interfere with their learn-
ing, academic success and school adjustment. Therefore, the effects of the
therapeutic interventions may further assist the children in regulating their
hyperactive and inattentive symptoms in the classroom, as well as in their
interpersonal relationships.
Another interesting finding was that the parents noted statistically signifi-
cant changes in overall social skills and problem behaviours. In addition to
the hyperactivity/inattention subscale, most of the changes reported on the
SSIS-RS parent form were on other problem behaviour subscales (i.e. external-
izing and Autism Spectrum). Several reasons may be offered to explain these
results. First, problem behaviours such as externalizing issues (i.e. fights with
others, disobeys rules and talks back to adults), Autism Spectrum behaviours
(i.e. non-functional routines) and hyperactivity/inattention are more periph-
eral and observable compared to other problem behaviours, such as internal-
ized feelings of anxiety. Second, the findings may be related to the therapeutic
modality itself; indeed, drama therapy is a dynamic and experiential process
that provides a unique context for children to express themselves (NADTA
2014). The techniques used in drama therapy allow participants to role play
and act out different social issues and problems in an active process. In this
sense, perhaps drama therapy techniques are particularly effective for facilitat-
ing change in externalized problem behaviours, which in turn, may have been
easier for the parents of this group to observe throughout the project.
Lastly, the SSIS-RS results also revealed that the ratings of certain behav-
iours were quite different on the student and parent forms. Indeed, parents
reported greater changes in the children’s behaviours both on the social skill
and problem behaviour subscales. For instance, the responsibility subscale on
the student form did not reveal any change, while parents reported notable

34
 Evaluating the efficacy of drama therapy …

improvements on this social skill subscale. According to Gresham and Elliott

(2008), this may be due to the fact that, compared to parents, some children
may interpret the behavioural statements on the SSIS-RS somewhat less
consistently across administrations of the rating scale. Indeed, the rating scale
requires that the children have adequate insight into their own social skills
and problem behaviours. In this respect, perhaps some of the children had
more difficulty interpreting the statements and reporting their own behav-
iours, which may explain why the findings across the respondents are less
congruent on some of the subscales.

Implications for the field of drama therapy

The implications of this study affirm that some social skills can be taught and
problem behaviours can be managed in group therapeutic settings that meet
the social and behavioural needs of children with high-functioning ASD. The
results of this project suggest that drama therapy likely lends itself to this kind
of intervention. Based on the pre- to post-test results, it appears that thera-
peutic interventions using drama therapy may be particularly effective in help-
ing these individuals engage with others and manage problem behaviours,
such as Autism Spectrum and externalizing behaviours in a group setting.
Therefore, one could suggest that the therapeutic modality should be based
on the child’s social and behavioural needs; for instance, a child with high-
functioning ASD that presents more externalized problem behaviours may
experience greater benefits from participating in a group therapeutic interven-
tion involving drama therapy than other creative arts therapies modalities or
other educationally based drama methods. Finally, the project also showed
that standardized outcome measures such as the SSIS-RS can be used to
demonstrate the effectiveness of therapeutic interventions that use creative
arts therapies. Future studies should consider using responses from multiple
raters as this would help to analyse the results from different respondents and
establish the validity of the findings.

Conclusion
To conclude, the purpose of this project was to use therapeutic interventions
to address specific areas of social difficulty and problem behaviours presented
by a group of preadolescent children with high-functioning ASD. The goal
was that by using creative arts therapies modalities, like those normally
employed at the Centre for the Arts in Human Development, the children
were provided with opportunities to deal with their social skills and prob-
lem behaviours within a group setting while experiencing more positive social
interactions. These experiences were important for these children given that
they are at a critical stage of development, wherein, addressing social skill
deficits is necessary to attenuate ensuing problems as they approach adoles-
cence. This project demonstrated that the therapeutic intervention using
drama therapy was especially effective in enhancing the children’s ability to
engage in social interactions with others, while also reducing competing prob-
lem behaviours such as hyperactivity and inattention, externalizing issues and
Autism Spectrum behaviours. The results demonstrated that the implementa-
tion of drama therapy methods can positively impact the lives of individuals
with ASD, and may have their own unique properties and role in therapeutic
work with these children. Indeed, the use of drama therapy in the therapeutic

35
Miranda D’Amico | Corinne Lalonde | Stephen Snow

intervention provided the children with the opportunity to become active

participants in their own treatment and empower them to use their imagina-
tion in both productive and meaningful ways.

Acknowledgements
The authors would like to gratefully acknowledge the skilful, creative and
effective work of the two drama therapists hired for this project: Kalie Rae, the
professional drama therapist, and Margaret Powell, the intern from Concordia
University’s Graduate Drama Therapy Program.

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Suggested citation
D’Amico, M., Lalonde, C. and Snow, S. (2015), ‘Evaluating the efficacy
of drama therapy in teaching social skills to children with Autism
Spectrum Disorders’, Drama Therapy Review 1: 1, pp. 21–39, doi: 10.1386/
dtr.1.1.21_1

Contributor details
Miranda D’Amico, Ph.D., is Associate Dean of Student Academic Services
and Professor in the Department of Education at Concordia University. She
co-founded the Centre for the Arts in Human Development at Concordia
University, a unique research and clinical training program where she is
Co-Director of Research.

38
 Evaluating the efficacy of drama therapy …

Contact: Associate Dean, Student Academic Services, L-AD 306-1, Concordia

University, 7141 Sherbrooke West, Montreal, QC H4B 1R6, Canada.
E-mail: miranda.damico@concordia.ca

Corinne Lalonde, MA, is a Special Needs Consultant and Educator at a

preschool that supports and promotes the integration of children with Autism
Spectrum Disorders. She is responsible for both the well-being of families and
their children in many roles: Program Specialist, Coordinator and Educator.
Contact: Associate Dean, Student Academic Services, L-AD 306-1, Concordia
University, 7141 Sherbrooke West, Montreal, QC H4B 1R6, Canada.
E-mail: corinne.k.lalonde@gmail.com

Stephen Snow, Ph.D., RDT-BCT, is the Co-Founder of the Drama Therapy

Masters Program in the Department of Creative Arts Therapies at Concordia
University, where he is presently Chair and Professor of Drama Therapy.
He is also Co-Director of Research at the Centre for the Arts in Human
Development.
Contact: Associate Dean, Student Academic Services, L-AD 306-1, Concordia
University, 7141 Sherbrooke West, Montreal, QC H4B 1R6, Canada.
E-mail: stephen.snow@concordia.ca

Miranda D’Amico, Corinne Lalonde and Stephen Snow have asserted their
right under the Copyright, Designs and Patents Act, 1988, to be identified as
the authors of this work in the format that was submitted to Intellect Ltd.

39
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