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Autism: Family Life - Tactics for Getting Normal Again
Autism continuing education psychology CEUs

Section 12
Sharing Humor & Laughter in Autism

CEU Question 12 | CEU Test | Table of Contents | Autism
Counselor CEUs, Social Worker CEUs, Psychologist CEs, MFT CEUs

Everyday humour and laughter can tell us about children's ability to engage with and understand others. A group of 19 pre-school children with autism and 16 pre-school children with Down's syndrome, matched on non-verbal mental age, participated in a cross-sectional study. Parental reports revealed no group differences in overall frequencies of laughter or laughter at tickling, peekaboo or slapstick. However, in the autism group, reported laughter was rare in response to events such as funny faces or socially inappropriate acts, but was common in strange or inexplicable situations. Reported responses to others' laughter also differed: children with autism rarely attempted to join in others' laughter and rarely attempted to re-elicit it through acts of clowning or teasing. Analysis of videotaped interactions also showed no group differences in frequencies of child or adult laughter. However, the children with autism showed higher frequencies of unshared laughter in interactive situations and lower frequencies of attention or smiles in response to others' laughter. Humour is an affective and cultural phenomenon involving the sharing of affect, attention and convention; children with autism show problems in some simple affective and mutual as well as joint attentional and cultural aspects of humorous engagement.

"The tragic (and the dramatic). . . are universal. The comic (is) ... bound to its time, society, cultural anthropology" (Umberto Eco, Travels in hyperreality, 1986)

Humour and laughter are fundamentally relational phenomena and can tell us a lot about the interpersonal, affective, socio-cognitive and cultural skills of young children. Despite their potential as developmental and diagnostic tools, however, we know little about their everyday occurrence in very early development and even less in atypical development. Humour and laughter in children with autism are of particular relevance because their difficulties centre specifically around relating to other people (Hobson, 1989), sharing cultural conventions (Lord, 1993; Loveland, 1991) and understanding others' emotional, attentional and intentional states (Baron-Cohen, 1989; Hobson, 1986a, b; Leslie, 1987; Mundy, 1995), and because the debate surrounding the nature of the primary deficit in autism is still unresolved. The present paper opens up a body of everyday phenomena for investigation in terms of interpersonal understanding and contributes to the debate about social understanding in autism with naturalistic data from children with autism and children with Down's syndrome.

Psychological theories of humour development in recent years have focused mainly on individual cognition, i.e. on the individual's processing of incongruity and its resolution, rather than on social, emotional or cultural processes. However, in older writings, humour and laughter are acknowledged as relational and social phenomena (Bergson, 1911; Freud, 1905; Johnson, 1978; Koestler, 1964; Lowenfield, 1935; Luquet, 1930; Wolfenstein, 1954/1978). A joke may be a joke when even one person laughs at it (Crawford, 1999), but one person's laughter is needed to make a joke funny. Whether humour and laughter could ever develop if they were never shared with another human being may be one of those questions that can only be indirectly answered. That humour exists between people rather than somehow in the joke itself, is also evident from the forms and topics of humour which do not travel well across cultures and contexts. Sharing humour may show a more complex acculturation than sharing tragedy, requiring subtle implicit reference to socio-cultural rules rather than their explicit acknowledgement (Eco, 1986). Sharing laughter with others reveals both cultural and emotional attunement with them, namely a mutuality of interest in the topic of the laughter and/or an interest in the laughter of the others as an affective state in its own right. It is well known that the presence of others facilitates laughter to humorous events in adults and in children (Chapman, 1976; Glenn, 1989) and that laughter itself can be contagious (Provine, 1992). Although no clear evidence exists regarding the onset of contagious or socially facilitated laughter in infancy, it may begin from the middle of the first year (Reddy, personal observation).

The primary focus on cognitive processes underlying humour has led to a dearth of information about humour early in development. The cognitive skills for the humorous appreciation of incongruity (absurdity or the juxtaposition of different frames of reference) are believed to develop after 18 months (McGhee, 1979), although primitive precursors to humour can be seen earlier in laughter in response to tickling, peekaboo and chasing (Shultz, 1976). Potentially humorous behaviour in infants younger than 18 months has consequently been rarely explored, and study of the production and use of humour in actual engagement has been neglected in favour of studies of responses to controlled humorous 'stimuli'.

