Effects of autistic traits on social and school adjustment in children and adolescents: The moderating roles of age and gender

Research in Developmental Disabilities 34 (2013) 254–265

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Research in Developmental Disabilities

Effects of autistic traits on social and school adjustment in children and adolescents: The moderating roles of age and gender Mei-Ni Hsiao a,1, Wan-Ling Tseng b,1, Hui-Yi Huang c, Susan Shur-Fen Gau a,c,d,* a

Department of Psychiatry, National Taiwan University Hospital, No. 7 Chung-Shan South Road, Taipei, Taiwan Institute of Child Development, University of Minnesota, Twin Cities Campus, 51 East River Parkway, Minneapolis, MN 55455, United States c Department of Psychiatry, College of Medicine, National Taiwan University, No. 7 Chung-Shan South Road, Taipei, Taiwan d Department of Psychology, Graduate Institute of Brain and Mind Sciences, National Taiwan University, No. 1, Section 1, Jen-Ai Road, Taipei, Taiwan b

A R T I C L E I N F O

A B S T R A C T

Article history: Received 12 April 2012 Received in revised form 29 July 2012 Accepted 3 August 2012 Available online 7 September 2012

This study examined the associations between children’s and adolescents’ autistic-like social deficits and school and social adjustment as well as the moderating roles of age and gender in these associations. The sample consisted of 1321 students (48.7% boys) in Grade 1 to Grade 8 from northern Taiwan. Children’s and adolescents’ autistic-like social deficits were assessed using the Social Responsiveness Scale (SRS), and their school and social adjustment (i.e., academic performance, negative attitudes toward schoolwork/teachers/classmates, behavioral problems at schools, negative peer relationships, and problems with peers) were assessed using the Social Adjustment Inventory for Children and Adolescents (SAICA). Both measures were completed by the mothers of the participants. Results from the linear mixed models demonstrated that autistic-like social deficits were associated with poor academic performance, negative attitudes toward schoolwork, teachers, and classmates, behavioral problems at schools, negative peer relationships, and problematic peer interactions. Moreover, gender and/or age moderated the associations between autistic-like social deficits and school and social adjustment problems. For example, autistic-like social deficits were more strongly related to negative school attitude, school social problems, and negative peer relationships in boys than in girls. Further, autistic-like social deficits were more strongly related to problems with peers in older girls than in older boys or younger children (regardless of gender). In conclusion, the present study suggests that autistic-like social deficits may place children and adolescents at increased risk for social and school maladjustment and that the extent of maladjustment may vary with the child’s age and gender and the domains of adjustment under discussion. ß 2012 Elsevier Ltd. All rights reserved.

Keywords: Autistic traits Autism spectrum disorders Social and school adjustment Age Gender

1. Introduction Social competence, the ability to integrate social, emotional, and cognitive processes for successful social adaptation, has been emphasized in the conceptual and empirical work of developmental psychopathology as the indicator of optimal developmental outcomes (Brothers, 1990; Sasson et al., 2007; Sasson, Pinkham, Carpenter, & Belger, 2011; Sroufe & Rutter, 1984). A large body of research has demonstrated the link between early social inadequacy or peer difficulties and a wide

* Corresponding author at: Department of Psychiatry, National Taiwan University Hospital and College of Medicine, No. 7 Chung-Shan South Road, Taipei 10002, Taiwan. Tel.: +886 2 2312 3456x66802; fax: +886 2 2381 2408. E-mail addresses: [email protected] (M.-N. Hsiao), [email protected] (W.-L. Tseng), [email protected] (H.-Y. Huang), [email protected] (S.-F. Gau). 1 Mei-Ni Hsiao and Wan-Ling Tseng have equal contribution as the first authors. 0891-4222/$ – see front matter ß 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ridd.2012.08.001

