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Investigating Social Competence in a Pilot Randomized Clinical Trial of a Theatre-Based Intervention Enhanced for Adults with Autism Spectrum Disorder

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Title: Investigating Social Competence in a Pilot Randomized Clinical Trial of a Theatre-Based Intervention Enhanced for Adults with Autism Spectrum Disorder
Language: English
Authors: Blythe A. Corbett (ORCID 0000-0003-2165-8015), Alexandra P. Key (ORCID 0000-0002-2669-8334), Mark E. Klemencic (ORCID 0000-0002-8722-6808), Rachael A. Muscatello (ORCID 0000-0002-9862-1686), Dorita Jones, Jennifer Pilkington, Christina Burroughs (ORCID 0000-0003-3569-9643), Simon Vandekar (ORCID 0000-0002-7457-9073)
Source: Journal of Autism and Developmental Disorders. 2025 55(1):130-146.
Availability: Springer. Available from: Springer Nature. One New York Plaza, Suite 4600, New York, NY 10004. Tel: 800-777-4643; Tel: 212-460-1500; Fax: 212-460-1700; e-mail: customerservice@springernature.com; Web site: https://link.springer.com/
Peer Reviewed: Y
Page Count: 17
Publication Date: 2025
Sponsoring Agency: National Institute of Mental Health (NIMH) (DHHS/NIH)
National Center for Advancing Translational Sciences (NCATS) (DHHS/NIH)
Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) (DHHS/NIH)
Contract Number: R33MH120149
CTSAUL1TR000445
Document Type: Journal Articles
Reports - Research
Descriptors: Autism Spectrum Disorders, Adults, Interpersonal Competence, Interpersonal Communication, Theater Arts, Enrichment Activities, Pilot Projects, Feasibility Studies, Program Effectiveness
DOI: 10.1007/s10803-023-06214-0
ISSN: 0162-3257
1573-3432
Abstract: Autism spectrum disorder (ASD) is characterized by challenges in social competence that persist in adulthood, yet few treatment options exist. A pilot randomized clinical trial (RCT) of a peer-mediated, theatre-based intervention with established efficacy in youth with ASD was examined in autistic adults. The final sample consisted of forty-seven 18-to-40-year-old participants randomized to the experimental (EXP N = 23) or waitlist control (WLC N = 24) condition. A multimodal, social interdependent model was employed to examine social competence changes in brain (incidental face memory (IFM) using event-related potentials), cognition (Wechsler Memory Scale-III), behavior (Contextual Assessment of Social Skills) and function (Social Responsiveness Scale (SRS); Adaptive Behavior Assessment Scale (ABAS) Social Composite). Using analysis of covariance in which pretest was controlled in the model, posttest between-group differences were observed on IFM (p = 0.016, n[superscript 2] = 0.139, d = 0.79) and several social and adaptive functional (SRS, ABAS) outcomes in social communication and interaction (SCI) (p = 0.019, n[superscript 2] = 0.121, d = -00.45), communication (p = 0.044 n[superscript 2] = 0.09, d = -00.31), and motivation (p = 0.001, n[superscript 2] = 0.229, d = -0.79) domains. At two-month follow-up, gains in social motivation remained (p = 0.041, n[superscript 2] = 0.100, d = -0.77). The results offer preliminary support for a unique theatre-based social skills intervention for autistic adults who have few treatment options to enhance social competence. The trial was pre-registered with ClinicalTrials.gov (Identifier: NCT04349644).
Abstractor: As Provided
Entry Date: 2025
Accession Number: EJ1460690
Database: ERIC
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  Value: <anid>AN0182844521;aut01jan.25;2025Feb10.03:00;v2.2.500</anid> <title id="AN0182844521-1">Investigating Social Competence in a Pilot Randomized Clinical Trial of a Theatre-Based Intervention Enhanced for Adults with Autism Spectrum Disorder </title> <p>Autism spectrum disorder (ASD) is characterized by challenges in social competence that persist in adulthood, yet few treatment options exist. A pilot randomized clinical trial (RCT) of a peer-mediated, theatre-based intervention with established efficacy in youth with ASD was examined in autistic adults. The final sample consisted of forty-seven 18-to-40-year-old participants randomized to the experimental (EXP N = 23) or waitlist control (WLC N = 24) condition. A multimodal, social interdependent model was employed to examine social competence changes in brain (incidental face memory (IFM) using event-related potentials), cognition (Wechsler Memory Scale-III), behavior (Contextual Assessment of Social Skills) and function (Social Responsiveness Scale (SRS); Adaptive Behavior Assessment Scale (ABAS) Social Composite). Using analysis of covariance in which pretest was controlled in the model, posttest between-group differences were observed on IFM (p = 0.016, η<sup>2</sup> = 0.139, d = 0.79) and several social and adaptive functional (SRS, ABAS) outcomes in social communication and interaction (SCI) (p = 0.019, η<sup>2</sup> = 0.121, d = -00.45), communication (p = 0.044 η<sup>2</sup> = 0.09, d = -00.31), and motivation (p = 0.001, η<sup>2</sup> = 0.229, d = -0.79) domains. At two-month follow-up, gains in social motivation remained (p = 0.041, η<sup>2</sup> = 0.100, d = -0.77). The results offer preliminary support for a unique theatre-based social skills intervention for autistic adults who have few treatment options to enhance social competence. The trial was pre-registered with ClinicalTrials.gov (Identifier: NCT04349644).</p> <p>Keywords: Autism; Social competence; Event related potentials; Social salience; Psychology and Cognitive Sciences Psychology</p> <hd id="AN0182844521-2">Introduction</hd> <p>Autism spectrum disorder (ASD)[<reflink idref="bib1" id="ref1">1</reflink>] is a neurodevelopmental condition characterized by core challenges in social competence (APA, [<reflink idref="bib4" id="ref2">4</reflink>]), involving neural, cognitive, behavioral, and functional components (Kennedy & Adolphs, [<reflink idref="bib41" id="ref3">41</reflink>]). Currently, the Centers for Disease Control estimates that 1:36 children are diagnosed with ASD (Maenner et al., [<reflink idref="bib57" id="ref4">57</reflink>]) and each year approximately 50,000 individuals with ASD turn 18 years old to enter adulthood (Shattuck et al., [<reflink idref="bib76" id="ref5">76</reflink>]). If untreated, difficulties in social competence are often intractable, persist into adulthood (Seltzer et al., [<reflink idref="bib73" id="ref6">73</reflink>]) and may worsen with age (Beadle-Brown et al., [<reflink idref="bib7" id="ref7">7</reflink>]). The worsening of challenges has been corroborated by autistic adults who report their social problems often peak in middle adulthood (Lever & Geurts, [<reflink idref="bib53" id="ref8">53</reflink>]). Meanwhile, social demands expand during the adult years intensifying the need for ongoing treatment. There is evidence that after secondary school, adults with ASD become increasingly more isolated from social activities in the community (Myers et al., [<reflink idref="bib61" id="ref9">61</reflink>]; Taylor et al., [<reflink idref="bib81" id="ref10">81</reflink>]; Umagami et al., [<reflink idref="bib84" id="ref11">84</reflink>]). Despite the growing need of this expanding population, after 18 years of age, services for persons with ASD decline significantly and are inadequate to meet their needs (Buescher et al., [<reflink idref="bib9" id="ref12">9</reflink>]; Dudley et al., [<reflink idref="bib24" id="ref13">24</reflink>]; Howlin & Magiati, [<reflink idref="bib36" id="ref14">36</reflink>]; Shattuck et al., [<reflink idref="bib75" id="ref15">75</reflink>]; Taylor & Henninger, [<reflink idref="bib78" id="ref16">78</reflink>]; Turcotte et al., [<reflink idref="bib82" id="ref17">82</reflink>]). Unfortunately, per-person spending for employment support, day care and transportation is highest for adults with ASD (Leigh et al., [<reflink idref="bib52" id="ref18">52</reflink>]).</p> <p>While there has been some progress in recent years, effective psychosocial interventions for adults are scarce (Kandalaft et al., [<reflink idref="bib40" id="ref19">40</reflink>]; Koehne et al., [<reflink idref="bib44" id="ref20">44</reflink>]; Laugeson et al., [<reflink idref="bib51" id="ref21">51</reflink>]; Spain & Blainey, [<reflink idref="bib77" id="ref22">77</reflink>]; Taylor et al., [<reflink idref="bib80" id="ref23">80</reflink>]; White et al., [<reflink idref="bib92" id="ref24">92</reflink>]), with only a few randomized control trials (RCTs) (Ashman et al., [<reflink idref="bib5" id="ref25">5</reflink>]; Gantman et al., [<reflink idref="bib27" id="ref26">27</reflink>]; Oswald et al., [<reflink idref="bib67" id="ref27">67</reflink>]). Most social skill interventions for adults with ASD follow a similar format, incorporating didactics, small and large group discussions, practice exercises (e.g., role play), and other activities related to the didactic content (e.g., identifying social cues in an example). Studies are generally small, non-randomized or quasi-experimental (Ashman et al., [<reflink idref="bib5" id="ref28">5</reflink>]; Gantman et al., [<reflink idref="bib27" id="ref29">27</reflink>]; McVey et al., [<reflink idref="bib60" id="ref30">60</reflink>]; Oswald et al., [<reflink idref="bib67" id="ref31">67</reflink>]; Turner-Brown et al., [<reflink idref="bib83" id="ref32">83</reflink>]). Overall, results are promising—all report improvement or trends toward improvement on measures of social skills— but gains are limited (e.g., Ashman et al., [<reflink idref="bib5" id="ref33">5</reflink>]; Koehne et al., [<reflink idref="bib44" id="ref34">44</reflink>]; Oswald et al., [<reflink idref="bib67" id="ref35">67</reflink>]; Spain & Blainey, [<reflink idref="bib77" id="ref36">77</reflink>]). In addition, studies highlight the challenge of generalizability or clinical efficacy. For example, Ashman ([<reflink idref="bib5" id="ref37">5</reflink>]) noted that, though social cognition improved per clinician-administered measures, improvement did not translate to contexts outside the study. Relatedly, McVey ([<reflink idref="bib60" id="ref38">60</reflink>]) found significant improvement in social skill knowledge, self-report measures of empathy and social anxiety, and parent-reported social skills after PEERS®, a social skills treatment for adults. However, participants did not indicate any improvement in reported loneliness, suggesting difficulty with implementing their new skills for friendships. Turner-Brown ([<reflink idref="bib83" id="ref39">83</reflink>]) used behavioral observation to look at multiple components of social communication yet found no significant post-intervention improvement. The lack of evidence for the generalizability of these interventions becomes even more problematic in the face of service gaps that are nearly ubiquitous among adults with ASD (Wong et al., [<reflink idref="bib95" id="ref40">95</reflink>]). Together, these studies portray a small body of research evaluating programs that seem to be effective in improving the specific skills targeted but have limited generalizability to the real-world, daily life of adults with ASD. Logical next steps would be to examine novel and ecologically valid interventions utilizing objective and multimodal measures.