Using computer-assisted interviewing to consult with children with autism spectrum disorders: An exploratory study

Abstract

This article explores the use of computer-assisted interviewing (CAI) as a tool for consulting with children with autism spectrum disorders (ASD). This is considered within the context of a research study which utilized one CAI programme, In My Shoes, to investigate children and young people's views of provision, support, and participation in meetings and involvement in decision making. Based on a process of reflection through dialogue, the authors report on the perceived value of this methodology compared with traditional semi-structured interviewing. The researchers conclude that this approach offers potential in interviewing children with ASD. Implications for practitioners and avenues for future research are considered.

Keywords

autism spectrum disorders computer-assisted interviewing consultation research methodology

During the last 20 years there has been increasing interest in the rights of children and young people to participate in decisions affecting their lives (Prout, 2003). These rights are enshrined in the United Nations Convention on the Rights of the Child (United Nations, 1989), which had been ratified by 193 countries by its 20th anniversary (UNICEF, 2009). Pertinent to this article, Article 12 holds that ‘state parties shall assure to the child who is capable of forming his or her own views the right to express those views freely in all matters affecting the child’ and Article 2 states that there should be no discrimination including that arising from a child having a disability.

This Convention has impacted national legislation and policy with 70 countries having ‘incorporated children's codes into national legislation’ (UNICEF, 2009, p. 2). Changing international perspectives on the rights of children to have their views heard has led to an emphasis on the development of appropriate methodologies for consulting with children (Hill, 2006). For example, in the area of social care and welfare, increasing importance is being placed on consultation with children and young people (hereafter children for the sake of brevity) about desired outcomes to assist in the development of services better tailored to their needs (Curtis, Roberts, Copperman, Downie, & Liabo, 2004; Sloper, Beresford, & Rabiee, 2009; Symes & Humphrey, 2010). Internationally, as the role of school psychologists has shifted from reliance on a medical model and embraced ecological and cultural perspectives, this has resulted in a broadening of the role and functions of educational psychologists (Farrell, 2009). Increasingly, school psychologists are developing approaches to consultation with children which help them express their views (Harding & Atkinson, 2009).

There is evidence that children's consultation rights are not exercised equally (Woods, Parkinson, & Lewis, 2010). Particular categories of children who are most likely to need access to quality services are less likely to be consulted about those services. These include children with a disability, disaffected children, and children excluded from school (Curtis et al., 2004; McLeod, 2007). However, the past decade has seen an increasing focus on seeking the views of children with disabilities about their care and welfare (Beresford, Tozer, Rabiee, & Sloper, 2004) and service outcomes (Sloper et al., 2009).

There has been criticism of the consultation literature in viewing children with disabilities as a homogeneous group, thus neglecting the specific features of children with autism spectrum disorders (ASD) (Preece, 2002; Sloper et al., 2009). There appear to be relatively few studies which have investigated the views of children with ASD about their daily lives and support services (Beresford et al., 2004; Preece & Jordan, 2009). Children with ASD present particular challenges in communication and as such could be regarded as hard to reach (Curtis et al., 2004). Within the ICD-10 diagnostic system (World Health Organisation (WHO), 1993), ASD is located within the broader category of pervasive developmental disorders. The triad of impairments, identified by Wing and Gould (1979), forms the basis for the two main diagnostic criteria used internationally, ICD-10 (Carlson, Benson, & Oakland, 2010; WHO, 1993) and DSM-IV (American Psychiatric Association (APA), 2000). The triad of impairments are (a) difficulties interacting with children and adults, (b) difficulties in all aspects of communication, and (c) difficulties in flexible thinking and behaviour (Wing, 1992).

It has been argued that the impairments associated with ASD potentially impact on the consultation process (Preece, 2002). Preece, drawing from literature and his own research, identifies a range of features which may lead to difficulties, including limited intrinsic motivation to engage in social communication and interaction; a tendency to have concrete thought processes; a sensitivity to sensory stimulation in the environment; social anxiety; dislike of change; and lack of personal insight.

In contrast to Lightfoot and Sloper's (2003) recommendation of employing an open-ended conversational style when consulting with children, Preece (2002) found that the children responded to closed questions. He further recommended the presence of a known adult, and the use of visually mediated methods. However, his sample of three children included one child with no speech and two with some speech but who relied on augmented communication, thus limiting the generalizability of his findings to the wider population of children with ASD.