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range of maladaptive outcomes, including interpersonal difficulties and, in the extreme, clinically significant behavioral and affective disorders such as anxiety, depression, and delinquency (Craig, 1998; Parker & Asher, 1987; Parker, Rubin, Erath, Wojslawowicz, & Buskirk, 2006). One group of children that is at significantly high risk of peer relationship problems and impaired social functioning, however, is those with autism spectrum disorders (ASDs). This is not surprising given that social impairment, such as lack of social reciprocity, failure to develop age-appropriate peer relationships, and inability to engage in age-appropriate social interaction and conversation, is part of the defining and diagnostic criteria of ASDs (American Psychiatric Association [APA], 2000). Additionally, evidence suggests that children with ASDs do not simply ‘‘outgrow’’ these social impairments; rather, these difficulties persist into adulthood, continuing to negatively impact social and occupational functioning in individuals with ASDs (Rao, Beidel, & Murray, 2008; Venter, Lord, & Schopler, 1992). Therefore, it is important to examine the influence of ASDs and autistic traits on children’s and adolescents’ school and social adjustment. ASDs consist of autistic disorder, Asperger’s syndrome, and pervasive developmental disorder, not otherwise specified (PDD–NOS). This disorder is one of the most common neurodevelopmental conditions, affecting approximately 0.6–1.6% of the general population (Baron-Cohen et al., 2009), with a male to female ratio of 4.3–1 (Fombonne, 2005, 2009; Lai et al., 2011). ASDs are heterogeneous neurodevelopmental disorders with prominent difficulties in social interaction and communication, along with the presence of restricted interests, difficulties adapting to change, and repetitive/stereotyped behaviors (APA, 2000; Baron-Cohen, 2008). Although abnormal social reciprocity is the core symptom of ASDs, individuals with ASDs may demonstrate varying degrees of social interaction deficits, which manifest in various domains of social adjustment and relationships with others including peers, family members, teachers, and other adults. For example, previous studies showed that sibling relationships of children with ASDs are characterized by less closeness and a decreased number of interactions (Kaminsky & Dewey, 2001). In addition, parent–child interactions of children with ASDs may be impaired because of their significantly severe emotional and behavioral problems, and parents of children with ASDs are more likely to be overprotecting, controlling, and show less affection than parents of children without ASDs (Gau et al., 2010; Kaminsky & Dewey, 2001). Moreover, previous research found that high-functioning children with ASDs in classroom settings are more often neglected and rejected by others, more likely to be bullied, have fewer friendships and poorer friendship quality, have difficulties initiating and maintaining friendships, and experience more loneliness than their typically developing peers (Bauminger & Kasari, 2000; Bauminger et al., 2008; Humphrey & Symes, 2010; Ochs, Kremer-Sadlik, Solomon, & Sirota, 2001). The social deficits associated with ASDs affect not only children’s social adjustment but also their academic performance. For example, in a recent study, Estes and colleagues reported that school-aged children with ASDs demonstrate significant discrepancies between their actual academic achievement and their potential level of academic achievement predicted from their overall intellectual ability (Estes, Rivera, Bryan, Cali, & Dawson, 2011). Specifically, this research found that within 30 school-aged children with ASDs, decreased social functioning predicted lower academic achievement three years later, after controlling for IQ. These results suggest that improved social functioning may be an important contributor to the variability in academic achievement observed in children with ASDs; thus, social domain should be incorporated into intervention to promote academic achievement in children with ASDs (Estes et al., 2011). The majority of the past studies examining school and social impairment associated with ASDs have been conducted in clinical population with ASDs. Investigation of the impact of autistic-like social deficits in the general population is of significance because it allows us to understand the effect of autistic trait with mild degree of severity on social functioning. In addition, assessing autistic traits in a dimensional approach, in addition to a categorical approach, will help provide a more comprehensive understanding of autistic characteristics and the associated impairment. Increasing evidence has clearly suggested that ASDs might not be a solely clinical phenomenon; rather, it represents the severe end of a continuum of traits that reflect habitually social, behavioral, and emotional patterns that are stable over time (Constantino, 2011; Constantino & Todd, 2003; Skuse et al., 2009). All individuals have these traits to a varying degree. In other words, autistic traits not meeting the threshold for a clinical diagnosis can be found continuously distributed in the general population (Constantino, 2011). These traits include difficulties with social reciprocity, inappropriate conversational skills, and behaviors that are perceived as bizarre or strange. As a result, research has emerged to investigate autistic traits and their impact on social and school functioning in general populations. Theory of mind, generally speaking, is the ability to understand mental states, such as beliefs, feelings, and intents, of oneself and others. Deficits in theory of mind have been considered as a key feature of autism (Baron-Cohen, 2001). In general populations, the ability of theory of mind was found to predict preschool-age children’s readiness for school and their later peer relations in school and school-age children’s social competence (Astington & Pelletier, 2005; Caputi, Lecce, Pagnin, & Banerjee, 2012; Liddle & Nettle, 2006; Slaughter, Dennis, & Pritchard, 2002). In a school-based sample, Skuse (2010) found that up to one-third of children who were excluded from primary schools have autistic-like behaviors of mild to moderate severity and that exclusion from school was associated with deficits in social-cognitive function of an autistic character in an even higher proportion (up to 70%). These findings indicate that children with subclinical autistic traits may act in the ways that bring them into conflict with teachers and peers and that they might process social information abnormally, in an autistic-like way, and are likely to be excluded from schools for similar reasons as with clinically-diagnosed children with ASDs (Skuse, 2010). In another study, Skuse and colleagues (2009) reported that even subthreshold autistic-like traits were associated with an increased risk of social and behavioral problems. In summary, it seems that not only children with clinical diagnoses of ASDs but also those whose symptoms do not reach the clinical threshold are at risk of social impairment and school adjustment problems. Nonetheless, few empirical studies have