Early humorous exchanges in typical development
Humorous exchanges are central to social interactions with infants as young as 3 months of age (Ambrose, 1963; Darwin, 1872; Washburn, 1929), and during the first year, developments in infant laughter at humorous events reveal an increase in non-reflexive laughter, an increasing appreciation of culturally inappropriate acts, and a grasp of playful intentions in others. In the middle of the first year, infants laugh mainly at events involving physical or intense sensory contact--especially tactile stimulation such as tickling -- but by 11 or 12 months of age, infants laugh more at distal events such as funny faces and sounds, or events involving socially inappropriate or incongruous acts such as mother waddling like a duck or sucking from the baby bottle (Sroufe & Wunsch, 1972). Laughter at increasingly more complex events may result from a tendency to respond most positively to challenges that are just at the edge of their capacities (Sroufe & Wunsch, 1972; Zigler, Levine, & Gould, 1966), and newly discovered patterns and norms are often violated and distorted in fun and exploration (Garvey, 1977; Groos, 1901/1976). Infant laughter at the violation of social expectancies (Sroufe & Wunsch, 1972) reveals the infant's grasp of the social conventions governing the use of objects and the performance of actions, and infant laughter at others' teasing and joking shows an understanding of playful versus serious intentions in others (Nakano & Kanaya, 1993; Trevarthen & Hubley, 1978).

From around 10 months of age, infants begin to be active humorists as well as appreciative respondents, laughing before rather than after the termination of humorous events (Sroufe & Wunsch, 1972), initiating key aspects of familiar playful sequences themselves (Bruner & Sherwood, 1976) and initiating novel games and humorous interactions as well as routine ones (Bates, Benigni, Bretherton, Camaioni, & Volterra, 1979; Reddy, 1991; Trevarthen & Hubley, 1978). Mischief begins at this age, specifically teasing and clowning, aimed at provoking laughter and other emotional reactions in others (Reddy, 1991). Clowning may involve the ritual violation of the sacred (Handelman, 1981), and the ability to accept intimacy (Lowenfield, 1935), but at its simplest level involves sensitivity to others' amusement and the repetition of, often exaggerated, acts that have previously elicited laughs. Teasing others requires some understanding of others' emotional attitudes, expectations and intentions (Dunn, 1988; Leekam, 1991; Nakano & Kanaya, 1993; Reddy, 1991; Stern, 1985) and the provocative violation of social understandings, conventions and agreements (Alford, 1983; Miller, 1986; Pawluk, 1989; Reddy, 1991). Clowning and teasing require two corresponding 'skills' in both the comic and their 'audience': one, an interest in others' emotional reactions and a desire to elicit them (or let them be elicited); and two, the ability to perceive (and respond to) causal links between one's actions and others' reactions. Teasing, in addition, requires a shared knowledge of social meanings, conventions and agreements that may then be playfully violated. Both clowning and teasing maybe precursors of joint attentional abilities (Bakeman & Adamson, 1984; Mundy, Sigman, & Kasari, 1993) as they involve the infant's active directing of others' attention to acts by the self before infants are able to direct attention to external targets (Reddy, Hay, Murray, & Trevarthen, 1997; Reddy, 1998, 1999).

Evidence of humour and laughter in autism
Evidence about humour in autism is sparse. Older writings and some anecdotal reports suggest that 'seeing the funny side of things' is a problem in autism, as is laughing in moderation or in balance with others (Asperger, 1952/1991; Lord, 1993). In typical development, humour is related to behaviours less evident in autism; playfulness, curiosity and disobedience (Barnett, 1991). Children with autism have deficits in 'showing-off' or drawing attention to themselves or to their acts (Dahlgren & Gillberg, 1989; Wetherby & Prutting, 1984), although it is unclear whether this extends to clowning. Although older autistic children are reported to tease, the nature of this teasing is unclear (Kanner, 1943; Lord, 1993), and while children with autism and Asperger's syndrome often get teased by peers, they are reported to have particular difficulty in responding to teasing with understanding, thus perhaps increasing the likelihood of being teased (Asperger, 1952/1991; Wing, 1991).