</p> <p>The social interdependent model (Kennedy & Adolphs, [<reflink idref="bib41" id="ref41">41</reflink>]) posits that to understand social competence, four levels of analysis are warranted, extending from the social brain that underlies social cognition, which produces and modulates social behavior and ultimately establishes generalized social functioning. The social brain subserves the complex integration of social signals and is measured via imaging techniques such as Event-Related Potentials (ERP). Social cognition pertains to processing that is signaled by and directed toward other people and measured by examining the perception of key social signals, such as faces. Social behavior is generally measured through direct observation of the individual interacting with others within a given context (Kennedy & Adolphs, [<reflink idref="bib41" id="ref42">41</reflink>]). Finally, social functioning pertains to the integration of cognition, affect, and interactions reflecting the daily way an individual negotiates the social world measured by self-report of informants reporting adaptive skills in the daily environment (Constantino & Gruber, [<reflink idref="bib13" id="ref43">13</reflink>]; Harrison & Oakland, [<reflink idref="bib31" id="ref44">31</reflink>]). Social functioning is also thought to be comprised of social motivation, cognition, and interaction skills (Pallathra et al., [<reflink idref="bib68" id="ref45">68</reflink>]). Collectively, leading theories in ASD (Baron-Cohen, [<reflink idref="bib6" id="ref46">6</reflink>]; Chevallier et al., [<reflink idref="bib11" id="ref47">11</reflink>]; Osterling et al., [<reflink idref="bib66" id="ref48">66</reflink>]) generally support the social interdependent framework (Adolphs, [<reflink idref="bib3" id="ref49">3</reflink>]; Kennedy & Adolphs, [<reflink idref="bib41" id="ref50">41</reflink>]) such that ASD may be conceptualized as a disorder of social competence with measurable challenges regarding social cognition, behavior and functioning.</p> <p>The <emph>Social Motivation Theory</emph> of autism speculates that early-onset challenges in social attention lead to a disruption in social learning experiences (Chevallier et al., [<reflink idref="bib11" id="ref51">11</reflink>]). Interventions that enhance social motivation via increasing the salience of or intrinsic interest in social stimuli should enhance performance in social functioning (Chevallier et al., [<reflink idref="bib11" id="ref52">11</reflink>]). Memory for faces is proposed as an index of social salience, a skill dependent on sufficient engagement with the stimuli and allocation of adequate processing resources (i.e., beyond initial stimulus detection and categorization). Therefore, face recognition and memory constitute a foundational building block for the development of age-appropriate social competence (Gauthier & Nelson, [<reflink idref="bib28" id="ref53">28</reflink>]; Nelson, [<reflink idref="bib62" id="ref54">62</reflink>]), facilitating social interactions, and creating social bonds. Remembering whether a face has been seen aids accessing information about past interactions, informs the selection of adaptive social behavior, and significantly improves the probability of social success (Corbett et al., [<reflink idref="bib18" id="ref55">18</reflink>]; Hauck, [<reflink idref="bib34" id="ref56">34</reflink>]).</p> <p>Research has shown that most individuals with ASD have particular difficulty remembering faces, especially following a delay (Griffin et al., [<reflink idref="bib29" id="ref57">29</reflink>]; Key & Corbett, [<reflink idref="bib42" id="ref58">42</reflink>]; Langdell, [<reflink idref="bib47" id="ref59">47</reflink>]; Osterling et al., [<reflink idref="bib66" id="ref60">66</reflink>]; Webb et al., [<reflink idref="bib86" id="ref61">86</reflink>]; Weigelt et al., [<reflink idref="bib91" id="ref62">91</reflink>]). Difficulty in face memory in people with ASD infer risk for development of social impairment (Marcus & Nelson, [<reflink idref="bib58" id="ref63">58</reflink>]). Behavioral and neuroimaging studies show that struggles with immediate and delayed recall of faces in persons with ASD persist into adulthood (O'Hearn et al., [<reflink idref="bib64" id="ref64">64</reflink>]; Williams et al., [<reflink idref="bib94" id="ref65">94</reflink>]). Difficulty with face identification in ASD is primarily observed on tasks with a memory component (Weigelt et al., [<reflink idref="bib91" id="ref66">91</reflink>]). For example, on the Wechsler Memory Scale-III (Wechsler, [<reflink idref="bib89" id="ref67">89</reflink>]), adults with ASD exhibited impaired memory for faces and everyday family scenes, but not for words or stories (Williams et al., [<reflink idref="bib94" id="ref68">94</reflink>]). In contrast to neurotypical same-age peers who continue to improve in face recognition, adults with ASD show increasing problems from adolescence to adulthood, presumably due to a developmental plateau (O'Hearn et al., [<reflink idref="bib64" id="ref69">64</reflink>]). The lack of improvement with age suggests unique and persistent structural and functional brain maturation patterns into adulthood in ASD, which can impact cognitive and social functioning (Floris et al., [<reflink idref="bib26" id="ref70">26</reflink>]; Hashem et al., [<reflink idref="bib33" id="ref71">33</reflink>]; Hyde et al., [<reflink idref="bib37" id="ref72">37</reflink>]; Johnson, [<reflink idref="bib39" id="ref73">39</reflink>]; Shafritz et al., [<reflink idref="bib74" id="ref74">74</reflink>]). As such, the lack of prototypical development widens the gap as adults with ASD fall further behind (Taylor & Seltzer, [<reflink idref="bib79" id="ref75">79</reflink>]). Finally, Lynn and colleagues ([<reflink idref="bib56" id="ref76">56</reflink>]) showed age-related changes in adults with ASD relative to TD adults with respect to reduced connectivity between the Fusiform Face Area and subcortical and temporoparietal regions, and the amygdala. Thus, face memory challenges persist in adults with ASD and are influenced by task (delay) and developmental (age) factors.</p> <p>Despite consistently noted difficulties, face memory has been shown to be modifiable by a theatre-based intervention called SENSE Theatre® (Corbett et al., [<reflink idref="bib16" id="ref77">16</reflink>], [<reflink idref="bib19" id="ref78">19</reflink>], [<reflink idref="bib20" id="ref79">20</reflink>]) and linked to improved functional outcomes of social competence (Corbett et al., [<reflink idref="bib16" id="ref80">16</reflink>], [<reflink idref="bib20" id="ref81">20</reflink>], [<reflink idref="bib21" id="ref82">21</reflink>]). Using a randomized clinical trial (RCT), youth in the SENSE Theatre® experimental (EXP) group relative to the wait-listed control (WLC) group [AUTHORS BLINDED] demonstrated improvement in delayed memory for faces (MFD NEPSY; Korkman et al., [<reflink idref="bib45" id="ref83">45</reflink>]) (<emph>d</emph> = 0.98) and an event-related potential (ERP) Incidental Face Memory (IFM) task (<emph>d</emph> = 0.93). Face memory was strongly correlated with SRS Communication (index of social functioning) at posttest (r=-0.49, <emph>p</emph> = 0.01) and at follow-up (r=-0.47, <emph>p</emph> = 0.02) (Corbett et al., [<reflink idref="bib21" id="ref84">21</reflink>]). Recently, in a large multisite RCT of SENSE Theatre® compared to an active control condition (ACC), better IFM at posttest mediated increased social behavior at follow-up (Corbett et al., [<reflink idref="bib22" id="ref85">22</reflink>]). Taken together, it has been hypothesized that engaging in peer-mediated theatre activities increases attention to reinforcing social stimuli (supportive peers) such that participants are increasingly drawn to peers' faces (increased salience) resulting in more generalized social attention to other people (Corbett et al., [<reflink idref="bib20" id="ref86">20</reflink>]). These findings provide support for the predictability and strength of the interconnected social competence framework as well as the feasibility and utility of using face memory as a treatment target of social competence.</p> <p>The goal of the current study was to address the critical unmet need for the development of efficacious psychosocial interventions for adults with ASD by utilizing an innovative intervention with emerging efficacy in children and adolescents (Corbett et al., [<reflink idref="bib16" id="ref87">16</reflink>], [<reflink idref="bib20" id="ref88">20</reflink>], [<reflink idref="bib21" id="ref89">21</reflink>]). SENSE Theatre® combines established behavioral techniques alongside theatrical strategies delivered in a peer-mediated, community service model with strong evidence of significant improvement in social competence (i.e., face memory; (Corbett et al., [<reflink idref="bib16" id="ref90">16</reflink>], [<reflink idref="bib20" id="ref91">20</reflink>], [<reflink idref="bib21" id="ref92">21</reflink>])) as well as changes in stress (Corbett et al., [<reflink idref="bib20" id="ref93">20</reflink>]) and anxiety (Corbett et al., [<reflink idref="bib15" id="ref94">15</reflink>]) in children and adolescents with ASD. While previous research has been rigorous and efficacious in youth, the objective of the study was to determine if SENSE Theatre® is effective in impacting salience of social information, which in turn results in improved functional outcomes for adults with ASD.</p> <hd id="AN0182844521-3">Purpose</hd> <p>The purpose of the present study was to examine and extend the impact of SENSE Theatre® on adults with ASD using a randomized (EXP vs. WLC) design measuring social competence across the interdependent model involving neural, cognitive, behavioral and functional levels. Measurements were conducted at pretest, posttest and following a two-month follow-up period. Based on previous studies, the following Hypotheses (Hyp) were made. Hyp 1. Adults with ASD in the EXP group will demonstrate significantly greater posttest IFM index (primary dependent variable (DV)) than the WLC group. Hyp 2.a Adults in the EXP group will demonstrate significantly better posttest social cognition (i.e., Wechsler Memory Scale) and Hyp 2.b social behavior than adults in the WLC (i.e., Vocal Expression, Quality of Rapport). Hyp 3. Adults in the EXP group will demonstrate significantly more growth on functional social outcomes (Social Responsiveness Scale (SRS), Adaptive Behavior Assessment Scale (ABAS)). Hyp 4. The observed gains in social competence at posttest will be maintained at follow-up.</p> <hd id="AN0182844521-4">Methods</hd> <p>The research was carried out in accordance with the Code of Ethics of the World Medical Association (Declaration of Helsinki). The Vanderbilt University Institutional Review Board approved the study. Informed written consent was obtained from adult participants and a Surrogate Rider consent was obtained for six legally conserved participants prior to inclusion in the study.</p> <hd id="AN0182844521-5">Participants</hd> <p>Participants were recruited from a broad community sample via targeted outreach to medical and health-related services, clinics, research registries, regional autism/disability organizations, schools, and social media platforms. Inclusion criteria for the sample required a confirmed diagnosis of ASD based on DSM-5 criteria (APA, [<reflink idref="bib4" id="ref95">4</reflink>]) by a psychologist, pediatrician or psychiatrist with expertise in ASD, which was corroborated by the Autism Diagnostic Observation Schedule (ADOS-2) (Lord et al., [<reflink idref="bib55" id="ref96">55</reflink>]). Participants were required to have a full-scale IQ <uline>≥</uline> 70 (WASI; Wechsler, [<reflink idref="bib90" id="ref97">90</reflink>]). Adults with ASD with intellectual disability were excluded from the study because it is unclear if they will benefit from the intervention due to the demands on broad average cognitive and language ability. Moreover, previous research examining the efficacy of the treatment with youth has been conducted on individuals with IQ <uline>≥</uline> 70 (Corbett et al., [<reflink idref="bib21" id="ref98">21</reflink>], [<reflink idref="bib22" id="ref99">22</reflink>]). Participants with current, frequent, and uncontrolled aggression toward other persons or property in the past six months were excluded based on phone screening and questions from the Adult Behavior Checklist (Achenbach, [<reflink idref="bib1" id="ref100">1</reflink>]) (e.g., "Physically attacks people"). The rationale for exclusion based on aggressive behavior was to ensure the safety of all participants, peers and staff.