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examined the extent to which autistic-like traits, such as impaired social cognition and social reciprocity, are related to school functioning and peer relationships in the general population. Similarly, we know very little regarding how gender and developmental age influence the links between social deficits associated with ASDs and children’s social and school adjustment. For example, it is not clear yet whether autistic-like social deficits differentially affect boys and girls. This is largely due to an over-focus and predominance of males with ASDs and the limited sample size of females with ASDs in the past research. Few existing studies, nonetheless, have yielded mixed results with regard to gender differences in social adjustment among individuals with autistic traits or ASDs. Some researchers reported females (especially older females and adolescents) with high-functioning ASDs displaying more severe social and relationship impairment than their male counterparts (Holtmann, Bolte, & Poustka, 2007; McLennan, Lord, & Schopler, 1993). This may be due to difficulties adjusting to social expectation that females are generally more sociable and sociallyinclined than males (Holtmann et al., 2007) or due to changes in social task demands for pubescent and adolescent girls (McLennan et al., 1993). In contrast, boys with autistic traits may experience more school and social adjustment problems than girls with autistic traits because boys may have higher levels of severity in autistic features and difficulties in social and communication development than girls. Indeed, Constantino and Todd (2003), using the SRS in a population-based school-age sample, found that the mean SRS score for females was 25% lower than that for males and that 1.4% of males and 0.3% of females fell at or above the cutoff SRS score for PDD–NOS (Constantino & Todd, 2003). The lower prevalence of autistic traits in females than in males in a general population parallels the male predominance pattern (3 to 1 ratio) in the clinical population of ASDs (Constantino, 2011). However, it should be noted that some studies reported an opposite pattern of gender differences – girls with ASDs show greater communication impairment than boys (Carter et al., 2007), or no prominent gender differences in the severity of autistic dysfunctions after the effect of IQ was accounted for (Holtmann et al., 2007; Volkmar, Szatmari, & Sparrow, 1993). Another reason that boys with autistic traits may be more impaired than girls is because girls are more socially-oriented and are often more aware of or feel a need to interact with others (Maccoby, 1998), thereby, being more motivated to develop compensatory skills that help them to appear ‘‘socially typical’’ (Lai et al., 2011). Additionally, relative to the male peer groups, in the female peer groups, typically developing girls may be more empathic, caring, and tolerant of the girls with autistic-like difficulties (Baron-Cohen & Wheelwright, 2003); consequently, girls with autistic traits may have better social and school adjustment than boys with autistic traits. Still others suggested that females with ASDs are just as likely as males with ASDs to appear odd in social situations and are vulnerable to being ostracized socially (Koenig & Tsatsanis, 2005). Clearly more research is needed before firm conclusions can be drawn on the gender effect of autistic traits on school and social adjustment. With respect to the effect of age, recent studies have provided evidence to support that autistic traits are highly stable across lifespan in the general population (Robinson et al., 2011), similar to what was found in the clinical population of ASDs (Robinson et al., 2011; Whitehouse, Hickey, & Ronald, 2011). However, the impact of autistic traits on social functioning may not present until under pressure from demands for new social adaptation arising across major developmental transition. For example, social adaptation problems and peer interaction difficulties may exacerbate as children approach adolescence because of the increasing salience of peer relationships during adolescence (Hartup & Stevens, 1997) and also because children with ASDs are more aware of their social impairments as they get older (Tantam, 2003). One recent study showed that children with ASDs were less accepted by peers and had fewer reciprocated friendships than typically-developing children. Such peer impairment is particularly evident in late childhood (i.e., Grade 4 to Grade 5) than in early childhood (i.e., kindergarten to 1st grade; Rotheram-Fuller, Kasari, Chamberlain, & Locke, 2010). Taken together, these findings illustrate that the relation between social ability and adjustment outcome may vary with age and gender; therefore, it is crucial to take age and gender into consideration when examining how autistic-like social deficits influence children’s social and school adjustment. Overall, existing studies on this issue have made some progress and have provided important information with regard to school and social maladjustment that may be associated with autistic symptoms. However, most studies are limited by a focus on specific domains of autistic trait-like impairment (e.g., theory of mind) or by the limited areas of social and school maladjustment examined. No studies have investigated how autistic-like social deficit as a general construct relates to a wide array of school and social adjustment (i.e., academic performance, attitudes toward school, behavioral problems at schools, peer relationships, and peer problems). Additionally, past work has primarily focused on children and adolescents in clinical settings and in the Western cultures and has failed to recognize the influences of important contextual factors (i.e., age and gender) in the link between autistic symptoms and school and social adjustment. Therefore, we conducted the present study in an attempt to address these limitations in the literature by using a large, representative Taiwanese sample of 1321 students from Grade 1 to Grade 8 in Taipei, Taiwan. The purpose of this study was to examine (1) the association between children’s and adolescents’ social deficits that are characteristic of ASDs and school and social adjustment in a Chinese culture and (2) the moderating effects of age and gender and the interaction of both on this putative association. Based on our literature reviews, we hypothesized that autistic features (i.e., autistic-like social deficits) would place children and adolescents at a great risk for school and social maladjustment, and that age, gender, and the interaction of both may moderate the effects of autistic symptoms on school and social adjustment. Specifically, we expected that autistic-like social deficits would be associated with poor academic performance, negative attitudes toward schools, more behavioral problems at schools, negative peer relationships, and more problems with peers. In addition, age and gender would

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moderate the associations between autistic traits and social adjustment problems in school such that these associations would be stronger for males, older children and adolescents or the combination of both. 2. Methods 2.1. Participants We targeted a representative school-based sample of 1443 students from Grade 1 to Grade 8 in Taipei city. In January 2010, we randomly selected 41 primary and 11 junior high schools in Taipei city that had at least six classes in each grade. Letters were sent to the principals and directors of academic affairs to explain the purpose and procedure of this study. Participants who have been diagnosed with developmental delay (n = 13), attention-deficit/hyperactivity disorder (n = 69), ASDs (n = 12), or more than one of the above conditions (n = 28), according to mothers’ reports, were excluded from the study. As a result, 1321 students (boys, 48.7%) from 93 classes of 16 schools participated in this study, and their data were used in the analyses (response rate = 91.5%). Participants’ age ranged from 6.7 years to 15.6 years (M = 10.20, SD = 2.12). The numbers of the participants by grade levels were: 139 (Grade 1), 275 (Grade 2), 178 (Grade 3), 168 (Grade 4), 146 (Grade 5), 201 (Grade 6), 170 (Grade 7), and 44 (Grade 8). Gender distribution (percentages of boys) by grade levels was: 53.23% (Grade 1), 49.09% (Grade 2), 47.19% (Grade 3), 51.79% (Grade 4), 52.74% (Grade 5), 48.26% (Grade 6), 44.12% (Grade 7), and 31.82% (Grade 8). We divided the participants into four groups according to their gender (male and female) and grades (younger group: Grades 1–4 and older group: Grades 5–8). Our decision on dividing the participants into younger and older groups (Grades 1– 4 and Grades 5–8, respectively) is based on several reasons. First, the transition into Grade 5 in Taiwan represents a period characterized by increasing academic workload, increased levels of difficulties in subjects and course contents, and increasing pressures from parents and teachers to perform well academically. Secondly, we attempted to differentiate between early childhood and middle childhood by dividing the sample into Grades 1–4 (early childhood) and Grades 5–8 (middle childhood) because research has suggested that in middle childhood, children increasingly spend more time with peers and that the significance of peer relationships and social support from peers become more salient during middle childhood (Rubin, Bukowski, & Parker, 1998). As such, having autistic-like traits may place older children at a greater risk of experiencing difficulties with peers. Third, because grade retention is not permitted in elementary and junior high schools (Grade 1 to Grade 9) in Taiwan, grade level could be regarded as a proxy for age. Table 1 presents demographics and characteristics of the participants and their parents by gender and age (Grades 1–4 and Grades 5–8) groups. To examine group differences in demographics, chi-square tests were conducted for categorical outcome variables while one way analyses of variance (ANOVA) were conducted for continuous outcome variables. In the current sample, older girls were less likely to be the single child in the family as compared to the other three groups (p < .05); older boys were less likely to be the single child than younger boys (p < .05). Mothers of older girls were less educated than Table 1 Sample characteristics. Younger (Grades 1–4)

Child Age (mean  SD) Singleton (%) Father Age (mean  SD) Education (%) College and above Under college Job (%) Professional Skilled work Mother Age (mean  SD) Education (%) College and above Senior high school Job (%) Employed Unemployed Family type (%) Nuclear family Extended family Joint-stem family Note. SD, standard deviation.

