1 Attachment Styles, Parenting Styles and Theory of Mind: An Exploration of their relationships with Social Deficits in Autism Spectrum Disorder. NAKEETA CATHERINE BAILEY BLYNAK001 n w o T Minor-Dissertation presented in partial fulfilment of the req uirements for the degree of MA e (Clinical Psychology) at the Universipty of Cape Town. a C f o Supervisor: D r. Susan Malcolm-Smith y t i s r e v Word count: i n Abstract: 44U3 Body: 25995 Faculty of the Humanities University of Cape Town September 2016 n w The copyright of this thesis vests in the author. No o T quotation from it or information derived from it is to be published without full acknowledgeement of the source. p The thesis is to be used for private study or non- a C commercial research purposes only. f o Published by the Universit y of Cape Town (UCT) in terms y t of the non-exclusive license granted to UCT by the author. i s r e v i n U 2 Compulsory Plagarism Declaration 1. This work has not been previously submitted in whole, or in part, for the award of any degree. It is my own work. Each significant contribution to, and quotation in this dissertation from the work, or works, of other people has been attributed, and has been cited and referenced. 2. I know that plagiarism is wrong. Plagiarism is to use another’s work and pretend that it is one’s own. 3. I have used the APA convention for citation and referencing. Each contribution to, and quotation in, this dissertation from the work(s) of other people has been attributed, and has been cited and referenced. 4. This dissertation is my own work. 5. I have not allowed, and will not allow, anyone to copy my work with the intention of passing it off as his or her own work. Signature: Date: Signature removed 3 Acknowledgements My ability to enroll for this Masters Degree and therefore this study was made possible through funding by the National Research Foundation and the Harry Crossley Foundation. I thank you for your generous support throughout these two years. I would also like to thank the children, parents and schools for participating in this study. Your contribution has taught me such a beautiful understanding and empathy of all your unique experiences with ASD. I hope that I have helped start a new direction in the diagnosis and interventions for ASD to help your families. I would like to thank Dr Susan Malcolm-Smith for allowing me to be part of your team, answering emails and so many meetings outside office hours. Thank you so much for your belief and faith in my capabilities, especially when I could not see them. Katie Hamilton I could not have asked to have worked with a better, intelligent, dillegent and tenacious PhD candidate than you. All the parralel working, long drives for recruitment and phone calls helped me achieve what I have. Most importantly, thank you for the amazing friendship that we have developed. To my parents, all four of you, thank you for your unrelenting faith, support and secret prayers. I would also like to thank the rest of my family and friends for your patience, love and support throughout all my years of studying that took up so much time, and for still being in my life. Lastly and most importantly, to my husband Wade Frank Petersen, you have been in my life right at the beginning of this journey, since my second year of University. Thank you for being a shoulder to cry on when things felt impossible, for reading my incoherent essays, and for always believing that I could achieve anything. I am so grateful that you are a part of every chapter in my book, I love you person! 4 Table of Contents List of Tables ....................................................................................................................................... 6 Abstract ................................................................................................................................................ 7 Introduction .......................................................................................................................................... 9 Literature Review ............................................................................................................................... 10 Autism Spectrum Disorder (ASD) ................................................................................................. 10 Attachment Theory ........................................................................................................................ 12 Parenting Styles .............................................................................................................................. 19 Theory of Mind .............................................................................................................................. 24 Rationale for Present Study ................................................................................................................ 28 Aims of the Present Study .................................................................................................................. 29 Methods .............................................................................................................................................. 31 Research Design ............................................................................................................................. 31 Participants ..................................................................................................................................... 32 Measures ........................................................................................................................................ 34 Procedure ....................................................................................................................................... 40 Data Analysis ................................................................................................................................. 41 Results ................................................................................................................................................ 42 Participants ..................................................................................................................................... 42 Study 1: Attachment Styles, Parenting Styles and Social Deficits ................................................ 45 Study 2: ToM in ASD and the Relationships with Parenting Styles and Social Deficits .............. 52 Discussion .......................................................................................................................................... 57 Study 1: Attachment Styles, Parenting Styles and Social Deficits in Children with ASD ............ 57 Study 2: ToM and Its Relationships with Parenting Styles and Social Deficits. ........................... 74 Limitations and Recommendations for Future Research ............................................................... 82 Conclusion ......................................................................................................................................... 85 References .......................................................................................................................................... 86 APPENDIX A .................................................................................................................................. 102 Roles and responsibilities of Research Team .............................................................................. 102 APPENDIX B .................................................................................................................................. 103 Ethical approval from the Faculty of Science Ethics Board ........................................................ 103 5 APPENDIX C .................................................................................................................................. 104 Ethical approval from the Psychology Department Ethics Board at UCT .................................. 104 APPENDIX D .................................................................................................................................. 