Children with ASD may experience social anxiety (Preece, 2002) which would impact on consultation involving an unfamiliar adult. Beresford et al. (2004) recommend two approaches to reduce social anxiety when consulting with children with ASD, namely the use of social stories in preparation for the interview, and minimizing the use of face to face interaction. They further suggest that interviews should take place in the child's school as this is a context in which children are used to seeing unfamiliar adults. However, they acknowledge that these children may have difficulty thinking and talking about a context outside of the interview, e.g. home.

The use of computers appears to offer potential as a means of facilitating communication with children with ASD. In recent years, computers have been used effectively with children with ASD as an instruction method (DiGenarro Reid, Hyman, & Hirst, 2011; Kodak, Fisher, Clements, & Bouxsein, 2011), and for assessment purposes (Ozonoff et al., 2004). Increasingly, there is interest in the use of computer-based approaches to interviewing. Computers are a familiar and enjoyable medium for children (Berger, 2006) facilitating engagement in the interview process (Greene & Hill, 2005). Aubrey and Dahl (2006) demonstrated that children younger than 12 years enjoyed computer-based assessment and interviews were assisted by activity based approaches. Research based on investigative interviews suggest that children feel their opinions are taken more seriously when technology, including computers, is used (Powell, Wilson, & Hasty, 2002).

There are two approaches involving computers, broadly categorized as computer assisted self-interviewing (CASI) and computer-assisted interviewing (CAI). CASI (sometimes called computer-assisted personal interviewing) involves the individual completing a questionnaire on a computer without assistance (Davies & Morgan, 2005) and is often used to survey highly sensitive issues. Black and Ponirakis (2000) found that the anonymity offered by this method encouraged adolescents to respond to questions about sensitive topics such as drug and alcohol use or sexual experience. However, there is evidence that whilst this may be a useful approach in the investigation of socially sensitive issues, it is less helpful in dealing with emotional issues such as psychological distress (Newman et al., 2002). Hill (2006), reviewing the literature, found that young people disclose to the same extent or more when using CASI as compared with paper and pencil questionnaires and traditional interviews.

CAI is closer to a traditional interview as it involves the interviewee being scaffolded and supported by the interviewer, however a distinctive feature is the three-way process (interviewer-computer-interviewee). There appear to be few studies evaluating the use of CAI with children. Connolly (2005), using a between groups experimental design, established that face to face interviewing with children resulted in the generation of more statements and the sharing of more problems compared with CAI. Barrett (2007) undertook an exploratory study in Scotland involving a small sample of children, none of whom were identified as having ASD, in mainstream and specialist educational provision, into the psychological factors underpinning the use of one CAI programme (In My Shoes) (Calam, Cox, Glasgow, Jimmieson, & Groth Larsen, 2000). The identified factors included joint attention, the ability of the young people to exert control over the pace of the interview, the degree of eye contact, and the transparency of what the adult records during the interview. Recently, one local authority in England has reported using In My Shoes (IMS) to ‘ascertain the views of pupils with the most significant learning and communication difficulties’ (Harding & Atkinson, 2009, p. 135).

There appear to be no published studies looking at the use of CAI specifically with children with ASD. Literature in computer-assisted learning involving children with ASD offers insights which may be transferable to CAI. Specific characteristics include the child's ability to take control, avoidance of social factors, and the predictability of a computer (Swettenham, 1996).

Literature in the area of dialogic teaching suggests that the use of tools is valuable in joint meaning making. Van Boxtel (2004), for example, argues that tools can help to ‘structure and sustain communication’ (p. 133). This may be of particular interest to those involved in communicating with children with ASD who have difficulties with communication. Computer-mediated role-play, involving the use of the Bubble Dialogue programme, has been utilized in studies involving young people and adults with Asperger Syndrome (AS) to assess and develop interpersonal understanding (Rajendran & Mitchell, 2000), and to assess understanding of non-literal language (Rajendran, Mitchell, & Rickards, 2005). The procedure in both studies involved a researcher and a participant creating dialogue in contrast to an individual working through a computer programme alone. This approach can be likened to CAI where the computer is used as a tool and does not take the place of the ‘other’ in an interview. Rajendran and Mitchell, in their discussion of the value of the computer as a tool in dialogue, argue that computers may have particular benefits in reducing the speed of communication thus providing more time for the individual to respond. This, they argue, may be particularly important to individuals with AS, and other forms of ASD, who may have difficulty coping with sensory overload.