</p> <p>Participants were assigned to either the EXP or WLC across 3 cohorts using a block randomization table created by the university statistics core independent from the research team. Following consent, participants received an ID number that corresponded to group assignment for that number. To conceal group allocation from assessors and coders, individuals naïve to treatment assignment conducted outcome assessments.</p> <p>The eligible sample consisted of 64 participants between 18 and 40 years randomized to EXP (<emph>N</emph> = 29) or WLC (<emph>N</emph> = 35); however, analyses were conducted on a final sample of 47 participants who completed a per protocol number of <uline>≥</uline> 7 of 10 sessions (see CONSORT Diagram Fig. 1 for details). Power analyses using effect sizes from a previous recent RCT of the intervention (Corbett et al., [<reflink idref="bib21" id="ref101">21</reflink>]) indicated a target sample size of 40 subjects with 10% attrition is sufficient to obtain 80% power.</p> <p>Graph: Fig. 1 Consort Diagram. Note: CONSORT = Consolidated Standards of Reporting Trials; Footnotes: a Completed "per protocol" intervention (i.e., attended ≥ 7 intervention sessions), bData from subjects who completed "per protocol" intervention and at least one Primary or Secondary DV at Pretest, Posttest, or Follow-Up.</p> <p>The demographic data are presented in Table 1. The mean age was 24.30 years across the groups. The sex distribution was nearly evenly distributed with 31 (48%) females and 33 (52%) males. The racial and ethnic characterization of the sample was comprised of 10.9% Black, 75.0% White, 1.6% Asian, and 12.5% multiracial. There were 4.7% Hispanic and 95.3% non-Hispanic participants.</p> <p>Table 1 Demographic and pretest variables</p> <p> <ephtml> <table frame="hsides" rules="groups"><thead><tr><th align="left"><p>Variable</p></th><th align="left" colspan="2"><p>EXP</p><p>(<italic>N</italic> = 29)</p></th><th align="left" colspan="2"><p>WLC</p><p>(<italic>N</italic> = 35)</p></th><th align="left"><p>Test Statistic</p></th><th align="left"><p><italic>p</italic></p></th></tr><tr><th align="left" /><th align="left"><p><italic>M</italic></p></th><th align="left"><p><italic>SD</italic></p></th><th align="left"><p><italic>M</italic></p></th><th align="left"><p><italic>SD</italic></p></th><th align="left" /><th align="left" /></tr></thead><tbody><tr><td align="left"><p><bold>Demographics</bold></p></td><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left"><p> Age</p></td><td char="." align="char"><p>24.48</p></td><td char="." align="char"><p>4.92</p></td><td char="." align="char"><p>24.30</p></td><td char="." align="char"><p>5.97</p></td><td align="left"><p>t(62) = -0.001</p></td><td char="." align="char"><p>0.999</p></td></tr><tr><td align="left"><p> WASI-II (FSIQ-4)</p></td><td char="." align="char"><p>102.45</p></td><td char="." align="char"><p>17.21</p></td><td char="." align="char"><p>103.06</p></td><td char="." align="char"><p>22.86</p></td><td align="left"><p>t(61) = -0.12</p></td><td char="." align="char"><p>0.91</p></td></tr><tr><td align="left"><p> ADOS-2</p></td><td char="." align="char"><p>7.34</p></td><td char="." align="char"><p>1.86</p></td><td char="." align="char"><p>7.51</p></td><td char="." align="char"><p>1.62</p></td><td align="left"><p>t(62) = -0.39</p></td><td char="." align="char"><p>0.698</p></td></tr><tr><td align="left"><p> SCQ-L</p></td><td char="." align="char"><p>17.83</p></td><td char="." align="char"><p>7.78</p></td><td char="." align="char"><p>16.32</p></td><td char="." align="char"><p>7.4</p></td><td align="left"><p>t(53) = 0.716</p></td><td char="." align="char"><p>0.477</p></td></tr><tr><td align="left"><p><bold>Pretest Variables</bold></p></td><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left"><p> ERP/IFM</p></td><td char="." align="char"><p>0.2944</p></td><td char="." align="char"><p>1.55727</p></td><td char="." align="char"><p>0.106</p></td><td char="." align="char"><p>1.91583</p></td><td align="left"><p>F(1,58) = 0.173</p></td><td char="." align="char"><p>0.679</p></td></tr><tr><td align="left"><p> WMS-III (Faces II)</p></td><td char="." align="char"><p>7.17</p></td><td char="." align="char"><p>3.048</p></td><td char="." align="char"><p>7.19</p></td><td char="." align="char"><p>2.428</p></td><td align="left"><p>t(58) = -0.03</p></td><td char="." align="char"><p>0.976</p></td></tr><tr><td align="left"><p> CASS</p></td><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left"><p> Vocal Expressiveness</p></td><td char="." align="char"><p>4.62</p></td><td char="." align="char"><p>1.498</p></td><td char="." align="char"><p>4.00</p></td><td char="." align="char"><p>1.366</p></td><td align="left"><p>t(58) = 1.679</p></td><td char="." align="char"><p>0.099</p></td></tr><tr><td align="left"><p> Quality of Rapport</p></td><td char="." align="char"><p>4.83</p></td><td char="." align="char"><p>1.441</p></td><td char="." align="char"><p>4.59</p></td><td char="." align="char"><p>1.132</p></td><td align="left"><p>t(59) = 0.708</p></td><td char="." align="char"><p>0.482</p></td></tr><tr><td align="left"><p> SRS-2</p></td><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left"><p> Total Score</p></td><td char="." align="char"><p>67.04</p></td><td char="." align="char"><p>11.107</p></td><td char="." align="char"><p>67.00</p></td><td char="." align="char"><p>9.829</p></td><td align="left"><p>t(57) = 0.013</p></td><td char="." align="char"><p>0.990</p></td></tr><tr><td align="left"><p> Social Cognition</p></td><td char="." align="char"><p>64.0</p></td><td char="." align="char"><p>9.611</p></td><td char="." align="char"><p>64.74</p></td><td char="." align="char"><p>9.476</p></td><td align="left"><p>t(57) = -0.298</p></td><td char="." align="char"><p>0.767</p></td></tr><tr><td align="left"><p> Social Communication</p></td><td char="." align="char"><p>67.14</p></td><td char="." align="char"><p>10.255</p></td><td char="." align="char"><p>64.87</p></td><td char="." align="char"><p>10.683</p></td><td align="left"><p>t(57) = 0.831</p></td><td char="." align="char"><p>0.409</p></td></tr><tr><td align="left"><p> Social Motivation</p></td><td char="." align="char"><p>64.39</p></td><td char="." align="char"><p>12.05</p></td><td char="." align="char"><p>67.74</p></td><td char="." align="char"><p>11.43</p></td><td align="left"><p>t(57) = -1.095</p></td><td char="." align="char"><p>0.278</p></td></tr><tr><td align="left"><p> Social Awareness</p></td><td char="." align="char"><p>61.07</p></td><td char="." align="char"><p>11.349</p></td><td char="." align="char"><p>58.58</p></td><td char="." align="char"><p>8.131</p></td><td align="left"><p>t(57) = 0.976</p></td><td char="." align="char"><p>0.333</p></td></tr><tr><td align="left"><p> SCI</p></td><td char="." align="char"><p>66.36</p></td><td char="." align="char"><p>10.695</p></td><td char="." align="char"><p>65.90</p></td><td char="." align="char"><p>9.779</p></td><td align="left"><p>t(57) = 0.17</p></td><td char="." align="char"><p>0.454</p></td></tr><tr><td align="left"><p> ABAS Social Composite</p></td><td char="." align="char"><p>84.08</p></td><td char="." align="char"><p>11.02</p></td><td char="." align="char"><p>80.43</p></td><td char="." align="char"><p>15.373</p></td><td align="left"><p>t(54) = 1.005</p></td><td char="." align="char"><p>0.319</p></td></tr></tbody></table> </ephtml> </p> <p> <emph>Note.</emph> EXP = Experimental Group; WLC = Waitlist Control Group; WASI-II = Wechsler Abbreviated Scale of Intelligence Second Edition; ADOS-2 = Autism Diagnostic Observation Schedule, Second Edition; SCQ-L = Social Communication Questionnaire, Lifetime Form; ERP/IFM = Event Related Potential/Incidental Face Memory; WMS-III (Faces II) = Wechsler Memory Scale, Third Edition—Faces II Subtest; CASS = Contextual Assessment of Social Skills; SRS-2 = Social Responsiveness Scale, Second Edition (SCI Subscale = Social Communication and Interaction); ABAS-3 = Adaptive Behavior Assessment System Third Edition</p> <hd id="AN0182844521-6">Diagnostic Procedures</hd> <p> <emph>Autism Diagnostic Observation Schedule</emph> (ADOS-2; (Lord et al., [<reflink idref="bib55" id="ref102">55</reflink>]) is a semi-structured interview and series of activities to assess behaviors indicative of autism. A Module 4 score consistent with ASD was required for inclusion. The ADOS-2 Module 4 was administered by research-reliable personnel.</p> <p> <emph>Wechsler Abbreviated Scale of Intelligence</emph> (WASI; (Wechsler, [<reflink idref="bib90" id="ref103">90</reflink>]) is a measure of cognitive ability used to obtain a quick, reasonable estimate of an adult's intellectual functioning (IQ <uline>≥</uline> 70 required). The composite IQ score was used.</p> <p> <emph>Social Communication Questionnaire</emph> (Rutter et al., [<reflink idref="bib71" id="ref104">71</reflink>]) is a screening tool for ASD completed by parents or other adult informants. Scores of 15 or higher are highly suggestive of ASD.</p> <hd id="AN0182844521-7">Intervention</hd> <p>The SENSE Theatre® intervention consisted of ten 2-hour sessions that occurred once a week (i.e., Saturday) as well as two days of technical and dress rehearsals, which culminated in the performance of a 45-minute play.</p> <p>The SENSE Theatre® approach involves: (<reflink idref="bib1" id="ref105">1</reflink>) highly interactive, trained <bold>peers</bold> to facilitate social engagement and communication, (<reflink idref="bib2" id="ref106">2</reflink>) theatrical <bold>play</bold> which enhances motivation to engage with others, and (<reflink idref="bib3" id="ref107">3</reflink>) a <bold>performance</bold> approach allowing participants to actively practice newly learned skills in a safe, supportive environment. The theatre provides an inclusive space with receptive and trained social partners. Thus, it gives the autistic adult the chance to observe and actively engage in reciprocal social interactions with accepting peers who serve as expert models of social communication. The original SENSE Theatre® copyrighted manual was generally applied with modifications. Specifically, the implementation for the adult participants included: (<reflink idref="bib1" id="ref108">1</reflink>) having trained adult peers, (<reflink idref="bib2" id="ref109">2</reflink>) more age-appropriate theatrical play themes (e.g., becoming an adult, social relationships), and (<reflink idref="bib3" id="ref110">3</reflink>) individualized character development (e.g., creation of personal monologues and performance goals).</p> <p>All participants completed pretest (before the EXP group treatment), posttest (after EXP treatment), and follow-up assessments (two months after EXP treatment). The EXP group received the SENSE Theatre® intervention first. The WLC group completed the intervention after the final follow-up visit; they were not assessed after the treatment.