The very few recent studies on this topic suggest that children and adults with autism may not have a problem with humour per se, but only with humour involving complex cognitive skills. High functioning adults with autism produce a variety of forms of humour, including verbal and conceptual incongruities, multiple meanings and jocular acts of pretence with the functions of objects, and only show deficits in humour with high cognitive demands (Van Bourgondien & Mesibov, 1987). Parents of school-age children with autism do, however, report some problems in humour-related interactions, particularly in relation to clowning rather than to teasing (Briscall, 1995). In the only available exploration of humour and laughter in young school-age children with autism, St James and Tager-Flusberg (1994) suggest that the simpler forms of humorous interaction (which typically occur in the first year of infancy) may be unaffected. They observed parent-child interactions in the home for six children with autism and six children with Down's syndrome (DS) individually matched on language level with ages ranging from 3 to 7 years. Although there was a large variability within groups, they found more humour episodes overall in the DS group, but when total humour was a covariate, there was a significant difference between groups in only one category of humorous response -- non-verbal incongruity (i.e. humorous inappropriate acts with objects) -- with the children with DS producing (or responding to) relatively higher frequencies of such acts than the children with autism. In all other categories--tickling, familiar routines, silly/slapstick, funny sounds, teasing, verbal incongruity and riddles-there were no significant group differences, although jokes and riddles were completely absent in the autism group. The authors suggest that it may be only the cognitively more complex forms of humour that are affected in autism (incongruity and above), since the developmentally simpler, more affective, forms of humour such as tickling, familiar routines and slapstick show no apparent deficit in autism.

However, we cannot yet conclude that children with autism are 'above' the 12-month level of typically developing infants in terms of humour and laughter, or that there are no simple affective and relational problems in humorous exchanges in autism. This study involved very small and heterogeneous groups of school-age children, and the findings may not generalize to a larger sample or to pre-school children. Only episodes where laughter actually occurred were analysed, and there may have been critical failures to laugh or unsuccessful attempts by others to elicit laughter. In more private contexts, there may be other differences in the elicitors of laughter between the two groups of children that can be reported by the family. Furthermore, we do not yet know anything about children's interest in and responses to others' laughter or their own attempts to make others laugh, all of which are necessary before we can determine whether the affective aspects of humour and laughter are disrupted in children with autism.

Debates about the primary deficit in autism
Research on autism shows that deficits in young children with autism involve several aspects of social relations: affective engagement with others, the understanding of others' intentions, affective and attentional states and joint attention deficits. All of these skills are evident in the humorous interactions of typical infants before the end of their first year. However, there is considerable disagreement about the age of onset of the disorder and about the nature of the primary deficit. The mentality-specific conceptual deficit view (Baron-Cohen, 1989; Leslie, 1987; Perner, 1991) argues that the deficit appears at 18 months, following the failure of a critical cognitive representational mechanism. Affective disturbance views, however (Hobson, 1989; Trevarthen, Aitken, Papoudi, & Robarts, 1996), suggest an onset earlier in infancy, whose basis lies in disturbances in the ability to engage emotionally with others. Simple humorous exchanges involving emotional engagement may provide evidence to illuminate a part of the debate about autism. St James and Tager-Flusberg (1994), with their findings about the lack of group differences in simple humour, suggest support for a cognitive deficit view and conclude that the claim for an affective and interpersonal basis for the constellation of deficits in autism (Hobson, 1989) is weakened. However, even inappropriate acts with objects may require an affective and social basis. They need, for instance, an interest in what other people think of as appropriate actions (Williams, Costall, & Reddy, 1999; Williams, Reddy, & Costall 2001). More evidence is needed about other affective aspects of humour before we can resolve this issue.
- Reddy, Vasudevi, Williams, Emma & Amy Vaughan, Sharing humour and laughter in autism and down's syndrome, British Journal of Psychology, May 2002, Vol. 93, Issue 2.
The article above contains foundational information. Articles below contain optional updates.

Personal Reflection Exercise #5
The preceding section contained information about sharing humor and laughter in autism. Write three case study examples regarding how you might use the content of this section in your practice.

Online Continuing Education QUESTION 12
Why is humor and laughter in children with autism of particular relevance? Record the letter of the correct answer the CEU Test.