105 Ethical approval from the Western Cape’s Education Department ............................................. 105 APPENDIX E .................................................................................................................................. 106 Information Sheet ......................................................................................................................... 106 APPENDIX F ................................................................................................................................... 108 Consent Form ............................................................................................................................... 108 APPENDIX G .................................................................................................................................. 110 Demographic Questionnaire ........................................................................................................ 110 APPENDIX H .................................................................................................................................. 116 Attachment Style Classification Questionnaire (Adapted to parent interview) ........................... 116 APPENDIX I .................................................................................................................................... 117 Parenting Style and Dimension Questionnaire ............................................................................ 117 APPENDIX J ................................................................................................................................... 119 Assent for Psychological Assessment .......................................................................................... 119 6 List of Tables Table 1. Demographic Information for Preliminary Analyses, for Study 1 and Study 2.........42 Table 2. Attachment Styles in ASD Sample..…………………………………………………….….45 Table 3. Bivariate Correlations between Attachment Styles and Social Deficits…………..….46 Table 4. Parenting Styles in ASD Sample………………………………………………………..…48 Table 5. Bivariate Correlations between Parenting Styles with Social Deficits for ASD Sample…………………………………………………………………………………….…..49 Table 6. Hierarchical Multiple Regression for Age, Total Attachment Styles and Total Parenting Styles with Social Deficits as the Outcome: For Verbal Subgroup..……..50 Table 7. Means and Standard Deviations for Theory of Mind in ASD Sample: For Two Age Groups………………………………………………………………………..………….……52 Table 8. Means and Standard Deviations for First-Order False Beliefs in ASD Sample: For Two Age Groups………………………………………………………………………..……54 Table 9. Bivariate Correlations between Parenting Styles with ToM in Verbal Children with ASD……………………………………………………………………………………………55 Table 10. Bivariate Correlations between Authoritative PS and Subscales with ToM in Children with ASD…………………………………………………………………………..55 Table 11. Hierarchical Multiple Regression for Age, Total Parenting Styles and ToM with Social Deficits as the Outcome………………………………………………………..…..56 7 Abstract Autism Spectrum Disorder (ASD) is fundamentally characterised by social deficits. It is thus important to understand social functioning and what contributes to social development in children on the spectrum. It is widely accepted that ASD has a neurobiological basis, however research on understanding the lack of social skills found in ASD individuals remains indefinite and controversial. In this thesis we explored attachment styles, parenting styles and ToM to discern how they relate to social deficits in ASD. The literature for typically developing children has illustrated important relationships however there is a lack of exploration in the ASD populace. This protocol was divided into two studies. Study 1 assessed social deficits, attachment and parenting styles in 46 children with ASD aged 4 – 14 years and included both verbal (n = 19) and non-verbal (n = 27) children. The ADOS-2, Attachment Style Classification Questionnaire, and Parenting Style Dimension Questionnaire were used to measure these variables. Study 2 assessed ToM capacity and its relationship with parenting styles and social deficits in verbal children with ASD. In Study 1 we found verbal and non-verbal subgroups differed on social deficits. The aims for exploring attachment and parenting styles were to discern 1) what style dominates; 2) whether attachment and parenting styles differ between verbal and non-verbal children and 3) whether these variables relate to social deficits. We found odd patterns of attachment with no clear dominant style in our full sample. Only the non-verbal subgroup showed a relationship between secure attachment and reduced social deficits. In terms of parenting, the authoritative style was reported to be mostly employed by our parents and it related to reduced social deficits in both the full sample and the verbal subgroup. In Study 2 we explored 1) the extent of ToM deficits in ASD; 2) how parenting styles relate to ToM and 3) whether better ToM and parenting in combination related to reduced social deficits. We found severe ToM deficits in our sample which suggests delayed development. Authoritative parenting was significantly related to better ToM capacities. Furthermore, a regression of positive 8 parenting and ToM abilities in combination with social deficits indicated that only ToM and age predicted less social deficits. This current study suggests that specifically authoritative parenting and ToM skills may be important underlying mechanisms for better social abilities in ASD. Most notably, it stresses that ASD cannot be regarded as a homogenous population as a clear distinction between the verbal and non-verbal subgroups is reported herein; a currently underestimated notion. Although still in its preliminary stages, the work reported in this thesis opens up a new line of thinking that could, in principle prove to be beneficial to research in the area of ASD. 9 Introduction Autism Spectrum Disorder (ASD) is a neurodevelopmental disorder that becomes evident during early childhood, typically between the ages of twelve to twenty-four months (American Psychiatric Association, 2014). Notably, the symptoms of ASD vary between each child depending on the severity of the disorder and their developmental level and for this reason each child with ASD presents a unique manifestation of the disorder. Despite this diversity, social deficits constitute a core feature across all presentations of ASD. ASD is fundamentally characterised by social deficits and therefore it is important to understand social functioning and what contributes to social development in children on the spectrum (American Psychiatric Association, 2014; Buitelaar, 1995; Fein et al., 1986; Kanner, 1943). It is widely accepted that ASD has a neurobiological basis however there is no universal agreement on specific biomarkers or cognitive reasons for the diverse symptoms characteristic of ASD (Happé, Ronald & Plomin, 2006). At present, the research on understanding the lack of social skills found in ASD individuals remains indefinite and controversial. The literature for neuro-typical (NT) children has highlighted attachment styles, parenting styles and theory of mind (ToM) capacities as important contributors to social development (Ainsworth & Bowlby, 1991; Astington, 2005; Ayers, 2002; Baumrind, 1971; Gottman, 1997; Hutchins & Prelock, 2008). Although these three variables have been noted as fundamental to social abilities, there is only some support for relationships between social deficits and attachment styles, parenting styles, and ToM individually in ASD. Moreover, there is limited exploration of these relationships in combination, especially in the South African context. This gap in the literature is even more apparent regarding possible differences between verbal and non-verbal children with ASD. Hence this study is focused on exploring how these three variables present and how they relate to social abilities in children with ASD. This study adopts a neurobiological framework for understanding ASD. It is therefore the intention of this study to explore social deficits in ASD and their relationship with attachment