</p> <p>Participants were asked to keep non-project treatments stable for at least one month prior and without anticipated changes in the frequency or intensity of these treatments throughout the duration of the study. Participants kept all outside relevant interventions (i.e., social and/or communication skills) stable. Of the total sample, 3 participants initiated psychotherapy specifically for anxiety/depression at the mid-point (WLC = 1, EXP = 1) or posttest (EXP = 1). One other participant in the WLC started an SSRI after post-intervention assessments.</p> <hd id="AN0182844521-8">Peer Selection</hd> <p>Peers were 18 years of age or older and primarily recruited among Vanderbilt University undergraduate students (e.g., theatre, neuroscience, psychology majors) who sought clinical and research training opportunities. Prospective peers completed an interview with the PI and key personnel trained in clinical psychology to confirm their good reciprocal social communication skills and expressed interest in working with individuals with ASD. The comprehensive interview also ascertained prior personal or professional experience working with autistic or neurodiverse individuals. Involvement in the program was voluntary, yet written consent was required.</p> <p>Casting and peer assignment was determined by the PI and the Theatre Director based on theatrical experience, understanding of the model, and previous experience working with people with disabilities. When possible, peers and participants were matched based on sex/gender and age; however, other important determinants included the personality and skill set of the peer and functioning level of the participant.</p> <hd id="AN0182844521-9">Peer Training</hd> <p>The intervention was supervised by the PI and clinical research staff, yet primarily implemented by trained peers. The peers participated in a full day of comprehensive training on ASD, behavioral intervention techniques, and the SENSE Theatre® model. The training involved formal presentations (e.g., autism, core objectives), invited speakers (e.g., adult with ASD, parent of an adult with ASD), relevant topics (e.g., confidentiality), and practice of theatrical strategies (e.g., role-play, mirroring). Videotaped role-plays of target skills simplified for use with the peers (Bellini, [<reflink idref="bib8" id="ref111">8</reflink>]; Maurice et al., [<reflink idref="bib59" id="ref112">59</reflink>]) were provided. The peer-mediated intervention follows a hierarchical support model that involves active shaping of support in the beginning and gradual fading of supervision as skills are acquired. Weekly 15- to 30-min meetings were conducted with the peers prior to intervention sessions to answer questions, review objectives, and prevent drift. At the end of each day, process sessions gave peers the opportunity to discuss their experiences, obtain suggestions, and receive supportive feedback.</p> <hd id="AN0182844521-10">Treatment Fidelity & Acceptability</hd> <p>As in previous studies, design, training, and delivery fidelity were measured (Ory et al., [<reflink idref="bib65" id="ref113">65</reflink>]). Design fidelity was addressed by utilizing outlined sessions and training logs. Training fidelity was tested by an exam containing 20 questions pertaining to basic knowledge of ASD, the SENSE Theatre® model, and behavioral methods, conducted at the beginning and the end of the full day training. Delivery fidelity was implemented during sessions 1, 3, 5 and 7 by rating peer implementation based on the 10 core objectives and 6 behavioral techniques using a behaviorally anchored five-point Likert scale reported as percentages. Peers who achieved a score of 4 or 5 were deemed satisfactory.</p> <hd id="AN0182844521-11">Dependent Measures</hd> <p>We examined the significance and size of treatment effects on social brain, cognition, behavior and function using objective measures, naïve raters, and standardized clinical outcomes.</p> <hd id="AN0182844521-12">Measure of Social Brain -– Primary Target</hd> <p> <emph>ERP Incidental Memory for Faces (IFM) Paradigm (</emph>Key & Corbett, [<reflink idref="bib42" id="ref114">42</reflink>]<emph>)</emph>, is a non-verbal measure of social salience; specifically, face memory. Stimuli include social and nonsocial stimuli; 51 color photographs of unfamiliar faces (Radboud Faces Database (Langner et al., [<reflink idref="bib48" id="ref115">48</reflink>]), 51 color photographs of unfamiliar houses (façade view), and a drawing of a yellow smiley face. One of the unfamiliar faces and one of the houses was randomly selected and repeated 50 times throughout the experiment, yielding a unique set of 50 repeated faces and houses for each participant. Each of the remaining face/house stimuli was presented once (50 trials). From the viewing distance of 90 cm, the stimuli subtended visual angles of 19˚ (h) x 16˚(w). The yellow smiley face was 14.5 cm (9.21˚) in diameter. All stimuli were presented in random order for 1500 ms with a random inter-stimulus interval of 1300–1600 ms to prevent habituation and development of trial onset expectations. To monitor attention to the stimuli, participants were asked to press a response button when they saw the yellow smiley face (10 trials total, brain responses to this stimulus was not analyzed). Stimulus presentations were controlled by E-prime (v.2.0, PST, Inc., Pittsburgh, PA). The task (210 trials) lasted approximately 12 min. Although we are examining a parietal response overlapping the 300-500ms window, it is not the classic P300 because the task is passive, and the repeated and novel stimuli are presented with equal probability (not an oddball). We interpret the observed ERP component to represent change in activity of the fronto-parietal attentional control network (Cole et al., [<reflink idref="bib12" id="ref116">12</reflink>]; Lin et al., [<reflink idref="bib54" id="ref117">54</reflink>]) as part of the 'old/new' response previously labeled 'P600' (400-900ms window; (Wilding, [<reflink idref="bib93" id="ref118">93</reflink>]) in studies of active memorization and known to occur earlier for face stimuli (255–650 ms; Nelson et al., [<reflink idref="bib63" id="ref119">63</reflink>]).</p> <p> <emph>EEG Acquisition</emph>. Each participant was tested individually and in accordance with best practices for EEG data collection in ASD (Webb et al., [<reflink idref="bib87" id="ref120">87</reflink>]). The ERP signals were recorded using 128-channel hydrocel sensor net (Electrical Geodesics, Inc; Eugene, OR) with vertex reference and NetAmps 400 amplifier. The EEG was recorded using NetStation (v. 5.4), sampled at 250 Hz with filters set at 0.1–100 Hz. EEG signal was continuously monitored and during periods of motor activity or inattention, stimulus presentation was suspended until behavior settled. Single-trial ERPs were derived by segmenting EEG on stimulus onset to include a 100-ms baseline and a 900-ms post-stimulus interval and prepared for statistical analyses using standard procedures (e.g. (Key et al., [<reflink idref="bib43" id="ref121">43</reflink>])). Participants with less than 10 artifact-free trials per condition were excluded from analyses. Incidental face memory (IFM) was quantified as the difference in mean ERP amplitudes between repeated and single presentations at the parietal scalp locations within 250–500 ms after stimulus onset (Corbett et al., [<reflink idref="bib21" id="ref122">21</reflink>]; Key & Corbett, [<reflink idref="bib42" id="ref123">42</reflink>]).</p> <hd id="AN0182844521-13">Measure of Social Cognition</hd> <p> <emph>Wechsler Memory Scale (WMS-III) Faces</emph> (WMS-F) (Wechsler, [<reflink idref="bib88" id="ref124">88</reflink>]). The WMS-F task examines the extent to which adults can recognize and recall a series of 24 photographs of faces. In the task, the participant is initially exposed to 24 faces for 2-sec each, then asked to identify the previously shown faces in a series of 48 faces (Faces I). Following a 30-min delay, the participant is again asked to identify the faces amidst 48 faces (Faces II). WMS-F has been used in studies showing that adults with ASD are impaired in face memory (Williams et al., [<reflink idref="bib94" id="ref125">94</reflink>]) and it has also been used to test the impact of face expertise training in ASD (Faja et al., [<reflink idref="bib25" id="ref126">25</reflink>]).</p> <hd id="AN0182844521-14">Measure of Social Behavior</hd> <p> <emph>Contextual Assessment of Social Skills</emph> (CASS<bold>)</bold> (Ratto et al., [<reflink idref="bib70" id="ref127">70</reflink>]) is a direct observation measure of social competence explicitly developed for use with individuals with ASD. The CASS consists of two brief role-play conversations with two similar-age, opposite-gender, unfamiliar confederates. It measures the extent to which an individual adapts behavior to changing social context across the Interested condition (I-CASS; confederate shows social interest, engaged verbal and non-verbal demeanor) and Bored condition (B-CASS; another confederate displays bored/disinterested demeanor with minimal eye contact and verbal and nonverbal responding). Consistent with other studies (Corbett et al., [<reflink idref="bib22" id="ref128">22</reflink>]), only the CASS-I was used in the analysis as past studies show the CASS-I condition yielded variables sensitive to treatment effects (Dolan et al., [<reflink idref="bib23" id="ref129">23</reflink>]; Rabin et al., [<reflink idref="bib69" id="ref130">69</reflink>]; White et al., [<reflink idref="bib92" id="ref131">92</reflink>]). The CASS was developed for young adults with ASD and has been used to measure treatment outcomes in adults (White et al., [<reflink idref="bib92" id="ref132">92</reflink>]) as well as in children and adolescents with ASD (Corbett et al., [<reflink idref="bib22" id="ref133">22</reflink>]; Dolan et al., [<reflink idref="bib23" id="ref134">23</reflink>]). Based on prior studies reporting demonstrable CASS changes following a social skills intervention (Corbett et al., [<reflink idref="bib22" id="ref135">22</reflink>]; Laugeson et al., [<reflink idref="bib50" id="ref136">50</reflink>]), two indices were selected: <emph>Vocal Expressiveness</emph> (degree to which the participant varies the tempo, pitch, tone, volume and/or rhythm of speech) and <emph>Quality of Rapport</emph> (degree of rapport and reciprocity between the participant and confederate). Raters were trained to reliability and naïve to group assignment or assessment period when coding video recordings.</p> <hd id="AN0182844521-15">Measure of Social Functioning</hd> <p> <emph>Social Responsiveness Scale, Second Edition</emph> (SRS-2) (Constantino & Gruber, [<reflink idref="bib14" id="ref137">14</reflink>]) covers several areas of behavior characteristic of autism: namely, Awareness, Cognition, Communication, Motivation and Restricted, Repetitive Behaviors. Standard scores of 60 or higher represent clinically significant difficulty in reciprocal social functioning. Due to the age of the participants and inconsistent access to informants, the self-report form was used. Internal consistency ranges from 0.77 to 0.90 and test-retest ranges from 0.77 to 0.88. The SRS has been used as a functional outcome measure in treatment studies in ASD (Corbett et al., [<reflink idref="bib21" id="ref138">21</reflink>]; Hardan et al., [<reflink idref="bib30" id="ref139">30</reflink>]; Hendren et al., [<reflink idref="bib35" id="ref140">35</reflink>]; LaGasse, [<reflink idref="bib46" id="ref141">46</reflink>]; Laugeson & Park, [<reflink idref="bib49" id="ref142">49</reflink>]; Yui et al., [<reflink idref="bib96" id="ref143">96</reflink>]). The SRS has been validated for use in adults, showing concurrent and predictive validity, and strong convergent and discriminant validity (Chan et al., [<reflink idref="bib10" id="ref144">10</reflink>]). Also, strong correlations with face memory and the SRS have been shown supporting its use as a linked functional outcome of the treatment (Corbett et al., [<reflink idref="bib21" id="ref145">21</reflink>]).