 
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Impact of a digital Modified Checklist for Autism in Toddlers–Revised on likelihood and age of autism diagnosis and referral for developmental evaluation
Autism, Ahead of Print.
The present study is a single-site quality improvement project within pediatric primary care involving the implementation of a digital version of the Modified Checklist for Autism in Toddlers–Revised. We evaluated the impact of the digital screener on the likelihood of physician referral for a developmental evaluation or autism diagnosis, and the age of the patients at the time of the event. Patients were children 16–30  months old seen for 18 and 24 months’ well-child visits (1279 encounters), who screened positive for risk for autism spectrum disorder on the Modified Checklist for Autism in Toddlers–Revised without a previously documented autism spectrum disorder diagnosis. Comparisons were made between a cohort of children screened with the paper and pencil version of the Modified Checklist for Autism in Toddlers–Revised before the digital version was implemented and a cohort of children screened during the intervention period. Patients were followed until 48 months and referrals were obtained from electronic health records. Patients screened with the digital Modified Checklist for Autism in Toddlers–Revised were five times more likely to be referred for a developmental evaluation. The automatic scoring, risk assessment, and referral decision support features helped to improve screening outcomes. In this clinic, process change to a digital screening method with automatic guidance for next steps improved adherence to evidence-based clinical care.Lay abstractThis was a project in primary care for young children (1–2 years old). We tested a parent questionnaire on a tablet. This tablet questionnaire asked questions to see whether the child may have autism. We compared the paper and pencil version of the questionnaire to the tablet questionnaire. We read the medical charts for the children until they were 4 years old to see whether they ended up having autism. We found that doctors were more likely to recommend an autism evaluation when a parent used the tablet questionnaire. We think that the tablet’s automatic scoring feature helped the doctors. We also think that the doctors benefited from the advice the tablet gave them.
Implementing early intensive behavioral intervention in community settings
Autism, Ahead of Print.
Although research shows early intensive behavioral intervention is efficacious when delivered in university or private intervention centers, little is known about effectiveness or feasibility of disseminating early intensive behavioral intervention to larger communities. The Michigan State University Early Learning Institute was developed to address gaps in distribution of early intensive behavioral intervention to community settings, with an emphasis of serving children and families on Medicaid. This short report describes the Early Learning Institute’s approach and preliminary utilization data among Medicaid families. Results suggest the model has potential for dissemination within community settings and promote utilization among Medicaid children.Lay abstractAlthough research shows early intensive behavioral intervention can be very beneficial for children with autism spectrum disorder when delivered in university or private intervention centers, little is known about the best way to provide early intensive behavioral intervention within the broader community. The Michigan State University Early Learning Institute was developed to address challenges with providing early intensive behavioral intervention in community settings, with an emphasis on serving children and families on Medicaid. This short report describes the approach taken by the Early Learning Institute and reports data regarding enrollment and utilization among Medicaid families. Results suggest the model has potential to be used within community settings and that children on Medicaid are likely to consistently attend their treatment sessions.
Work, living, and the pursuit of happiness: Vocational and psychosocial outcomes for young adults with autism
Autism, Ahead of Print.
Longitudinal data on the functioning of adults referred for possible autism as children are sparse and possibly different from datasets consisting of adult clinical referrals. A total of 123 young adults, mean age of 26, referred for neurodevelopmental disorders in early childhood were categorized into three outcome groups: autism spectrum disorder (ASD) diagnosis at some point and current intelligence quotient (IQ) ⩾ 70 (Ever ASD-Higher IQ), ever ASD and current IQ < 70 (Ever ASD-Lower IQ), and individuals who never received an ASD diagnosis (Never ASD). Independence and well-being were assessed through direct testing, questionnaires, and interviews. Verbal IQ, beyond intellectual disability status, accounted for group differences in employment; autistic features (Autism Diagnostic Observation Schedule Calibrated Severity Score) were uniquely related to adaptive skills and friendships. In many ways, the Never ASD group had similar outcomes compared to the ASD groups. However, lower well-being and fewer positive emotions were related to ASD diagnosis across IQ. The Ever ASD-Lower IQ group had the highest levels of irritability, hyperactivity, and medications. Families played a major role in supporting adults with and without ASD at all intellectual levels. Realistic ways of increasing independence should be developed through working with adults and their families, while acknowledging the contribution of individual differences in mental health, intelligence, and autism symptoms across neurodevelopmental disorders.Lay abstractIt is important to better understand how adults with autism are functioning in adulthood. Studies that have tracked individuals across the lifespan can help identify developmental factors influence differences in adult outcomes. The present study examines the independence, well-being, and functioning of 123 adults that have been closely followed since early childhood. Autism diagnosis and cognitive assessments were given frequently throughout childhood and during adulthood. We examined differences between adults who had received an autism diagnosis at some point with higher cognitive abilities (Ever ASD-High IQ) and lower cognitive abilities (Ever ASD-Low IQ), as well as adults who never received a diagnosis of autism in the course of the study (Never ASD). We found that autistic features specifically related to adaptive skills and friendships, and verbal intelligence related to work outcomes. In many ways, the Never ASD group had similar outcomes compared to the ASD groups. However, adults with ASD tended to have lower well-being and fewer positive emotions. Families played a major role in supporting adults with and without ASD at all intellectual levels. The findings suggest that realistic ways of increasing independence need to be developed by working with adults and their families, while acknowledging the contribution of individual differences in mental health, intelligence and autism symptoms across neurodevelopmental disorders.