Older (Grades 5–8)

Chi-square, p value

Male

Female

Male

Female

n = 380

n = 380

n = 263

n = 298

8.62  1.10 21.6

8.63  1.07 18.7

12.19  1.08 15.2

12.44  0.98 9.7

–

42.02  5.22

42.47  5.56

44.76  5.12

45.45  4.82

–

66.6 33.4

63.2 36.8

59.4 40.6

59.7 40.3

x21 ¼ 4:02, p = .260

12.5 87.5

14.5 85.5

12.3 87.7

12.5 87.5

x21 ¼ 0:79, p = .851

39.07  4.44

39.13  4.56

41.93  4.54

42.38  4.57

–

66.3 33.7

61.1 38.9

55.2 44.8

53.3 46.7

x21 ¼ 13:33, p = .004

61.5 38.5

59.2 40.8

49.3 50.7

53.8 46.2

x21 ¼ 9:97, p = .019

52.1 30.2 17.7

54.3 26.2 19.5

60.9 24.3 14.8

62.2 23.0 14.8

x21 ¼ 10:73, p = .097

x21 ¼ 18:30, p < .001

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mothers of younger boys and girls (p < .05); mothers of older boys were less educated than mothers of younger boys (p < .01). In addition, mothers of older boys were more likely to be unemployed than mothers of younger boys and girls (p < .02). There were no significant differences in fathers’ educational levels and employment status, and family types among the four groups. 2.2. Procedures The Research Ethics Committee of National Taiwan University Hospital approved this study before implementation of this study (IRB ID: 201005041R; ClinicalTrials.gov number, NCT01247662). Written informed consent was obtained from the parents and the teachers after explanation of the purpose and procedures of the study as well as reassurance of confidentiality. 2.3. Instruments 2.3.1. Social Responsiveness Scale The SRS (Constantino & Gruber, 2005), a widely-used quantitative measure of autistic traits in the general population, is a 65-item rating scale that measures the severity of autism spectrum symptoms over the past six months as they occur in natural social settings. It was designed for children and adolescents aged 4–18 years. It can be completed by a parent or a teacher in just 15–20 min in general use. In this study, mothers were asked to complete this measure. Items were rated on a 4-point Likert scale from ‘‘0’’ (not true) to ‘‘3’’ (almost always true). The SRS has been demonstrated to have good internal consistency, construct validity, inter-rater reliability, test–retest reliability, and discriminative validity in prior research (Constantino & Gruber, 2005). The Chinese version of the SRS was prepared with culture-relevant expressions and two-way translation by Taiwan Autism Study Group, led by Drs. Gau and Wu, and was officially approved by Dr. Constantino in 2008. Given that the exploratory and confirmatory factor analyses indicated that the Chinese version of the SRS, after removing five items, has a four-factor structure (social communication, stereotyped behaviors/interest, social awareness, and social emotion), but is better conceptualized as an one-factor model, we used the SRS total score in the analyses as a general index of social impairment. High internal consistency was found for the four subscales (Cronbach’s alpha, .94–.95) and the total scale (Cronbach’s alpha, .95) in the present sample. Higher total score on the SRS indicates greater severity of autistic social deficits. 2.3.2. Social Adjustment Inventory for Children and Adolescents Participants’ social and school adjustment was assessed by the Chinese version of the SAICA which was completed by the mothers. The SAICA was designed to assess the adaptive functioning of children and adolescents aged 6–18 years in four major role areas, including school, spare time activities, peer relations, and home life (John, Gammon, Prusoff, & Warner, 1987). The school subscales (Biederman, Faraone, & Chen, 1993) of academic performance (5 items), school attitude (4 items), school social problems (12 items), and the peer relations subscales of peer relationships (5 items) and problems with peers (12 items) were selected in the present study as the indices of children’s social and school adjustment. Impairment in each domain was rated on a 4-point scale from 1 (positive or not a problem) to 4 (negative or severe problem; John et al., 1987). A higher score indicates either poorer functioning or more severe problem. The academic performance subscale assessed mothers’ perceptions of their children’s academic functioning in different subjects, including Chinese, English, math, science, and social study. The School Attitude subscale assessed mothers’ perceptions of their children’s attitude toward homework and toward interactions with teachers and classmates. The school social problems subscale assessed children’s behavioral problems at school (e.g., disruptive behaviors, getting into fights, withdrawal, and vandalism). The peer relationships subscale reflected mothers’ perceptions of their children’s ability to make friends and maintain relationships. The subscale of problems with peers was used to assess mothers’ perceptions of their children’s negative behaviors and social problems when interacting with their peers, such as shyness, bullying, and peer victimization. Previous studies have found the SAICA to be a reliable and valid measure in assessing children’s and adolescents’ social adjustment in both clinical and research settings (Biederman et al., 1993). The Chinese version of the SAICA was found to have satisfactory psychometric properties (Gau, Shen, & Chou, et al., 2006). The SAICA has been widely used in clinical (Gau, 2007), treatment (Gau, Shen, Soong, & Gau, 2006; Griswold, Barnhill, Myles, Hagiwara, & Simpson, 2002), and community (Humphrey & Symes, 2010; Kawabata, Tseng, & Gau, 2012; Tseng, Kawabata, & Gau, 2011) studies in child and adolescent populations. In the current sample, Cronbach’s coefficient alpha for academic performance, school attitude, school social problems, peer relationships, and problems with peer were .75, .73, .66, .74, and .71, respectively. The overall standardized Cronbach’s coefficient alpha of .76 is greater than the suggested value of .70 and provides an acceptable lower bound for the reliability coefficient (Nunnally & Bernstein, 1994). Sum scores on each of the subscales were used in the analyses. 2.4. Statistical analysis All analyses were conducted using SAS 9.2 (SAS Institute Inc, Cary, NC, USA). ANOVA was used to assess group differences in the SRS and the SAICA. The Pearson correlations (r) between the subscales of the SAICA and the SRS by gender were used to