</p> <hd id="AN0182844521-16">Measure of Adaptive Functioning</hd> <p> <emph>Adaptive Behavior Assessment System-Third Edition</emph> (ABAS-3) (Harrison & Oakland, [<reflink idref="bib32" id="ref146">32</reflink>]) is a measure of adaptive skills in the home and community. Participants completed the Adult self-report. Test-retest reliability for the self-report is 0.65-0.88 for the adaptive skill areas, 0.82-0.89 for the domains, and 0.87 for the general adaptive composite. Previous SENSE Theatre® research (Corbett et al., [<reflink idref="bib19" id="ref147">19</reflink>]) has shown improvement in adaptive functioning of youth with ASD using the ABAS Parent. The ABAS Adult has been used to measure adaptive skills in adults with ASD (Oswald et al., [<reflink idref="bib67" id="ref148">67</reflink>]; Wallace et al., [<reflink idref="bib85" id="ref149">85</reflink>]). To examine socially relevant adaptive skills, the Social Composite Subdomain was examined in analyses.</p> <hd id="AN0182844521-17">Community Involvement</hd> <p>The study design and intervention modifications were informed by key stakeholders (e.g., autistic adults, parents of individuals on the autism spectrum) that participated in a Community Engagement Studio (CES) held one year prior to the initiation of the study. Information gleaned from the stakeholders guided the length of treatment, selection of dependent measures, and content of the theatrical play themes. Moreover, team members of the theatre-based program are autistic adults.</p> <hd id="AN0182844521-18">Statistical Analyses</hd> <p>A series of Analysis of Covariance (ANCOVA) models were used to test the between-group differences on each dependent variable at the immediate posttest and at the follow-up periods separately using the pretest values as a covariate. Independent samples t-tests were used to identify statistically significant differences on all pretest dependent variables. Analyses were performed using SPSS (IBM SPSS Statistics for Macintosh, Version 28.0).</p> <hd id="AN0182844521-19">Results</hd> <p></p> <hd id="AN0182844521-20">Fidelity Results</hd> <p>Delivery fidelity was conducted by research-reliable trainers examining the extent to which peers implemented the program as intended and could range from 0 (no objectives met) to 100 (complete fidelity). Fidelity was conducted during sessions 1, 3, 5, and 7. The mean ratings for the quality of peer implementation of Behavioral Techniques were 95.17 (4.63), 96.89 (5.25), 96.76 (4.37), and 99.00 (2.24), respectively and ratings for the Core Objectives were 97.44 (4.13), 97.21 (3.61), 98.06 (2.41), and 98.20 (4.02), respectively. The results suggest robust and consistent fidelity over time. Training Fidelity was conducted by peers completing pre- and post-testing. The pre-test results for peer training were 0.75 (0.12), while post-test results were 0.85 (0.08) showing good knowledge at baseline and significant improvement following training indicating strong fidelity.</p> <hd id="AN0182844521-21">Preliminary Results</hd> <p>Independent samples t-tests compared initial pretest (T1) difference between the groups on diagnostic and dependent variables. There were no pretest differences for any of the diagnostic measures (age, ADOS or IQ) or dependent variables (See Table 1).</p> <hd id="AN0182844521-22">Primary Results on Dependent Outcome Measures</hd> <p>Multiple levels of Social Competence were measured at Pretest (T1), Posttest (T2) and a two-month Follow-up (T3). ANCOVA assumes homogeneity of variance of the dependent variable is equal across the groups. The homogeneity of variance assumption was tested using Levene's Test of Equality of Error Variance and it was not violated for any of the dependent variables (all <emph>p</emph> > 0.05). Results for each level of Social Competence are reported below and outlined in Table 2.</p> <p>Table 2 Means, standard deviations, and analysis of covariance statistics at posttest</p> <p> <ephtml> <table frame="hsides" rules="groups"><thead><tr><th align="left"><p>Variable</p></th><th align="left" colspan="2"><p>EXP</p></th><th align="left" colspan="2"><p>WLC</p></th><th align="left"><p><italic>F</italic> ratio</p></th><th align="left"><p><italic>df</italic></p></th><th align="left"><p><italic>p</italic></p></th><th align="left"><p><italic>d</italic></p></th></tr><tr><th align="left" /><th align="left"><p><italic>M</italic></p></th><th align="left"><p><italic>SD</italic></p></th><th align="left"><p><italic>M</italic></p></th><th align="left"><p><italic>SD</italic></p></th><th align="left" /><th align="left" /><th align="left" /><th align="left" /></tr></thead><tbody><tr><td align="left"><p>ERP/IFM</p></td><td char="." align="char"><p>0.6588</p></td><td char="." align="char"><p>0.90058</p></td><td char="." align="char"><p>-0.1604</p></td><td char="." align="char"><p>1.17511</p></td><td char="." align="char"><p>6.315</p></td><td char="." align="char"><p>1,30</p></td><td char="." align="char"><p><bold>0.016</bold></p></td><td char="." align="char"><p>0.79</p></td></tr><tr><td align="left"><p>WMS-III (Faces II)</p></td><td char="." align="char"><p>8.35</p></td><td char="." align="char"><p>3.242</p></td><td char="." align="char"><p>7.88</p></td><td char="." align="char"><p>2.740</p></td><td char="." align="char"><p>1.987</p></td><td char="." align="char"><p>1,44</p></td><td char="." align="char"><p>0.166</p></td><td char="." align="char"><p>0.16</p></td></tr><tr><td align="left"><p>CASS</p></td><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left"><p> Vocal Expressiveness</p></td><td char="." align="char"><p>4.82</p></td><td char="." align="char"><p>1.708</p></td><td char="." align="char"><p>4.52</p></td><td char="." align="char"><p>1.648</p></td><td char="." align="char"><p>0.007</p></td><td char="." align="char"><p>1,42</p></td><td char="." align="char"><p>0.932</p></td><td char="." align="char"><p>0.18</p></td></tr><tr><td align="left"><p> Quality of Rapport</p></td><td char="." align="char"><p>5.43</p></td><td char="." align="char"><p>1.409</p></td><td char="." align="char"><p>5.13</p></td><td char="." align="char"><p>1.262</p></td><td char="." align="char"><p>1.539</p></td><td char="." align="char"><p>1,44</p></td><td char="." align="char"><p>0.221</p></td><td char="." align="char"><p>0.22</p></td></tr><tr><td align="left"><p>SRS-2</p></td><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left"><p> Total Score</p></td><td char="." align="char"><p>63.23</p></td><td char="." align="char"><p>9.107</p></td><td char="." align="char"><p>67.50</p></td><td char="." align="char"><p>10.338</p></td><td char="." align="char"><p>3.89</p></td><td char="." align="char"><p>1,43</p></td><td char="." align="char"><p><bold>0.05</bold></p></td><td char="." align="char"><p>-0.44</p></td></tr><tr><td align="left"><p> Social Cognition</p></td><td char="." align="char"><p>60.95</p></td><td char="." align="char"><p>7.730</p></td><td char="." align="char"><p>65.58</p></td><td char="." align="char"><p>10.172</p></td><td char="." align="char"><p>3.602</p></td><td char="." align="char"><p>1,43</p></td><td char="." align="char"><p>0.064</p></td><td char="." align="char"><p>-0.51</p></td></tr><tr><td align="left"><p> Social Communication</p></td><td char="." align="char"><p>62.55</p></td><td char="." align="char"><p>9.917</p></td><td char="." align="char"><p>65.79</p></td><td char="." align="char"><p>11.069</p></td><td char="." align="char"><p>4.314</p></td><td char="." align="char"><p>1,43</p></td><td char="." align="char"><p><bold>0.044</bold></p></td><td char="." align="char"><p>-0.31</p></td></tr><tr><td align="left"><p> Social Motivation</p></td><td char="." align="char"><p>61.23</p></td><td char="." align="char"><p>9.631</p></td><td char="." align="char"><p>69.46</p></td><td char="." align="char"><p>11.002</p></td><td char="." align="char"><p>12.75</p></td><td char="." align="char"><p>1,43</p></td><td char="." align="char"><p><bold>< 0.001</bold></p></td><td char="." align="char"><p>-0.79</p></td></tr><tr><td align="left"><p> Social Awareness</p></td><td char="." align="char"><p>60.50</p></td><td char="." align="char"><p>8.371</p></td><td char="." align="char"><p>58.92</p></td><td char="." align="char"><p>10.008</p></td><td char="." align="char"><p>0.002</p></td><td char="." align="char"><p>1,43</p></td><td char="." align="char"><p>0.965</p></td><td char="." align="char"><p>0.17</p></td></tr><tr><td align="left"><p> SCI</p></td><td char="." align="char"><p>62.73</p></td><td char="." align="char"><p>8.908</p></td><td char="." align="char"><p>67.08</p></td><td char="." align="char"><p>10.198</p></td><td char="." align="char"><p>5.905</p></td><td char="." align="char"><p>1,43</p></td><td char="." align="char"><p><bold>0.019</bold></p></td><td char="." align="char"><p>-0.45</p></td></tr><tr><td align="left"><p>ABAS Social Composite</p></td><td char="." align="char"><p>93.30</p></td><td char="." align="char"><p>15.420</p></td><td char="." align="char"><p>83.87</p></td><td char="." align="char"><p>15.855</p></td><td char="." align="char"><p>5.50</p></td><td char="." align="char"><p>1,43</p></td><td char="." align="char"><p><bold>0.024</bold></p></td><td char="." align="char"><p>0.60</p></td></tr></tbody></table> </ephtml> </p> <p> <emph>Note.</emph> EXP = Experimental Group; WLC = Waitlist Control Group; WASI-II = Wechsler Abbreviated Scale of Intelligence Second Edition; ADOS-2 = Autism Diagnostic Observation Schedule, Second Edition; SCQ-L = Social Communication Questionnaire, Lifetime Form; ERP/IFM = Event Related Potential/Incidental Face Memory; WMS-III (Faces II) = Wechsler Memory Scale, Third Edition—Faces II Subtest; CASS = Contextual Assessment of Social Skills; SRS-2 = Social Responsiveness Scale, Second Edition (SCI Subscale = Social Communication and Interaction); ABAS-3 = Adaptive Behavior Assessment System Third Edition</p> <hd id="AN0182844521-23">Social Brain</hd> <p>Using confirmatory analysis based on previous studies, it was predicted that the IFM index (repeated - single face difference score at Pz) would not be significantly different between the groups at baseline (T1; see Table 1) but would be larger in the EXP than WLC group at Posttest (T2). Results demonstrated that the groups did not differ at T1 (See Table 1). At T2, there was a significant group difference, F(<reflink idref="bib1" id="ref150">1</reflink>,<reflink idref="bib30" id="ref151">30</reflink>) = 6.315, <emph>p</emph> = 0.016, η<sups>2</sups> = 0.139, d = 0.79, showing higher IFM index in the EXP than WLC group (See Fig. 2; Table 2).