The Profile of Friendship Skills in Asperger’s Syndrome
This article was published in the Jenison Autism Journal, 2002 Volume 14 Number 3. The Jenison Autism Journal is available in the USA from 616 457-8955.
When we observe and examine the social play and friendship skills of children with Asperger’s Syndrome, we first asses whether there is a delay in the conceptual stage of friendship. The child may have an overall intellectual ability within the normal range, but their conception of friendship resembles a much younger child. Indeed the natural choice of companion or friend may be someone from within their level of friendship maturity and be considerably younger than their chronological age. However, it is not simply a matter of developmental delay. While the diagnostic criteria in DSM IV, the primary diagnostic text, includes the criterion failure to develop peer relationships appropriate to development level it includes reference to a qualitative impairment in social interaction. Thus, there are aspects that are conspicuously unusual for any of the stages. The diagnostic criteria refer to qualitative impairments in behaviour to regulate the interaction and a lack of social or emotional reciprocity. What are qualitative differences at each stage from the perspective of the child with Asperger’s Syndrome and their peers?
The child with Asperger’s Syndrome can be genuinely pleased to be left alone enjoying solitude; or their preference can be to interact with adults. The author’s sister-in-law has Asperger’s Syndrome and she recalls that, “ ... as a child, a teenager, and a young adult, I seldom got along well with my peers, preferring the company of older adults. Probably because they are likely to be more mellow in temperament and of course quieter.” The child’s motivation may not be to engage in social play, but to learn. Adults (and books) provide information about the world. Their peers may have little knowledge on the topic that they find interesting.
There can be a difference in perception and priorities. The child with Asperger’s Syndrome can walk into a room and focus on the toys to play with rather than potential friends. Observation indicates that the child’s play is constructive, but not interactive. The child’s “friend” are objects. My sister-in-law recalls, “ ... it’s easy to bestow love onto objects rather than people because although they can’t love back they can’t rebuke either. It is very safe from idolisation where no-one can get hurt.”.
To the child with Asperger’s Syndrome social play, at this stage, can be quite unpleasant. They have difficulty coping with the noise, interruptions, new ideas of their peers and apparent chaos. They may be more tolerant and interactive in a room with just one playmate.
Children with Asperger’s Syndrome have a clear end product in mind when playing with toys, but may fail to effectively communicate this to the other child, or tolerate or incorporate their suggestions, which would produce an unanticipated outcome. The child with Asperger’s Syndrome wants predictability while their peers want spontaneity and variety. A description is perhaps the “Frank Sinatra approach“- My Way. The child becomes very agitated and possibly aggressive when thwarted by having to change their ideas or play to accommodate the intentions or preferences of the other child. Liane Holliday-Wiley explains in her autobiography, Pretending to be Normal (1999), “ ... the fun came from setting up and arranging things. Maybe this desire to organise things rather than play with things, is the reason I never had a great interest in my peers. They always wanted to use the things I had so carefully arranged. They would want to rearrange and redo. They did not let me control thee environment“(p. 19).
The child has a clear determination to control the activity. The concepts of sharing, waiting and turn taking are not apparent in their play with peers at this stage, but it may be apparent in their interactions with adults. Their play can be considered as self-centred rather than selfish, with social play avoided to maintain control. As one young lady said, “My friends don’t let me do what I want to do.” They tend not to see themselves as part of a group but as an individual who prefers to relate to adults. Other children are considered as bewildering, ignorant or a nuisance. The bewilderment is due to difficulties reading the social cues of their peers. They may not read the social expressions and body language to indicate feelings that would be intuitively recognised by much younger typical children. Other children instantly recognise overt and subtle signs of anger, fear, delight and disgust, yet these signals may not be perceived or considered as factors to modify the interaction by the child with Asperger’s Syndrome.
Children with Asperger’s Syndrome clearly have difficulty knowing how to socialise with their peers. Their frustration can lead to aggression but it can also lead to anxiety. This can be so severe that the child develops elective mutism at school or school refusal. Programs to encourage friendship skills should be part of treatment programs for anger and anxiety management.
One of the characteristics of Asperger’s Syndrome is to have a literal interpretation of the comment or request of other children. A girl with Asperger’s Syndrome came home from school extremely agitated and told her mother they must pack all their belongings and move house immediately. When her mother asked why, she said that at school, a boy said, “I’m going to marry you”.