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demonstrate the bivariate correlations between the two measures. Main analyses were conducted using mixed linear models by the PROC MIXED procedure in SAS with maximum likelihood (ML) estimation. The PROC MIXED procedure was used (instead of traditional regression) because it is a better mechanism for handling data that are missing at random (Raudenbush & Bryk, 2002) and also because it takes into account the non-independence of observations within the same classrooms. This procedure estimates more accurate effects of predictors than the traditional ordinary least squares (OLS) regression approach. To investigate the associations between autistic-like social impairment and social and school adjustment and how age and gender were involved in these associations, five sets of mixed linear models were conducted. Mother ratings of academic performance, school attitude, school social problem, peer relationships, and problems with peers served as criterion variables. Age, gender, and total score of the SRS were entered to examine the main effects of these variables while demographic variables that were significantly different among groups (i.e., ‘‘single child status,’’ ‘‘maternal education level,’’ and ‘‘maternal employment status’’) were included in the models as covariates. Two-way interaction terms (Age  SRS, Gender  SRS, and Age  Gender) and three-way interaction term (Age  Gender  SRS) were then entered to examine the moderation effects of age and gender on the associations between autistic-like social impairment and social and school adjustment. Statistical significance (p value) was defined at the .05 level. 3. Results 3.1. Means and standard deviations of the SRS and SAICA Table 2 presents the comparisons of the means and standard deviations of autistic-like social impairment assessed by the Chinese SRS, and school and social adjustment assessed by the Chinese SAICA among the four age-by-gender groups. Results indicated that younger boys showed more severe autistic traits, including more stereotyped behaviors/interest, less social awareness, and less social emotion than younger girls (ps < .01). Moreover, boys (regardless of age) showed more severe deficits in social awareness than older girls (ps < .05). Older boys showed more severe impairment in social awareness and social emotion than younger girls (p < .001). In addition, older girls showed more impairment in social emotion than younger girls (p < .05). With regard to school function, older students (regardless of gender) had poorer academic performance and more negative attitude toward schoolwork than younger boys, followed by younger girls (ps < .05). Further, boys had more severe school social problems than girls; older boys, in particular, showed higher levels of school social problems than girls (ps < .05). In terms of peer function, older boys and girls and younger boys had significantly more problems with peers than younger girls (ps < .01). No group differences were found in negative peer relationships. 3.2. Correlations between the SRS and SAICA by gender Table 3 shows the correlations among the four subscales and the total score of the SRS and the five subscales from the SAICA for boys and girls. Overall, there were significant correlations among autistic traits and poor academic performance, negative school attitude, school social problems, negative peer relationships and problems with peers in both genders (ps < .001). In addition, the correlations of social communication, stereotyped behaviors/interest, social emotion, and total score of the SRS with negative school attitude, school social problems, and negative peer relationships were significantly higher in boys than girls (all ps < .05 except for the correlation between social emotion and school social problem).

Table 2 Means and standard deviations of the Social Responsiveness Scale and Social Adjustment Inventory for Children and Adolescents by age  gender groups.

Autistic traits Social communication Stereotyped behaviors/interest Social awareness Social emotion Total score School and social adjustment Poor academic performance Negative school attitude School social problems Negative peer relationships Problems with peers

Younger (Grades 1–4)

Older (Grades 5–8)

(1) Male

(2) Female

(3) Male

(4) Female

n = 380

n = 380

n = 263

n = 298

10.34  9.04 6.20  5.14 14.46  6.20 6.32  4.40 37.39  20.51

8.81  7.29 5.08  4.08 13.07  6.36 5.55  3.83 32.51  17.09

10.24  8.76 5.87  4.91 15.30  6.45 6.37  4.23 37.80  20.12

9.70  9.12 5.85  5.43 13.37  6.56 6.22  4.36 35.17  21.08

7.55  3.04 5.48  1.94 13.72  4.06 9.29  3.08 13.35  3.37

7.07  2.53 5.16  1.64 12.96  2.79 8.87  2.66 12.70  2.65

8.75  3.59 5.94  2.12 13.98  4.11 9.36  3.00 13.65  3.54

8.88  3.74 6.01  2.07 13.27  3.62 9.09  2.76 13.48  4.42

* Adjusted p values using Bonferroni method for multiple comparisons.

p-Values

Comparisons*

2.39 3.46 7.75 2.91 5.22

.068 .016 <.001 .033 .001

– 1>2 1 > 2,4; 3 > 2,4 1,3,4 > 2 1,3 > 2

25.29 14.25 5.04 1.99 4.80

<.001 <.001 .002 .114 .003

4,3 > 1 > 2 4,3 > 1 > 2 1 > 2; 3 > 2,4 – 1,3,4 > 2

F (3, 1317) statistics

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Table 3 Correlations between the SRS and the SAICA for male students (right upper) and female students (left lower). Female

Social communication Stereotyped behaviors/interest Social awareness Social emotion SRS total score Poor academic performance Negative school attitude School social problems Negative peer relationships Problems with peers

Male Social communication

Stereotyped behaviors/ interest

Social awareness

Social emotion

SRS total score

Poor academic performance

Negative school attitude

School social problems

Negative peer relationships

Problems with peers

– 0.83*

0.87* –

0.33 0.42

0.77 0.77

0.92* 0.92

0.25 0.29

0.36* 0.37*

0.53* 0.53*

0.43* 0.47*

0.48 0.49

0.29 0.75 0.90* 0.26

0.44 0.73 0.91 0.30

– 0.23 0.62 0.32

0.31 – 0.80 0.20

0.62 0.83 – 0.34

0.24 0.19 0.30 –

0.24 0.32* 0.39* 0.43

0.26 0.43 0.54* 0.45

0.35 0.38* 0.50* 0.26

0.21 0.43 0.49 0.29

0.19*

0.21*

0.20

0.19*

0.25*

0.45

–

0.54*

0.44*

0.39*

0.45*

0.43*

0.20

0.40

0.45*

0.41

0.43*

–

0.47

0.62

*

*

0.36

0.20

*

0.29

0.38

–

0.45*

0.47

0.27

0.24*

0.55

0.33*

–

0.25

0.32

0.31

0.29

0.47

0.41

0.25

0.37

*

*

All ps < .001. * Significant differences (at p < .05) in Pearson’s correlations between male students and female students by the Fisher’s exact test.