</p> <p>Graph: Fig. 2 Incidental Face Memory Event-Related Potentials for EXP and WLC groups at T1 (Pretest), T2 (Posttest), and T3 (Follow-up). Note: EXP = Experimental; WLC = Waitlist Control; T1 = Pretest; T2 = Posttest; T3 = Follow-up; ms = milliseconds. Rectangular marker identifies the time window used in the analysis</p> <hd id="AN0182844521-24">Social Cognition</hd> <p>It was hypothesized that adults in the EXP group would demonstrate significantly better social cognition via the Wechsler Memory Scale (WMS), Faces II Subtest at posttest compared to the WLC group. However, results demonstrated no significant between-group differences at T2 (Table 2).</p> <hd id="AN0182844521-25">Social Behavior</hd> <p>Based on previous studies in youth (Corbett et al., [<reflink idref="bib22" id="ref152">22</reflink>]), it was hypothesized that adults in the EXP group would demonstrate significantly better posttest social behavior on the I-CASS than adults in the WLC. While controlling for pre-test scores, no significant differences between groups were observed at posttest for the I-CASS variables of interest (Vocal Expression, Quality of Rapport) (Table 2).</p> <hd id="AN0182844521-26">Social Functioning</hd> <p>Adults in the EXP group were expected to demonstrate significantly more growth from pretest to posttest on functional social outcomes (SRS, ABAS). Results largely supported the hypothesis as the EXP group reported significant functional differences on the SRS in several areas of social functioning including Communication (<emph>p</emph> = 0.044), Social Communication and Interaction (SCI) (<emph>p</emph> = 0.019), Social Motivation (p < 0.001; Fig. 3), and the SRS Total Score (<emph>p</emph> = 0.05). There was also a trend for Cognition (<emph>p</emph> = 0.064). Further, participants in the EXP group demonstrated a significant increase in adaptive social functioning compared to the WLC group as measured by the ABAS Social Composite Score (<emph>p</emph> = 0.024). Full SRS and ABAS results are available in Table 2.</p> <p>Graph: Fig. 3 Clustered Bar Mean of Social Responsiveness Scale Motivation for Pretest, Posttest and Follow-up for EXP and WLC. Note: SRS = Social Responsiveness Scale; Pre = Pretest; Post = Posttest; EXP = Experimental; WLC = Waitlist Control; Mean = Mean for Motivation T-Scores.</p> <hd id="AN0182844521-27">Follow-up (T3)</hd> <p>It was hypothesized that the observed gains in social competence at posttest would be maintained at follow-up. Except for Social Motivation, F(<reflink idref="bib1" id="ref153">1</reflink>,<reflink idref="bib40" id="ref154">40</reflink>) = 4.445, <emph>p</emph> = 0.041, η<sups>2</sups> = 0.100, d = -0.77 (Fig. 3), there were no significant gains maintained at follow-up across the social cognition, behavioral and functional outcomes (<emph>p</emph> > 0.05). Complete results are displayed in Table 3.</p> <p>Table 3 Means, standard deviations, and analysis of covariance statistics at follow-up</p> <p> <ephtml> <table frame="hsides" rules="groups"><thead><tr><th align="left"><p>Variable</p></th><th align="left" colspan="2"><p>EXP</p></th><th align="left" colspan="2"><p>WLC</p></th><th align="left"><p><italic>F</italic> ratio</p></th><th align="left"><p><italic>df</italic></p></th><th align="left"><p><italic>p</italic></p></th><th align="left"><p><italic>d</italic></p></th></tr><tr><th align="left" /><th align="left"><p><italic>M</italic></p></th><th align="left"><p><italic>SD</italic></p></th><th align="left"><p><italic>M</italic></p></th><th align="left"><p><italic>SD</italic></p></th><th align="left" /><th align="left" /><th align="left" /><th align="left" /></tr></thead><tbody><tr><td align="left"><p>ERP/IFM</p></td><td char="." align="char"><p>0.469</p></td><td char="." align="char"><p>1.279</p></td><td char="." align="char"><p>-0.77</p></td><td char="." align="char"><p>1.869</p></td><td char="." align="char"><p>1.161</p></td><td char="." align="char"><p>1,37</p></td><td char="." align="char"><p>0.288</p></td><td char="." align="char"><p>0.346</p></td></tr><tr><td align="left"><p>WMS-III (Faces II)</p></td><td char="." align="char"><p>8.35</p></td><td char="." align="char"><p>4.052</p></td><td char="." align="char"><p>8.05</p></td><td char="." align="char"><p>3.184</p></td><td char="." align="char"><p>0.965</p></td><td char="." align="char"><p>1,42</p></td><td char="." align="char"><p>0.331</p></td><td char="." align="char"><p>0.08</p></td></tr><tr><td align="left"><p>CASS</p></td><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left"><p> Vocal Expressiveness</p></td><td char="." align="char"><p>4.30</p></td><td char="." align="char"><p>1.917</p></td><td char="." align="char"><p>4.26</p></td><td char="." align="char"><p>1.485</p></td><td char="." align="char"><p>0.026</p></td><td char="." align="char"><p>1,39</p></td><td char="." align="char"><p>0.873</p></td><td char="." align="char"><p>0.02</p></td></tr><tr><td align="left"><p> Quality of Rapport</p></td><td char="." align="char"><p>5.00</p></td><td char="." align="char"><p>1.168</p></td><td char="." align="char"><p>4.85</p></td><td char="." align="char"><p>1.226</p></td><td char="." align="char"><p>0.438</p></td><td char="." align="char"><p>1,40</p></td><td char="." align="char"><p>0.512</p></td><td char="." align="char"><p>0.13</p></td></tr><tr><td align="left"><p>SRS-2</p></td><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left"><p> Total Score</p></td><td char="." align="char"><p>62.76</p></td><td char="." align="char"><p>10.183</p></td><td char="." align="char"><p>65.77</p></td><td char="." align="char"><p>8.815</p></td><td char="." align="char"><p>0.746</p></td><td char="." align="char"><p>1,40</p></td><td char="." align="char"><p>0.393</p></td><td char="." align="char"><p>-0.32</p></td></tr><tr><td align="left"><p> Social Cognition</p></td><td char="." align="char"><p>62.00</p></td><td char="." align="char"><p>7.376</p></td><td char="." align="char"><p>64.95</p></td><td char="." align="char"><p>9.529</p></td><td char="." align="char"><p>0.898</p></td><td char="." align="char"><p>1,40</p></td><td char="." align="char"><p>0.349</p></td><td char="." align="char"><p>-0.35</p></td></tr><tr><td align="left"><p> Social Communication</p></td><td char="." align="char"><p>62.05</p></td><td char="." align="char"><p>10.181</p></td><td char="." align="char"><p>65.45</p></td><td char="." align="char"><p>11.083</p></td><td char="." align="char"><p>3.217</p></td><td char="." align="char"><p>1,40</p></td><td char="." align="char"><p>0.080</p></td><td char="." align="char"><p>-0.32</p></td></tr><tr><td align="left"><p> Social Motivation</p></td><td char="." align="char"><p>61.48</p></td><td char="." align="char"><p>12.331</p></td><td char="." align="char"><p>69.55</p></td><td char="." align="char"><p>8.262</p></td><td char="." align="char"><p>4.445</p></td><td char="." align="char"><p>1,40</p></td><td char="." align="char"><p><bold>0.041</bold></p></td><td char="." align="char"><p>-0.77</p></td></tr><tr><td align="left"><p> Social Awareness</p></td><td char="." align="char"><p>58.10</p></td><td char="." align="char"><p>9.110</p></td><td char="." align="char"><p>56.55</p></td><td char="." align="char"><p>8.187</p></td><td char="." align="char"><p>0.073</p></td><td char="." align="char"><p>1,40</p></td><td char="." align="char"><p>0.789</p></td><td char="." align="char"><p>0.18</p></td></tr><tr><td align="left"><p> SCI</p></td><td char="." align="char"><p>62.43</p></td><td char="." align="char"><p>10.127</p></td><td char="." align="char"><p>66.77</p></td><td char="." align="char"><p>10.071</p></td><td char="." align="char"><p>2.512</p></td><td char="." align="char"><p>1,40</p></td><td char="." align="char"><p>0.121</p></td><td char="." align="char"><p>-0.43</p></td></tr><tr><td align="left"><p>ABAS Social Composite</p></td><td char="." align="char"><p>92.05</p></td><td char="." align="char"><p>13.559</p></td><td char="." align="char"><p>85.33</p></td><td char="." align="char"><p>15.236</p></td><td char="." align="char"><p>2.499</p></td><td char="." align="char"><p>1,39</p></td><td char="." align="char"><p>0.122</p></td><td char="." align="char"><p>0.47</p></td></tr></tbody></table> </ephtml> </p> <p> <emph>Note.</emph> EXP = Experimental Group; WLC = Waitlist Control Group; WASI-II = Wechsler Abbreviated Scale of Intelligence Second Edition; ADOS-2 = Autism Diagnostic Observation Schedule, Second Edition; SCQ-L = Social Communication Questionnaire, Lifetime Form; ERP/IFM = Event Related Potential/Incidental Face Memory; WMS-III (Faces II) = Wechsler Memory Scale, Third Edition—Faces II Subtest; CASS = Contextual Assessment of Social Skills; SRS-2 = Social Responsiveness Scale, Second Edition (SCI Subscale = Social Communication and Interaction); ABAS-3 = Adaptive Behavior Assessment System Third Edition</p> <hd id="AN0182844521-28">Discussion</hd> <p>Despite clear evidence that social challenges in ASD persist and may worsen in adulthood (Beadle-Brown et al., [<reflink idref="bib7" id="ref155">7</reflink>]; Seltzer et al., [<reflink idref="bib73" id="ref156">73</reflink>]), comparatively few social skill interventions (Kandalaft et al., [<reflink idref="bib40" id="ref157">40</reflink>]; Koehne et al., [<reflink idref="bib44" id="ref158">44</reflink>]; Laugeson et al., [<reflink idref="bib51" id="ref159">51</reflink>]; Spain & Blainey, [<reflink idref="bib77" id="ref160">77</reflink>]; Taylor et al., [<reflink idref="bib80" id="ref161">80</reflink>]; White et al., [<reflink idref="bib92" id="ref162">92</reflink>]) or RCTs (e.g., Ashman et al., [<reflink idref="bib5" id="ref163">5</reflink>]; Gantman et al., [<reflink idref="bib27" id="ref164">27</reflink>]; Oswald et al., [<reflink idref="bib67" id="ref165">67</reflink>]) exist. To address this notable gap, the current study used a multilevel social competence framework (neural, cognitive, behavioral, functional) to examine the impact of SENSE Theatre®, an intervention with established efficacy in youth with ASD, in a group of adults with ASD randomized to EXP or WLC conditions.</p> <p>It was postulated that the key components of peers (e.g., peer-mediation and support), play (e.g., theatrical methods and role play) and performance (e.g., actively engaging in social communication with and in front of others) set the stage to target and enhance core aspects of social competence in autism. Specifically, via increased social attention participants may become better able to recognize individual peers and more adaptively interact with others, which increases their motivation to interact more often, for longer periods, and in more contexts.</p> <p>The primary hypothesis, that adults with ASD in the EXP group would demonstrate significantly greater IFM posttest than the WLC group, was confirmed and consistent with previous studies (Corbett et al., [<reflink idref="bib21" id="ref166">21</reflink>], [<reflink idref="bib17" id="ref167">17</reflink>], [<reflink idref="bib22" id="ref168">22</reflink>]; Ioannou et al., [<reflink idref="bib38" id="ref169">38</reflink>]). As explicated below, the finding suggests the intervention enhances salience for relevant social stimuli. While there were no <emph>direct</emph> effects on social cognition (WMS) or behavior (i.e., Vocal Expressiveness, Overall Rapport) at posttest, adults in the EXP group demonstrated significantly more gains on functional (SRS Social Communication, Motivation) and adaptive (ABAS Social) outcomes at posttest which were partially maintained at follow-up.