When other children approach the child with Asperger’s Syndrome, they see a child who does not look any different in terms of size and facial characteristics. They may be engaged in complex constructive play but when approached they may not offer the expected welcome or inclusion in the activity. The child with Asperger’s Syndrome is perceived as bossy, sounding and behaving more like a teacher than a friend. Other children’s attempts to become a friend “fall on deaf ears” and they may be inclined to move on and play with someone more responsive and less insular or dictatorial. The child with Asperger’s Syndrome therefore misses an opportunity to use and develop the maturity of their friendship skills.
In stage 1 the child with Asperger’s Syndrome may have limited motivation to play with other children and develop friendships. In stage 2 they can actively want to join in but lack specific abilities. They want to interact harmoniously but are not sure what to do. Sometimes they become acutely aware of a lack of friendship and become quite distresses if their naïve attempts at social interaction are unsuccessful. They can develop compensatory mechanisms that range from denial and arrogance to low self-esteem and withdrawal.
Their initial myopic optimism for friendship can also turn to paranoia, especially if they fail to make the distinction between accidental and intentional acts. The research on Asperger’s Syndrome has established a difficulty with Theory of Mind tasks; that is conceptualising the thoughts, feelings, knowledge and beliefs of others. Other children may recognise from the context and often knowledge of the character of the other person whether the comment or action had benevolent or malicious intention. For example other children know when someone is teasing with friendly or unfriendly intentions. This knowledge may not be available to the child with Asperger’s Syndrome.
The author has noted that such children can have limited ability for character judgements. Other children will know which children are not good role models and should be avoided. The child with Asperger’s Syndrome can be somewhat naïve in character judgements and prone to be attracted to and imitate children who may not demonstrate good friendship skills.
Another aspect of this stage is a tendency to be possessive in friendships with an intensity that can eventually be intolerable to their chosen friend. They may not understand that the friend is a free agent who sometimes wants to play with other children and may refuse an invitation to play. When these situations occur the child with Asperger’s Syndrome may refuse any further contact with the person whom they perceive as having broken the rigid social rule that a friend will always play with you. A child with Asperger’s Syndrome said, “He can’t play with me one day and then other friends another day – that wouldn’t be a true friend”.
They may also be intolerant of their friend’s errors and quick to criticise but conversely, hate being criticised themselves. Other children are starting to learn to “think it not say it” so as not to hurt their friends feelings. At this stage, the concept of a “white lie” is a feature of friendship, but children with Asperger’s Syndrome seek honesty and truth as more important than someone’s feelings. They can be unaware of why their honest comment made their friend upset.
Children at this stage are playing more complex interactive games and children with Asperger’s Syndrome can become exceptionally emotional if they lose. Their concept of being fair is somewhat egocentric. They may always want to win or be first, not necessarily for dominance but to know the outcome. The person hates surprises or the unknown. In competitive games, of unknown outcome, the child wants certainty.
When one considers the friendship profile of the child with Asperger’s Syndrome at this stage, they are unusual in comparison to their peers in having fewer friends and often not seeking contact with friends out of school hours. Contact may be organised by parents rather than arranged spontaneously by the child.
In their attempts to make friends, the child’s intentions can be misinterpreted. The author’s sister-in-law explains that as a child she was “longing to make friends, when someone complimented a drawing I had done, I started giving people drawings until someone accused me of bragging – a rebuke I never forgot. I was only trying to win friendship”. They are so vulnerable to exploitation, prepared to comply with requests that other children would recognise as inappropriate. They may tolerate being tormented just to have company. Sometimes they may fail to recognise that the other children are not displaying signs of friendship and are quite resistant to the suggestion that their “associates” are not genuine friends in their attitude and actions.
From the perspective of their peers, the child with Asperger’s Syndrome can be unusual in other ways. In stage 2, children are starting to talk more to each other while they are playing. The choice of conversational topic can be quite unusual for the child with Asperger’s Syndrome who may want to play or talk almost exclusively on some aspect of their special interest. There is a lack of reciprocity in the choice of activity or topic of conversation. They can also appear to be ill mannered or ungracious and somewhat autocratic. It is at this stage that empathy becomes recognised as an aspect of friendship and the typical child can expect words or gestures of compassion, compliments and offers of help. Observation of children with Asperger’s Syndrome suggests that they may not recognise the cues or know how to respond. Their friend may perceive them as uncaring.