Does implementing a new intervention disrupt use of existing evidence-based autism interventions?
Autism, Ahead of Print.
This study examines how the introduction of TeachTown:Basics, a computer-assisted intervention for students with autism spectrum disorder, influenced teachers’ use of other evidence-based practices. In a randomized controlled trial that enrolled 73 teachers nested within 58 schools, we used three-level hierarchical linear models to evaluate changes in teachers’ use of evidence-based practices across the school year for those who received TeachTown:Basics versus those assigned to control. Both groups received training and implementation support to deliver three well-established evidence-based practices for autism spectrum disorder. Qualitative interviews were conducted with 25 teachers who used TeachTown:Basics to better understand their experience. Compared with teachers in the control group, teachers in the TeachTown:Basics group reported significantly less growth over the 9-month period in their use of evidence-based practices that require one-to-one instruction (ps < 0.05), but no difference in their reported use of evidence-based practices that do not involve one-to-one instruction (p = 0.637). Qualitative interviews indicated that teachers viewed TeachTown:Basics as an effective substitute for one-to-one instruction because it was less burdensome, despite the lack of support for TeachTown:Basics’ effectiveness. Before introducing new practices, education leaders should carefully consider both evidence of effectiveness and the potential impact on the use of other evidence-based practices.Lay abstractInterventions for children with autism spectrum disorder are complex and often are not implemented successfully within schools. When new practices are introduced in schools, they often are layered on top of existing practices, with little attention paid to how introducing new practices affects the use of existing practices. This study evaluated how introducing a computer-assisted intervention, called TeachTown:Basics, affected the use of other evidence-based practices in autism support classrooms. We compared how often teachers reported using a set of evidence-based practices in classrooms that either had access to TeachTown:Basics or did not have the program. We found that teachers who had access to the computer-assisted intervention reported using the other evidence-based practices less often as the school year progressed. Teachers also reported that they liked the computer-assisted intervention, found it easy to use, and that it helped overcome challenges to implementing other evidence-based practices. This is important because the computer-assisted intervention did not improve child outcomes in a previous study and indicates that teachers may use interventions that are appealing and easier to implement, even when they do not have evidence to support their effectiveness. These findings support the idea of interventions’ complexity and how well the intervention fits within the classroom affect how teachers use it and highlight the need to develop school-based interventions that both appeal to the practitioner and improve child outcomes.
Autistic peer-to-peer information transfer is highly effective
Autism, Ahead of Print.
Effective information transfer requires social communication skills. As autism is clinically defined by social communication deficits, it may be expected that information transfer between autistic people would be particularly deficient. However, the Double Empathy theory would suggest that communication difficulties arise from a mismatch in neurotype; and thus information transfer between autistic people may be more successful than information transfer between an autistic and a non-autistic person. We investigate this by examining information transfer between autistic adults, non-autistic adults and mixed autistic-with-non-autistic pairs. Initial participants were told a story which they recounted to a second participant, who recounted the story to a third participant and so on, along a ‘diffusion chain’ of eight participants (n = 72). We found a significantly steeper decline in detail retention in the mixed chains, while autistic chains did not significantly differ from non-autistic chains. Participant rapport ratings revealed significantly lower scores for mixed chains. These results challenge the diagnostic criterion that autistic people lack the skills to interact successfully. Rather, autistic people effectively share information with each other. Information transfer selectively degrades more quickly in mixed pairs, in parallel with a reduction in rapport.Lay abstractSharing information with other people relies on the ability to communicate well. Autism is defined clinically by deficits in social communication. It may therefore be expected that autistic people find it difficult to share information with other people. We wanted to find out whether this was the case, and whether it was different when autistic people were sharing information with other autistic people or with non-autistic people. We recruited nine groups, each with eight people. In three of the groups, everyone was autistic; in three of the groups, everyone was non-autistic; and three of the groups were mixed groups where half the group was autistic and half the group was non-autistic. We told one person in each group a story and asked them to share it with another person, and for that person to share it again and so on, until everyone in the group had heard the story. We then looked at how many details of the story had been shared at each stage. We found that autistic people share information with other autistic people as well as non-autistic people do with other non-autistic people. However, when there are mixed groups of autistic and non-autistic people, much less information is shared. Participants were also asked how they felt they had got on with the other person in the interaction. The people in the mixed groups also experienced lower rapport with the person they were sharing the story with. This finding is important as it shows that autistic people have the skills to share information well with one another and experience good rapport, and that there are selective problems when autistic and non-autistic people are interacting.

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