3.3. Prediction from autistic-like social impairment to school and social adjustment Table 4 summarizes the results from the main analyses of autistic-like social impairment’s prediction of school function and peer function. Results demonstrated that autistic-like social impairment was significantly associated with poor academic performance, negative school attitude, school social problems, negative peer relationships, and more problems with peers, after age, gender, single child status, and maternal education and employment status were controlled for. In addition, the associations of autistic-like social impairment with negative school attitude, with school social problems, and with negative peer relationships were moderated by gender. Follow-up analyses were conducted to tests the simple slopes for boys and girls. Results indicated that the association between autistic-like social impairment and negative school attitude was stronger for boys than for girls (B = 0.04, p < .001 for boys and B = 0.02, p < .01 for girls; two simple slopes were significantly different at p < .01). Likewise, the association between autistic-like social impairment and school social problems was stronger for boys than for girls (B = 0.11, p < .001 for boys and B = 0.07, p < .001 for girls; two simple slopes were significantly different at p < .01). Similarly, the association between autistic-like social impairment and negative peer relationships was stronger for boys than for girls (B = 0.08, p < .001 for boys and B = 0.05, p < .001 for girls; two simple slopes were significantly different at p < .01). Furthermore, three-way interaction of Age  Gender  SRS was significant in the model predicting problems with peers; that is, age and gender interacted with the SRS total score in predicting problems with peers. Tests of simple slopes for the four age-by-gender groups were conducted to probe the significant three-way interaction. Fig. 1 presents the plot for the simple slopes and detailed statistics for tests of slope differences. Results indicated that the positive association between autistic-like social impairment and problems with peers for each of the four groups was significantly different from zero (ps < .001) and that strongest association was found in older girls (B = 0.10), followed by younger boys and older boys (Bs = 0.09 and 0.08, respectively; the two groups of boys did not differ from each other), and weakest association was found in younger girls (B = 0.06). 4. Discussions The current study is among the first to investigate the associations between social deficits that are characteristic of ASDs and social and school adjustment in Asian children and adolescents in a general population, using reliable quantitative measurement in assessing autistic-like social deficits. This study is also the first one to examine the moderation effects of age and gender on the associations between autistic-like social deficits and school and social adjustment. Overall, results from the present study suggested that autistic-like social deficits may place children and adolescents at a great risk for social and school maladjustment, including poor academic performance, negative attitudes toward school and teachers, more social and behavioral problems at schools, negative peer relationships, and more problematic peer interactions. Further, gender and/or age moderated the associations between autistic-like social deficits and school and social adjustment problems. For example, autistic-like social deficits were more strongly related to negative attitudes toward school and teachers, school social problems, and negative peer relationships in boys than in girls, which was consistent with our hypotheses. Interestingly, autistic-like social deficits were more strongly related to problems with peers in older girls than in older boys or younger children (regardless of gender). We discuss each of these findings in turn and address the implications of these findings.

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261

25

Problems with Peers

20

15

10 (1) Boys, Older (2) Boys, Younger

5

(3) Girls, Older (4) Girls, Younger

0 Low SRS

High SRS

Fig. 1. Plot of significant three-way interaction of age  gender  SRS. Note. SRS, Social Responsiveness Scale. Low SRS was plotted at the value of 1 SD below the mean on the SRS total score while high SRS was plotted at the value of at 1 SD above the mean on the SRS total score. Significant pairwise comparisons of the simple slopes: older boys > younger girls at p = .009; younger boys > younger girls at p = .004; older girls > younger girls at p = .001; older girls > older boys at p = .004; older girls > younger boys at p = .003.

4.1. Academic performance and school attitude Although the link between social competence and academic achievement has been well-documented in the general population, this has not been well studied in children and adolescents with autistic-like social deficits (Estes et al., 2011). Consistent with a recent study reporting a positive association between social abilities in children with ASDs and academic achievement (Estes et al., 2011), findings from the present study revealed a significant positive association between autisticlike social impairment and impaired school functioning, including poor academic performance and negative attitude toward homework and teacher–student interaction. In other words, students who were rated by their mothers as having higher levels of autistic traits were also reported as having lower academic achievement and more negative attitudes toward homework and toward their interactions with teachers and other students. It is possible that students with autistic traits may have difficulties communicating, interacting, and solving social conflict (Oswald, Coutinho, Johnson, Larson, & Mazefsky, 2008), especially when working on a group project with peers (Rotheram-Fuller et al., 2010) or when the task requires help and assistance from the teachers. These difficulties may hinder their ability to learn in a cooperative classroom environment that involves close interaction and communication with teachers and their peers. It is also plausible that students with autistic traits may have lower frustration tolerance while facing academic struggles (Carpenter, 2011) or may tend to over focus on particular disciplines that interest them the most while neglecting or putting minimum efforts into other disciplines (Boyd, Conroy, Mancil, Nakao, & Alter, 2007), all of which may contribute to poor academic outcomes and negative attitudes toward schoolwork and teacher–student interaction (Griswold et al., 2002; Oswald et al., 2008).