The child’s problems in peer relationships can be re-enacted at home, taking on the role of antagonist with younger siblings. They may appear to be a Dr. Jekyl and Mr. Hyde in behaving calmly and sociably with their peers at school but extremely autocratic and intolerant when interacting with their family. There can also be a vehement denial that they have any difficulties. When the subject of friendship is bought up at home or school the child is adamant that they have similar friendships to their peers. We do not know if this is a reflection of their lack of an accurate perception of the nature of their peers friendships or an attempt to convince themselves, more than others that they are successful. This denial or arrogance can be impenetrable.
Another reaction was explained by the author’s sister-in-law, “The fact is, no one likes others to know their weakness, but with an affliction like mine, it’s impossible to always avoid making a fool of yourself or looking indignant/undignified. Because I never know when the next “fall” is going to occur, I avoid climbing up onto a “confidence horse” so to speak”. At this stage the child with Asperger’s Syndrome may be socially withdrawn and clinically depressed as a reaction to their insight into their difficulties with friendship. Socialising with their peers can also be exhausting. Stephen comments, “It takes all my brain power to be a friend”.
During stage 3, friends are learning to constructively manage conflict, but experience has shown that children with Asperger’s Syndrome have considerably difficulty with the subtle arts of persuasion, negotiation, knowing when to back down, trying another way, admitting making a mistake and making personal sacrifices for the sake of friendship. These interpersonal management skills require a comprehensive understanding of another person’s thoughts and feelings. This aspect of stage 3 can be quite elusive for the person with Asperger’s Syndrome.
Peers expect an allegiance to the group. For the child with Asperger’s Syndrome, their allegiance is to the rules. They can be perceived as the class policeman, not a popular role with peers. As regards to the choice of a friend, there is an expectation among their peers of choosing someone of the same sex, age, and values; social conventions not readily recognised by the child with Asperger’s Syndrome. He may have several friends, including girls who are kind and sociable. The friend may be considerably younger or older, or from a different cultural background. Their choice of friend may cause them to be ridiculed, as their peer group may not value their chosen friend.
From the perspective of their peers, the child with Asperger’s Syndrome is “poor” in terms of the currency of friendship. S/he may not wear fashionable clothes or be interested in the popular television programs or merchandise. In return, the child with Asperger’s Syndrome perceives peers as having limited currency for his or her culture, namely knowledge. Peta, a girl who has an encyclopaedic knowledge of the weather finds other girls her age boring, as they only want to talk about magazines and make up. She wants to talk about meteorology, which is perceived as equally boring by her peers.
For typical teenagers this stage begins in high school and continues throughout adult years. The difficulties encountered by someone with Asperger’s Syndrome include the practical issues of finding someone with the same interests, experiences and thought processes. They can express strong feelings of loneliness and yearning to have a genuine friend. One adult said, “It’s not that I’m antisocial, It’s that I don’t meet many people that I like”. Another characteristic can be a lack of personal hygiene and an eccentric personal appearance, which obviously has an effect on other people’s perception of them. During this stage there should be an ability and fluency with self disclosure and the concept of self. As Geoff describes, “When there is a social conversation it’s like a different language.” There can be real difficulty in knowing what to say and the translation and communication of the social language.
The author’s experience of psychotherapy with young adults with Asperger’s Syndrome indicates considerable difficulty with the concept of self and introspection. A difficulty conceptualising the thoughts and feelings of others (Theory of Mind skills) can include a difficulty verbalising their own thoughts and feelings. The different way of thinking can include an advanced method of visualisation that means in educational terms, a picture is worth a thousand words. However, as Daniel described, in his mind he has a picture but not the thousand words. The person with Asperger’s Syndrome does experience emotions that would be relevant to include a conversation, but not the vocabulary or eloquence to convey those feelings using speech.
At this stage the person with Asperger’s Syndrome can become acutely aware of their problems and errors in social interaction. This can lead to anxiety and a genuine social phobia. They may seek excessive reassurance that their intention was understood and dwell on potential social errors. One young lady commented, “The worst thing about disappointing yourself is that you never forgive yourself fully”.