</p> <p>Face memory is a fundamental social skill necessary for appropriate social development in mammals (Adolphs, [<reflink idref="bib2" id="ref170">2</reflink>]) enabling recognition and categorization of conspecifics (Sclafani et al., [<reflink idref="bib72" id="ref171">72</reflink>]). Frequently observed deficits in face memory (Key & Corbett, [<reflink idref="bib42" id="ref172">42</reflink>]; Langdell, [<reflink idref="bib47" id="ref173">47</reflink>]; Osterling et al., [<reflink idref="bib66" id="ref174">66</reflink>]; Webb et al., [<reflink idref="bib86" id="ref175">86</reflink>]; Weigelt et al., [<reflink idref="bib91" id="ref176">91</reflink>]) persist into adulthood (O'Hearn et al., [<reflink idref="bib64" id="ref177">64</reflink>]; Williams et al., [<reflink idref="bib94" id="ref178">94</reflink>]) and are associated with many aspects of social engagement. Therefore, face memory has been proposed as a primary target of engagement in interventions aimed at enhancing social competence (Corbett et al., [<reflink idref="bib18" id="ref179">18</reflink>]). The increase in social salience of faces reflected in the greater ERP amplitude indexing incidental memory for the repeated image in the current and previous studies of SENSE Theatre® (Corbett et al., [<reflink idref="bib21" id="ref180">21</reflink>], [<reflink idref="bib17" id="ref181">17</reflink>]; Ioannou et al., [<reflink idref="bib38" id="ref182">38</reflink>]) lends strong support for the notion that the treatment results in greater motivational value placed on social stimuli.</p> <p>Despite the significant changes in incidental face memory outlined above, there were no group differences on the WMS-III face task (Wechsler, [<reflink idref="bib89" id="ref183">89</reflink>]), which has previously revealed impairment in autistic adults (Williams et al., [<reflink idref="bib94" id="ref184">94</reflink>]). The WMS-III has been used to show changes in face memory following face expertise training (Faja et al., [<reflink idref="bib25" id="ref185">25</reflink>]); however, that intervention employed explicit rule-based skills training in face identification and memory (e.g., configural processing, core features, and shifting attention within stimuli). In contrast, the SENSE Theatre® intervention does not use direct educational approaches, rather it takes a performance-based approach targeting broader social competence skills. Additionally, the WMS-III may be considered a challenging task with multiple immediate (<reflink idref="bib48" id="ref186">48</reflink>) and delayed stimuli (<reflink idref="bib48" id="ref187">48</reflink>). Anecdotally, several participants remarked on the difficulty and length of the task. Thus, it is unclear if the measure's level of difficulty or repetition resulted in floor effects rendering it less sensitive as a treatment outcome measure for some types of interventions.</p> <p>In addition, the experimental treatment did not have a significant effect on the CASS posttest measures of Vocal Expressiveness or Overall Rapport. The results are somewhat similar to a recent RCT of [SENSE Theatre® in youth that did not show immediate gains on these measures at posttest, rather the follow-up behavioral indices were mediated by posttest IFM (Corbett et al., [<reflink idref="bib22" id="ref188">22</reflink>]). It may be the case that it takes time for gains in the treatment to translate into social interaction with novel peers; however, follow-up measures were also not significant. While the CASS has been used in youth and adults with ASD, it may not be an optimal measure for repeat testing. At posttest and follow-up, some adults shared that they were anticipating meeting new peers that would show interest or boredom behavior, respectively. Such awareness calls into question the utility of using the CASS as a behavioral outcome for some adults on the spectrum. The task uses natural conversation that may be valuable during an initial exposure, yet the insight of the adult participants suggests it may have limited ecological validity for re-exposure. Turner-Brown and colleagues ([<reflink idref="bib83" id="ref189">83</reflink>]) used behavioral observation to examine various components of social communication and found no substantial post-intervention improvement. The specific type of social communication measure that may be sensitive to treatment response in adults warrants additional study.</p> <p>One of the primary goals of a social skills program is to demonstrate perceived functional gains in daily life with other people. In the current study, this was accomplished via self-report in key areas of social and adaptive functioning. For a social skills program to be impactful, improvement needs to be experienced and observed in daily life. Indeed, core diagnostic symptom areas were positively impacted including reciprocal social communication and interaction with others. Autistic adults reported better adaptive functioning in their day-to-day communication and engagement with others following the treatment.</p> <p>In addition to social communication, the strongest group differences were reported by the EXP group regarding social motivation, which lends support for the idea that SENSE Theatre® contributes to increased social salience for peer engagement. The subscale pulls for interest and comfort in social settings and interactions with other people. It has been suggested that interventions that improve social motivation by increasing the salience of social stimuli should enhance social functioning (Chevallier et al., [<reflink idref="bib11" id="ref190">11</reflink>]). Face memory measured by IFM is considered an index of social salience, and remembering a face informs the selection of adaptive social behavior, thereby increasing the likelihood of social success (Corbett et al., [<reflink idref="bib18" id="ref191">18</reflink>]; Hauck, [<reflink idref="bib34" id="ref192">34</reflink>]). It is notable that the strongest outcomes were related to aspects of social motivation pertaining to neural and core functional competence. As with previous studies in youth showing strong correlations with face memory and the SRS (Corbett et al., [<reflink idref="bib21" id="ref193">21</reflink>]), the current findings suggest that SENSE Theatre® is effective in impacting salience of social information (IFM), which in turn results in improved social functional outcomes (SRS) for adults with ASD.</p> <p>Intervention research in adults with ASD has underscored the lack of generalizability in clinical efficacy to real-world contexts (Ashman et al., [<reflink idref="bib5" id="ref194">5</reflink>]). While many post-treatment gains were not maintained, significant differences in social motivation remained at follow-up. As stated, it has been hypothesized that engaging with supportive peers enhances attention to and interest in social stimuli, and this increase in social salience leads to more generalized social attention and motivation to interact with other people (Corbett et al., [<reflink idref="bib18" id="ref195">18</reflink>]). Collectively, the results highlight the importance of targeting social salience to broadly improve social competence.</p> <hd id="AN0182844521-29">Strengths, Limitations, and Future Directions</hd> <p>There are several strengths of this preliminary RCT, which include careful characterization of the sample, inclusion of multimodal objective measures, naïve raters for behavioral protocols, standardized clinical outcomes, and random assignment. Moreover, in contrast to many studies in ASD, nearly half of the sample was female as the study team actively recruits autistic females for greater representation. Despite these assets, there were limitations in participant representation such that the sample did not include individuals with intellectual disability, and most of the participants were White. There was also larger attrition than expected due, in part, to the COVID-19 pandemic, such that even after restrictions were eased, some participants remained reluctant about meeting in-person and thereby dropped from the study after enrollment. Also, in contrast to studies in youth, in which parental involvement facilitated retention, some adult participants did not have invested family members or friends to provide encouragement to remain in the treatment. Though the selection of peers has been historically based on an interview conducted by the PI and study personnel, the addition of a quantitative measure of social communication skills may help to identify necessary skills to serve as an optimal peer.</p> <p>Future studies are aimed at addressing the acknowledged limitations to include a more representative sample. While the study team utilized recruitment resources to enroll minority groups, consideration of expanded explanation of potential treatment benefits and compensation may increase interest and commitment. Finally, a careful examination of outcome measures that may be more ecologically valid for adults with ASD is being taken into consideration. It may be that other treatment gains are not captured by the selection of measures, such as receptive and expressive language, emotion regulation, and positive impact on peer relationships in the community. Therefore, greater consideration of functional outcome measures is warranted.</p> <p>As with many treatment studies, the findings suggest improvement in specific skills; however, the extent to which such skills generalize to other people, settings and contexts is limited. Future work is needed to determine factors that may build on the initial findings to improve generalization of skills. Treatment approaches that generalize to consequential outcomes are needed and an aim of future endeavors.</p> <hd id="AN0182844521-30">Conclusions</hd> <p>Few treatments exist to target social competence in autistic adults. The SENSE Theatre® intervention increases salience of social stimuli in the form of incidental face memory and motivation to engage socially with others. Enhanced social interest provides the opportunity for autistic adults to communicate and engage with others adaptively in their daily lives. Taken together, results lend support to the idea that improving motivation by increasing the salience of social stimuli can lead to improved social functioning (Chevallier et al., [<reflink idref="bib11" id="ref196">11</reflink>]). Findings extend previous research supporting the inclusion of trained peers, utilization of innovative theatre techniques and an active performance-based approach allowing autistic adults the opportunity to learn and engage in reciprocal social interactions in a safe, supportive, and inclusive setting. The theatre provides a welcoming environment in which to learn, practice and perform social skills alongside receptive and encouraging social partners. Clinical interventions, such as SENSE Theatre® that go beyond mere instruction of discrete social skills to promote active, dynamic and reinforced performance, increase the likelihood that growth will be maintained and generalized to other people, settings and contexts.</p> <hd id="AN0182844521-31">Acknowledgements</hd> <p>This study was funded by the National Institute of Mental Health (R33 MH120149 PI: Corbett) with core support from the National Center for Advancing Translational Sciences (CTSA UL1 TR000445) and Eunice Kennedy Shriver National Institute of Child Health and Human Development (P50 HD103537 - Vanderbilt Kennedy Center). The content is solely the responsibility of the authors and does not necessarily represent the official views of the funding agencies (NIMH, NICHD, Vanderbilt University Medical Center). We are grateful for the creative contributions from Leah Lowe, Ph.D. from Vanderbilt University Department of Theatre and Director of the Curb Center.