Table 4 Prediction of autistic-like social deficits on school and social adjustment. Predictors/estimates (SE)

Poor academic performance

Intercept Age (Grades 5–8 vs. Grades 1–4) Gender (male vs. female) Singleton Maternal education level Maternal employment status SRS Age  SRS Gender  SRS Age  gender Age  gender  SRS

6.88 0.76 0.04 0.21 1.28 0.25 0.03 0.02 0.01 0.48 0.02

(0.37)*** (0.48) (0.45) (0.22) (0.19)*** (0.18) (0.01)*** (0.01) (0.01) (0.68) (0.02)

Note. SE, standard error; SRS, Social Responsiveness Scale. * p < .05. ** p < .01. *** p < .001.

Negative school attitude 4.59 0.39 0.54 0.23 0.11 0.01 0.02 0.01 0.02 0.17 0.01

(0.23)*** (0.30) (0.28) (0.14) (0.12) (0.11) (0.01)** (0.01) (0.01)** (0.43) (0.01)

School social problems 10.76 0.42 1.02 0.65 0.11 0.34 0.07 0.01 0.04 0.69 0.01

(0.39)*** (0.50) (0.48)* (0.24)** (0.20) (0.19) (0.01)*** (0.01) (0.01)** (0.73) (0.02)

Negative peer relationships 7.01 0.05 0.95 0.20 0.49 0.28 0.05 0.00 0.03 0.35 0.01

(0.33)*** (0.42) (0.41)* (0.20) (0.17)** (0.16) (0.01)*** (0.01) (0.01)** (0.62) (0.02)

Problems with peers 10.91 0.98 0.61 0.34 0.06 0.36 0.06 0.04 0.02 1.37 0.05

(0.38)*** (0.48)* (0.46) (0.23) (0.19) (0.18)* (0.01)*** (0.01)*** (0.01)* (0.70) (0.02)**

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As hypothesized, the association between autistic-like social impairment and negative school attitudes was stronger for boys than for girls. One possible explanation for this finding might be that boys tend to have higher levels of autistic-like social impairment than girls. The impairing nature of these autistic-like social deficits may contribute to boys’ negative interactions with teachers and with other students that were observed in the present study. In addition, past studies found that physical aggression was more common in boys than in girls (Card, Stucky, Sawalani, & Little, 2008). Such high rates of aggression in boys may give rise to conflicts during their interactions with teachers and classmates. Nonetheless, it should be noted that these results may be specific to Chinese culture where academic achievement is highly emphasized from the early school years onward (Chen, Chang, & He, 2003). Chinese parents often place great emphasis on academic achievement as a means to attain personal advancement, higher social status and respect in the Chinese society (Lin & Fu, 1990). Higher expectation is usually held for boys because boys are expected to carry on the family name and bring honor and success to the family by obtaining high academic achievement. In light of this, Chinese mothers may be more concerning about boys’ academic progress and are highly attentive to any signs or problematic behaviors that may impede their child’s learning and academic performance, which may result in an inflated association between autistic traits and school functioning found in this study. 4.2. School social problems The present study also revealed that children and adolescents with more severe autistic-like social impairment were more likely to have behavioral problems in school, including disruptive behaviors, getting into fights, and vandalism. This is in line with the literature suggesting that many children and adolescents with ASDs exhibit co-occurring disruptive behavior disorders such as oppositional defiant disorder and conduct disorders (Gadow, Devincent, Pomeroy, & Azizian, 2005; Mattila et al., 2010). It is likely that disruptive behaviors, such as symptoms of oppositional defiant disorders, may be part of the manifestation of the ‘‘stubbornness and difficulties in compliance’’ that are often seen in children and adolescents with pervasive developmental disorders (Mattila et al., 2010). This notion can also be supported by a past study in preschools suggesting that preschoolers with autism may be particularly likely to engage in disruptive behaviors to gain or maintain access to items with which they engage in repetitive behaviors or to evade sensory stimuli to which they have an idiosyncratic aversion (Reese, Richman, Belmont, & Morse, 2005). Findings of this study further suggested that the association between autistic-like social deficits and behavioral problems in school was especially stronger in boys than in girls, regardless of age. If the function of engaging in disruptive behaviors, as Reese and colleagues (2005) suggested, is to gain or maintain access to items with which individuals with ASDs engage in repetitive behaviors, it seems reasonable to argue that individuals who show more stereotyped interests and behaviors may be more likely to display co-occurring disruptive behaviors. Indeed, past studies suggested that boys with ASDs tend to have higher rates of restricted or repetitive behaviors than girls with ASDs across developmental periods from early childhood (Lord, Schopler, & Revicki, 1982) to late childhood, adolescence, and early adulthood (McLennan et al., 1993). Our finding that younger boys (Grades 1–4) showed more restricted behaviors/interests than their female counterparts also partially supports this notion. Therefore, we have reasons to believe that boys with autistic traits may be more likely than girls with autistic traits to engage in disruptive behaviors as a way to gain or maintain their repetitive or restricted behaviors/interests. Another possible explanation for this finding may be due to gender differences in aggressive behaviors. Specifically, it is welldocumented that boys typically enact more direct aggression than girls (Card et al., 2008). As such, it is plausible that relative to girls with autistic-like social impairment, boys with such impairment may be more likely to express their frustration facing social challenges by acting out or engaging in aggressive behaviors. However, because little is known regarding gender differences in aggression or disruptive behaviors among children and adolescents with autistic traits in the general population, future empirical research is needed to test this notion and validate our finding. 4.3. Negative peer relationships Consistent with previous studies (Bauminger et al., 2008; Ochs et al., 2001), the present study demonstrated that autisticlike social deficits were related to more negative peer relationships including difficulties making or maintaining friendships. It may be that children with autistic-like social deficits, similar to those with ASDs, may be impaired in the ability to experience relationship-based emotions (Hobson, 2005) which, in turn, contribute to difficulties in developing affective closeness and intimacy that are key dimensions in friendships (Bauminger et al., 2008). It is also possible that deficits in theory of mind, a core feature of ASDs, may result in difficulties in understanding other people’s thoughts, feelings, and emotions for these children and adolescents. Consequently, these difficulties may impede these youths’ ability to engage in reciprocated behaviors such as caring, sharing, and listening which are also key elements in friendships (Bauminger et al., 2008). Interestingly, the association between autistic-like social deficits and negative peer relationships was stronger in boys than in girls. This can be accounted for by the idea that perhaps in the female peer groups, typically-developing girls are more empathic, more tolerant, and more inclusive of girls with autistic-like difficulties, as compared to the male peer groups (Baron-Cohen & Wheelwright, 2003). As a result, girls with autistic traits may experience less difficulties making or maintaining friendships than boys with autistic traits. Another possible explanation might have to do with theory of mind. It has been shown that preschool girls may have better theory-of-mind understanding and ability than preschool boys (Charman, Ruffman, & Clements, 2002; Walker, 2005). Theory of mind, in turn, has been shown to be positively related to