The person can be gullible and vulnerable with regard to the misinterpretation of signals and intentions. A friendly remark or gesture may be perceived as meaning more than was intended. A friendly smile or touch during conversation could be conceived as indicating the person would like to progress to a more intimate relationship. Others would know that such actions or gestures were simply signs of an effusive personality. The person with Asperger’s Syndrome can misinterpret the actions and develop an emotional attachment that progresses to a special interest in that person which may be mis-perceived by the others as an infatuation. There can also be desperation to be included in a group, but this can be a group whose values and lifestyle can lead the person to be in conflict with the law. They can act the part, and wear the costume of a marginalised group. Members of that group realise that they are not the genuine article and encourage them to break their strict adherence to their moral and legal code, knowing they are not “street wise” and more likely to be caught by the authorities.
When a friendship becomes a boyfriend-girlfriend relationship there can be misinterpretation of the other person’s feelings and body language. A young man with Asperger’s Syndrome, Corey, had a girlfriend; but the relationship with the girl had ended. His mother was concerned that Corey was not reading the signals and compounding the situation by buying her expensive presents. When I explored Corey’s perception of his girlfriend’s body language, he described someone who expressed the subtle signs of embarrassment. When I asked him how he though she was feeling, he said “ ... sad ... that’s why I buy her presents, to cheer her up”.
If people with Asperger’s Syndrome are unsuccessful in finding a friend, they may develop a friendship with animals that accept them for who they are, whose feelings are more easily understood and unlikely to take offence. Their substitute friends and “family” can be a menagerie of animals.
At some point they meet someone who shares some of the characteristics of Asperger’s Syndrome. At last they have a friend from their own culture who understands! They are a member of their natural peer group and friendships with other individuals with Asperger’s Syndrome can be remarkably successful and durable.
To the typical young adult, the person with Asperger’s Syndrome can appear to be quite eccentric, requiring considerable patience and understanding. However, in return this person can be a valued friend, renowned for their knowledge, integrity and loyalty. My sister-in-law explains, "Because of the way I talk and my dislike of things that are loud, people don’t always accept me or often judge me before even knowing me. If people with Asperger’s find it hard to integrate into society and socialise, it could have a lot to do with discrimination on the part of others." With mutual understanding there can be genuine, reciprocal friendships, free of ignorance and discrimination.
Why Does Chris do that?
Some suggestions regarding the cause and management of the unusual behaviour of children and adults with autism and Asperger's Syndrome.
Tony wrote this book as an update of the original 'Why Does Chris do that?' which was published by the National Autistic Society in the United Kingdom. This book provides information on the unique characteristics of individuals who have classic autism and the underlying causes as well as suggestions for how to manage the behaviour of children and adults with autism. The book can be obtained from the National Autistic Society in the United Kingdom but in the United States it is available from www.asperger.net
Chapter on Understanding and Managing Circumscribed Interests
- Written by Tony Attwood
Learning and Behaviour Problems in Asperger Syndrome, Edited by Margot Prior, The Guilford Press; New York
The following is the summary from the chapter on Circumscribed Interests in the new book edited by Margot Prior. The Circumscribed Interest is a distinct and enduring characteristic of Asperger's Syndrome. The intensity and focus of this interest usually distinguishes children with Asperger's Syndrome from their peers. The nature and number of interests change over time and specific triggers may precipitate a new interest. The functions of these interests range from expressing intellectual curiosity regarding the physical world to providing a source of pleasure. Parents are often concerned by how they have to adapt their personal and family life to accommodate their child's access to the interest. However strategies that reduce the time spent engaged in the interest or eliminate inappropriate interests are available. The interest can be either a barrier or bridge to social contact, in either case it can also be sued constructively at school and in therapy. The interest can be perceived as a problem and will then remain a barrier or as a talent and will then become a bridge. Some interests can even become a source of personal success and employment.
Is There a Difference Between Asperger's Syndrome and High-Functioning Autism
- Written by Tony Attwood
We have been exploring the nature of autism, as described by Leo Kanner, for nearly 60 years. He described a severe form of autism, typified by the silent and aloof child. We have only been exploring the profile of autism described by Hans Asperger for about 15 years. The children he described had speech and were active participants in social interactions. There is currently some debate in the academic literature and between clinicians as to whether Asperger's syndrome is a unique disorder with a profile of abilities that does not occur in any other syndrome or simply a form of autism with a higher intelligence quotient.