</p> <hd id="AN0182844521-32">Author Contributions</hd> <p>BC conceived of the SENSE Theatre® intervention and study design, conducted peer training, supervised the implementation of the treatment, contributed to diagnostic assessment and drafted and finalized the manuscript; AK developed the ERP paradigm, supervised the ERPs, analyzed and interpreted the ERP data, and contributed to the manuscript: MK coordinated the study visits, facilitated recruitment, prepared study and performance materials, and maintained IRB materials; RAM trained and supervised peer research helpers and students, assisted with implementation of study protocols, and prepared data for statistical analyses; DJ conducted the ERP protocols, facilitated data collection, and participated in ERP data analysis; JP participated in diagnostic assessments, conducted behavioral coding protocols, supervised students and trained naïve coders to reliability; CB contributed to diagnostic and psychological assessments, led fidelity implementation, provided clinical supervision of peers and contributed to interpretation of study findings; SV assisted with study design, conducted statistical analyses and contributed to interpretation of findings. All authors contributed to and read the final manuscript.</p> <hd id="AN0182844521-33">Declarations</hd> <p></p> <hd id="AN0182844521-34">Conflict of interest</hd> <p>Blythe Corbett is the founder of SENSE Theatre® 501(c)(<reflink idref="bib3" id="ref197">3</reflink>) but does not derive any financial compensation from the organization. The other authors declare no conflicts of interest.</p> <hd id="AN0182844521-35">Ethics approval and consent to participate</hd> <p>All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants included in the study.</p> <hd id="AN0182844521-36">Public Health Significance</hd> <p>Few treatments exist to target social competence in adults with autism spectrum disorder (ASD). The present study provides preliminary evidence for a peer-mediated, theatre-based treatment to enhance salience of social stimuli and generalized effects on social functioning in adults with ASD.</p> <hd id="AN0182844521-37">Publisher's Note</hd> <p>Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.</p> <ref id="AN0182844521-38"> <title> References </title> <blist> <bibl id="bib1" idref="ref1" type="bt">1</bibl> <bibtext> Achenbach, T. M. (2001). Manual for the ASEBA School-Age forms & profiles. University of Vermont, Research Center for Children, Youth, & Families.</bibtext> </blist> <blist> <bibl id="bib2" idref="ref106" type="bt">2</bibl> <bibtext> Adolphs R. Social cognition and the human brain. Trends in Cognitive Neuroscience. 1999; 3: 469-479. 10.1016/S1364-6613(99)01399-6</bibtext> </blist> <blist> <bibl id="bib3" idref="ref49" type="bt">3</bibl> <bibtext> Adolphs R. The neurobiology of social cognition. 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Journal of Clinical Psychopharmacology. 2012; 32; 2: 200-206. 10.1097/JCP.0b013e3182485791. 22370992</bibtext> </blist> </ref> <ref id="AN0182844521-39"> <title> Footnotes </title> <blist> <bibtext> At the time of writing this manuscript there is debate regarding the use of terminology and whether <emph>person-first</emph> language in which the individual (e.g., adult) is referenced before the condition (e.g., autism) or whether <emph>identity-first</emph> language (e.g., autistic adult) should be used. Because such issues have not been resolved, we have opted to take a mixed terminology approach. Similarly, we will use the terms <emph>autism</emph>, <emph>autism spectrum disorder</emph> and <emph>autistic</emph> interchangeably.</bibtext> </blist> </ref> <aug> <p>By Blythe A. Corbett; Alexandra P. Key; Mark E. Klemencic; Rachael A. Muscatello; Dorita Jones; Jennifer Pilkington; Christina Burroughs and Simon Vandekar</p> <p>Reported by Author; Author; Author; Author; Author; Author; Author; Author</p> </aug> <nolink nlid="nl1" bibid="bib41" firstref="ref3"></nolink> <nolink nlid="nl2" bibid="bib57" firstref="ref4"></nolink> <nolink nlid="nl3" bibid="bib76" firstref="ref5"></nolink> <nolink nlid="nl4" bibid="bib73" firstref="ref6"></nolink> <nolink nlid="nl5" bibid="bib53" firstref="ref8"></nolink> <nolink nlid="nl6" bibid="bib61" firstref="ref9"></nolink> <nolink nlid="nl7" bibid="bib81" firstref="ref10"></nolink> <nolink nlid="nl8" bibid="bib84" firstref="ref11"></nolink> <nolink nlid="nl9" bibid="bib24" firstref="ref13"></nolink> <nolink nlid="nl10" bibid="bib36" firstref="ref14"></nolink> <nolink nlid="nl11" bibid="bib75" firstref="ref15"></nolink> <nolink nlid="nl12" bibid="bib78" firstref="ref16"></nolink> <nolink nlid="nl13" bibid="bib82" firstref="ref17"></nolink> <nolink nlid="nl14" bibid="bib52" 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  Data: Investigating Social Competence in a Pilot Randomized Clinical Trial of a Theatre-Based Intervention Enhanced for Adults with Autism Spectrum Disorder
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  Data: <searchLink fieldCode="AR" term="%22Blythe+A%2E+Corbett%22">Blythe A. Corbett</searchLink> (ORCID <externalLink term="http://orcid.org/0000-0003-2165-8015">0000-0003-2165-8015</externalLink>)<br /><searchLink fieldCode="AR" term="%22Alexandra+P%2E+Key%22">Alexandra P. Key</searchLink> (ORCID <externalLink term="http://orcid.org/0000-0002-2669-8334">0000-0002-2669-8334</externalLink>)<br /><searchLink fieldCode="AR" term="%22Mark+E%2E+Klemencic%22">Mark E. Klemencic</searchLink> (ORCID <externalLink term="http://orcid.org/0000-0002-8722-6808">0000-0002-8722-6808</externalLink>)<br /><searchLink fieldCode="AR" term="%22Rachael+A%2E+Muscatello%22">Rachael A. Muscatello</searchLink> (ORCID <externalLink term="http://orcid.org/0000-0002-9862-1686">0000-0002-9862-1686</externalLink>)<br /><searchLink fieldCode="AR" term="%22Dorita+Jones%22">Dorita Jones</searchLink><br /><searchLink fieldCode="AR" term="%22Jennifer+Pilkington%22">Jennifer Pilkington</searchLink><br /><searchLink fieldCode="AR" term="%22Christina+Burroughs%22">Christina Burroughs</searchLink> (ORCID <externalLink term="http://orcid.org/0000-0003-3569-9643">0000-0003-3569-9643</externalLink>)<br /><searchLink fieldCode="AR" term="%22Simon+Vandekar%22">Simon Vandekar</searchLink> (ORCID <externalLink term="http://orcid.org/0000-0002-7457-9073">0000-0002-7457-9073</externalLink>)
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  Data: <searchLink fieldCode="SO" term="%22Journal+of+Autism+and+Developmental+Disorders%22"><i>Journal of Autism and Developmental Disorders</i></searchLink>. 2025 55(1):130-146.
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  Data: Springer. Available from: Springer Nature. One New York Plaza, Suite 4600, New York, NY 10004. Tel: 800-777-4643; Tel: 212-460-1500; Fax: 212-460-1700; e-mail: customerservice@springernature.com; Web site: https://link.springer.com/
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  Data: 17
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  Data: 2025
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  Data: National Institute of Mental Health (NIMH) (DHHS/NIH)<br />National Center for Advancing Translational Sciences (NCATS) (DHHS/NIH)<br />Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) (DHHS/NIH)
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  Data: R33MH120149<br />CTSAUL1TR000445
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  Data: Journal Articles<br />Reports - Research
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  Label: Descriptors
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  Data: <searchLink fieldCode="DE" term="%22Autism+Spectrum+Disorders%22">Autism Spectrum Disorders</searchLink><br /><searchLink fieldCode="DE" term="%22Adults%22">Adults</searchLink><br /><searchLink fieldCode="DE" term="%22Interpersonal+Competence%22">Interpersonal Competence</searchLink><br /><searchLink fieldCode="DE" term="%22Interpersonal+Communication%22">Interpersonal Communication</searchLink><br /><searchLink fieldCode="DE" term="%22Theater+Arts%22">Theater Arts</searchLink><br /><searchLink fieldCode="DE" term="%22Enrichment+Activities%22">Enrichment Activities</searchLink><br /><searchLink fieldCode="DE" term="%22Pilot+Projects%22">Pilot Projects</searchLink><br /><searchLink fieldCode="DE" term="%22Feasibility+Studies%22">Feasibility Studies</searchLink><br /><searchLink fieldCode="DE" term="%22Program+Effectiveness%22">Program Effectiveness</searchLink>
– Name: DOI
  Label: DOI
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  Data: 10.1007/s10803-023-06214-0
– Name: ISSN
  Label: ISSN
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  Data: 0162-3257<br />1573-3432
– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: Autism spectrum disorder (ASD) is characterized by challenges in social competence that persist in adulthood, yet few treatment options exist. A pilot randomized clinical trial (RCT) of a peer-mediated, theatre-based intervention with established efficacy in youth with ASD was examined in autistic adults. The final sample consisted of forty-seven 18-to-40-year-old participants randomized to the experimental (EXP N = 23) or waitlist control (WLC N = 24) condition. A multimodal, social interdependent model was employed to examine social competence changes in brain (incidental face memory (IFM) using event-related potentials), cognition (Wechsler Memory Scale-III), behavior (Contextual Assessment of Social Skills) and function (Social Responsiveness Scale (SRS); Adaptive Behavior Assessment Scale (ABAS) Social Composite). Using analysis of covariance in which pretest was controlled in the model, posttest between-group differences were observed on IFM (p = 0.016, n[superscript 2] = 0.139, d = 0.79) and several social and adaptive functional (SRS, ABAS) outcomes in social communication and interaction (SCI) (p = 0.019, n[superscript 2] = 0.121, d = -00.45), communication (p = 0.044 n[superscript 2] = 0.09, d = -00.31), and motivation (p = 0.001, n[superscript 2] = 0.229, d = -0.79) domains. At two-month follow-up, gains in social motivation remained (p = 0.041, n[superscript 2] = 0.100, d = -0.77). The results offer preliminary support for a unique theatre-based social skills intervention for autistic adults who have few treatment options to enhance social competence. The trial was pre-registered with ClinicalTrials.gov (Identifier: NCT04349644).
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  Data: 2025
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        PageCount: 17
        StartPage: 130
    Subjects:
      – SubjectFull: Autism Spectrum Disorders
        Type: general
      – SubjectFull: Adults
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      – SubjectFull: Interpersonal Competence
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      – SubjectFull: Interpersonal Communication
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      – SubjectFull: Theater Arts
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      – TitleFull: Investigating Social Competence in a Pilot Randomized Clinical Trial of a Theatre-Based Intervention Enhanced for Adults with Autism Spectrum Disorder
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            – Type: issn-electronic
              Value: 1573-3432
          Numbering:
            – Type: volume
              Value: 55
            – Type: issue
              Value: 1
          Titles:
            – TitleFull: Journal of Autism and Developmental Disorders
              Type: main
ResultId 1