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high quality of interactions with friends (Cutting & Dunn, 1999; Walker, 2005). This notion, however, needs to be empirically tested in the future research given that our study did not directly assess theory of mind. 4.4. Problems with peers Another finding of this study is that autistic-like social deficits, in general, were associated with more problems with peers, including bullying, peer rejection, and preference of hanging out with older or younger children. Moreover, this association was moderated by age and gender such that it was particularly stronger in older females (Grades 5–8). This finding seems contradictory at first to the finding that girls with autistic traits showed less difficulties making and maintaining friendships than girls with autistic traits. However, it should be noted that the outcome variable under discussion here (i.e., bullying, peer rejection, and preference of hanging out with older or younger children) addresses problematic peer interactions that occur at a large peer group level, as opposed to a dyadic level (e.g., mutual friendships). With this point in mind, it is possible that although girls with autistic-like social deficits may manage to have friendships, they may still be at increased risk for experiencing bullying or rejection by unfamiliar peers. This is particularly the case in preadolescence or adolescence when peers become increasingly salient, and people hold a higher expectation for girls than for boys to be prosocial and socially-inclined (Holtmann et al., 2007). In addition, although somewhat unexpected, this finding actually mirrors that of a previous study reporting that females with ASDs were rated by their mothers as having more social problems as indexed by the CBCL (Holtmann et al., 2007). The CBCL social problems subscale contains items related to several areas of peer functioning, including peer rejection, being teased or not liked, or preferring younger children, that are very similar to the subscale of problems with peers from the SAICA. As such, Holtmann et al.’s study provides evidence to support the validity of our finding. Nonetheless, future research is clearly warranted, especially on the moderating roles of age and gender in the association between autistic traits and problematic peer interactions. 4.5. Limitations The current study, using a large community-based sample from a Chinese culture, adds new contributions to the literature given that the majority of the previous studies on this topic have primarily focused on clinical populations of ASDs and on Western cultures. Other strengths of the current study include utilizing reliable and well-validated measures (i.e., SRS and SAICA) and sound statistical analyses (i.e., MIXED models). However, several limitations of this study must be noted. First, the cross-sectional design of the study does not permit firm conclusions about the causal pathways involved in the link between autistic-like social deficits and school and social adjustment. Future research that uses longitudinal designs will help elucidate the causal relations involved in this link. Second, because dependent and independent variables were both collected using mothers’ reports, it is possible that the associations between autistic traits and school and social adjustment may have been influenced by the overall positive or negative reporting bias from the mothers. To reduce this rater bias and to avoid the issue of shared method variance, future studies should include additional informants (e.g., teachers or clinicians) and/or other methods in data collection (e.g., behavioral observation or interviews). Third, because we did not assess other emotional or behavioral problems, we could not rule out the possibilities that other comorbid conditions may have contributed to the significant associations between autistic-like social impairment and school and social adjustment problems reported in this study. Fourth, it is important to keep in mind not to equate the current sample to a clinical population of ASDs when interpreting results from this study. Fifth, our sample consisted of families from Taiwan and primarily from married households. Therefore, the findings of this study may not be generalized well to other Chinese societies (e.g., Hong Kong or mainland China) or to other types of families (e.g., single-parent households). 5. Conclusions Through establishing the link between autistic-like social deficits and social and school adjustment problems and the moderating roles involved, the present study provides evidence in support of the importance of identifying children and adolescents with autistic traits in the general population in the Chinese culture. Investigating the potential impact of autistic-like social deficits on children’s and adolescents’ school and social functioning in the general population is a key first step as it has important implications. First of all, there is clearly a need for identification of children and adolescents with autistic traits or social cognition deficits. Those students with mild or early signs of impaired social cognition usually have normal general intelligence and basic social competence; as such, even though some may have shown some degrees of school and social impairment, such impairment can go unnoticed by untrained observers. As a result, many with subthreshold autistic social deficits may struggle in mainstream school without professional support or help, and they are rarely referred for clinical assessment or treatment. Close communication and collaboration between clinical and school psychological services is likely to be helpful in meeting the needs of this group. Moreover, findings from this study further suggest that boys may deserve more attention when one concerns how autistic traits may influence their functioning in domains such as behavioral problems at school, friendships, and attitudes toward schoolwork and teachers/classmates. In contrast, more attention should be paid to girls (particularly preadolescent and adolescent girls) when the concern is about the impact of autistic traits on problematic peer interactions such as bullying

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and peer rejection. Additionally, children and adolescents who are identified by the SRS as being affected with subthreshold autistic traits may likewise benefit from interventions that have been traditionally designed for children who meet full diagnostic criteria for ASDs. For example, prevention or intervention programs that incorporate social skill training for youth with ASDs, as well as elements aimed at improving parents’ and school teachers’ knowledge on ASDs and the associated adjustment outcomes, may also be effective for youth with subthreshold ASDs. References American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders: DSM-IV-TR. Washington, DC: American Psychiatric Association. Astington, J. W., & Pelletier, J. (2005). Theory of mind, language, and learning in the early years: Developmental origins of school readiness. 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