There is general agreement that autism as defined by Leo Kanner and 'autistic psychopathy' (the original descriptive term of Hans Asperger which was later changed to the term Asperger's syndrome by Lorna Wing) are two conditions within the range of disorders known as Pervasive Developmental Disorders or Autistic Spectrum Disorders. In 1994 the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) provided diagnostic criteria for Asperger's syndrome. The opinion of the authors of the manual, which was revised in 2000 (DSM-IV-TR) was that Asperger's syndrome could be differentiated from autism by an examination of the child's early development and the existence of some characteristics that were rare in children with autism. They considered that early language and cognitive skills are not delayed significantly in children with Asperger's syndrome. There is also no clinically significant delay in age-appropriate self-help skills, adaptive behaviour and curiosity about the environment in childhood. The clinical profile of a child with Asperger's syndrome is also less likely to include motor mannerisms and preoccupation with parts of objects as occurs in autism but the child can have a circumscribed interest that consumes a great deal of their time amassing information and facts. They also noted that the profile of social skills in children with autism includes self-isolation or rigid social approaches, while in Asperger's syndrome there can be a motivation to socialise but this is achieved in a highly eccentric, one-sided, verbose and insensitive manner. Should the child's profile of abilities and developmental history be consistent with the criteria for both autism and Asperger's syndrome, the authors of the DSM state that a diagnosis of autism should take precedence.
The diagnostic criteria in the DSM, which provide a differentiation between autism and Asperger's syndrome, have been examined by several research studies over the last five years. There has been some criticism from clinicians and research that the criteria do not identify the disorder Hans Asperger originally described. The four cases he described in his original paper would be diagnosed, according to DSM criteria, as having autism not Asperger's syndrome. (Miller and Ozonoff 1997). If one was to use the DSM criteria, Asperger's syndrome would be a very rare condition.
Research has also been conducted on whether delayed language in children with autism can accurately predict later clinical symptoms. Three studies have cast considerable doubt over the use of early language delay as a differential criterion between autism and Asperger's syndrome (Eisenmajer, Prior, Leekam, Wing, Ong, Gould and Welham 1998, Dickerson Mayes and Calhoun 2001 Manjiviona and Prior 1999). Any differences in language ability that are apparent in the pre-school years between children with autism and Asperger's syndrome has largely disappeared by early adolescence (Eisenmajer, Prior, Leekam, Wing, Ong, Gould and Welham 1998, Ozonoff, South and Miller 2000).
There is general agreement that children with Asperger's syndrome may not show any conspicuous cognitive delay in early childhood. Indeed, some can be quite precocious or talented in terms of learning to read, numerical abilities and in some aspects of their constructive play and memory. Children with autism can be recognised as having developmental delay in their cognitive abilities from infancy and diagnosed as young as 18 months of age with a mean age of diagnosis of five years. Children with Asperger's syndrome are often not diagnosed until after they start school with a mean age of diagnosis of eleven years (Howlin and Asgharian 1999). However, the signs of Asperger's syndrome in very young children may be more subtle and easily camouflaged at home and school. On reflection, parents (especially mothers) and teachers have often been concerned about some aspects of the child's cognitive development, in particular their social reasoning, but their concerns may have been intuitive, and difficult to describe to clinicians. It is not until the child is expected to show more advanced cognitive abilities that formal assessments indicate significant delay or an unusual profile in cognitive development.
There has been research comparing the cognitive profile of adolescents with autism and Asperger's syndrome. The studies have examined the cognitive profile of what may be called 'High Functioning Autism', that is children with a diagnosis of autism with an Intelligence Quotient in the normal range, i.e. above 70. The term High Functioning Autism has been used in the past to describe children who had the classic signs of autism in early childhood but as they developed, formal testing of their cognitive skills indicated a greater degree of intellectual ability with greater social and adaptive behaviour skills than are usual with children with autism. Their clinical outcome was better than expected. The cognitive abilities of this group of children were then compared to the cognitive profile of children with Asperger's syndrome, who did not have a history of early cognitive or language delay. The results of the research has not established a distinct and consistent profile for each group. Ehlers, Nyden, Gillberg, Dahlgren Sanberg, Dahlgren, Hjelmquist and Oden (1997) found that only a minority of each diagnostic group showed a characteristic profile.
One group of researchers, based at Yale University in the United States have suggested, on the basis of their research studies, that the neuropsychological profiles of children with Asperger's syndrome and High Functioning Autism are different. (Klin, Volkmar, Sparrow, Cicchetti and Rourke 1995). However, research by other scientists examining diagnostic differentiation using neuropsychological testing has not identified a distinct profile that discriminates between the two groups. (Manjiviona and Prior 1999, Miller and Ozonoff 2000 Ozonoff South and Miller 2000).
The DSM criteria refer to children with Asperger's syndrome as having, in comparison to children with autism, no clinically significant delay in age-appropriate self-help skills and adaptive behaviour. Clinical experience indicates that parents, especially mothers of children and adolescents with Asperger's syndrome, often have to provide verbal reminders and advice regarding self-help and daily living skills. This can range from problems with dexterity affecting activities such as learning to tie shoelaces to reminders regarding personal hygiene, dress sense and time management. Clinicians have also recognised significant problems with adaptive behaviour, especially with regard to anger management, anxiety and mood. (Attwood 2002). Clinical experience and research has confirmed that in terms of the child's behavioural profile, children and adults with High Functioning Autism and Asperger's syndrome have a very similar presentation (Ozonoff, South, and Miller 2000). Both groups benefit from the same behavioural treatment programs.
The academic may decide whether a particular subject in a research study has a diagnosis of autism or Asperger's syndrome to ensure that their research examines the same clinical populations as in other studies. The clinician has other considerations and decides whether the child has a diagnosis of autism or Asperger's syndrome to help define and understand their differences to other children. However their recommendations for treatment for both High Functioning Autism and Asperger's syndrome are the same.
Clinicians have noted that as the clinical picture of Pervasive Developmental Disorders or Autistic Spectrum Disorders changes over time, a child may receive a diagnosis of severe autism or High Functioning Autism at one point in their developmental history and Asperger's syndrome at a later stage. (Attwood 1998, Gillberg 1998). There is also the opinion among clinicians that, contrary to DSM, if a child meets criteria for both autism and Asperger's syndrome, the child is given a diagnosis of Asperger's syndrome (Mahoney, Szatmari, MacLean, Bryson, Bartolucci, Walter, Jones and Zwaigenbaum 1998)
A dilemma for the clinician is whether a particular diagnosis enables the child to have access to the government services that they need. In some countries, a child may only have support in the classroom or the parents receive government allowances or medical insurance coverage if the child has a diagnosis of autism. Clinicians may write reports with a diagnosis of autism rather than the more accurate diagnosis of Asperger's syndrome. This is particularly relevant when one considers the epidemiological research suggests that one person in 250 has Asperger's syndrome, using the criteria being adopted by clinicians (Kadesjo Gillberg and Hagberg 1999). Government and non-government agencies, especially Education and Health departments, have usually not been funded for such an incidence and are reluctant to 'open the floodgates'.
Having reviewed the literature, we may be able to answer the question, is there a difference between Asperger's syndrome and High Functioning Autism? The reply is that the research and clinical experience would suggest that there is no clear evidence that they are different disorders. Their similarities are greater than their differences. We appear to be taking, particularly in Europe and Australia, a dimensional view of autism and Asperger' syndrome rather than a categorical approach. (Leekam, Libby, Wing Gould and Gillberg 2000). At present both terms can be used interchangeably in clinical practice.
A Cognitive Behaviour Therapy Intervention for Anxiety in Children with Asperger's Syndrome
- Written by Kate Sofronoff and Tony Attwood
Good Autism Practice 4, 228, 2003
Children and adults with Asperger's Syndrome and other autistic spectrum disorders frequently experience higher levels of anxiety and stress then the general neurotypical population. Finding ways in which they can be taught to recognise their levels of anxiety and to manage these feelings is therefore very important. In this paper, two clinical psychologists, Dr Kate Sofronoff and Dr Tony Attwood describe some of the methods they have developed and used with children with Asperger's Syndrome to understand and manage their emotions. They provide evaluative data from the children and their parents.
Sixty-five children aged between ten and twelve years of age, took part and their parents were involved in this work to differing degrees. Measures were taken on three occasions, pre intervention, immediately post intervention and at six weeks follow up. Two forms of the intervention were completed, on e in which only the children participated but parents were given written materials, and a second; in which parents were taught all strategies and information in the same manner as the children. The intervention groups were compared with the waiting list control group; limitations of the study as well as suggestions for future research are discussed.