Wegerif (2004), working in the area of computer-supported collaborative learning, draws attention to the distinction between interacting with humans and interacting with computers. He argues that computers have ‘ambivalent ontological status’ (p.180) as they can be made to act like subjects, in that they can provide a response, yet are in fact objects with no agency. He suggests that such ambivalence may allow the child a level of control in interaction with computers as opposed to interaction with humans thus offering a ‘safe’ (p.181) form of interaction for the child. Wegerif (2007) suggests that this may be of particular importance to children with ASD who can feel threatened by the demands of social interaction.

The present study sought to enhance understanding of the use of CAI as a tool for consulting with children with ASD, focusing on the use and potential application of IMS (Calam et al., 2000). This is considered within the context of a study which explored children's views of provision, support, participation in meetings, and involvement in decision making. The focus of this article is not on the findings of that study, which are reported elsewhere (Smith, Barrow, Hannah, Jindal-Snape, & Kerr, 2006), but rather reflections on the methodology.

The specific research questions which the article will address are: What are the advantages of using IMS as a computer-assisted interviewing method to consult with children with ASD? What are the disadvantages of using IMS as a computer-assisted interviewing method to consult with children with ASD?

Methods

Participants

Eight children aged 9- to 15-years-old, all of whom had a diagnosis of ASD, participated in the interviews. They attended a range of educational provisions: (a) five at mainstream primary schools; (b) two at mainstream secondary schools; and (c) one at a specialist secondary school.

Instruments

IMS is a CAI programme designed and developed by a multi-disciplinary team as a tool for investigative interviewing in cases of suspected child abuse (Calam et al., 2000). However, Calam et al. suggest that it has potential application with a range of children, including those with ASD.

IMS comprises a series of nine modules which explore ‘experiences, thoughts, feelings and wishes’ (Child and Family Training Services, n.d.). Four of the nine modules were used in this study. Module One (Introduction) provides a menu of black and white line drawings of individuals, with some attempt to reflect cultural diversity and disability. The child is prompted to choose one of these drawings as a self representation and type his/her name into a text box, supported as required by the interviewer. Module Two (Emotions) presents the child with a palette of emotions represented by simple line drawn faces and the interviewer asks the child to label the emotion. A perceived strength of the programme is the in-built flexibility to reduce the number of emotions if a child has difficulty labeling the full palette; a decision which can be made in advance or during the interview. Module Three (Emotions and Scenes) allows the interviewer to choose one of three sets of scenes (a) standard; (b) school; and (c) sensitive. The sensitive set may be used when there is a suspicion of abuse. The child chooses an expression to represent the perceived emotion of the individual in each scene. In Module Five (People), the child selects from a range of representative pictures of people who are with him/her in the setting from a choice of (a) school; (b) home; and (c) community.

IMS possesses a number of features which enable flexibility in the administration of the programme: (a) sequential use of the modules; (b) an audio guide prompt which can either be changed to suit the child's preference or switched off; (c) settings can be adapted to a child's personal circumstances; (d) use child's own vocabulary to label feelings, people, and settings; (e) when populating a setting a child can choose a desired number of people; and (f) the facility to log the child's responses, either typed by the child or the interviewer acting as a scribe.

The programme was selected by the researchers as it: (a) maintains the flexibility of a semi-structured or unstructured face to face interview; (b) allows the participants to take some control over the direction of the interview (Swettenham, 1996; Wegerif, 2004); (c) reduces the social anxiety of participants through the use of a three-way interaction process with the computer as a shared focus (Swettenham, 1996; Wegerif, 2004); and (d) uses a visually mediated approach (Preece, 2002).

Both authors completed two days accredited training in the use of IMS. In this study, which formed part of a wider investigation into the provision in two Scottish authorities for children with ASD (Smith et al., 2006), IMS was used as tool to explore the children's views about (a) help received in school; (b) help received outside of school; and (c) participation in decision making processes. The interview questions were designed to provide triangulation (Cohen, Manion, & Morrison, 2007) with data obtained from other stakeholders. Four dimensions were explored: (a) help in school; (b) help outside of school; (c) whether, and to what extent, the child is consulted about decisions made about him/her; and (d) the child's experience of attending meetings. For help in and outside of school, the children were asked similar probe questions (a) Who is there? (b) What do they do? (c) How do they help? and (d) What do you think about the help?

Procedure

Parents who completed a questionnaire as part of the wider study were asked to consent to their child being interviewed. Following the sampling process, parents were contacted by telephone to clarify arrangements, confirm their agreement and provide further information regarding what was involved.

Contact was made with designated staff in the child's school to ascertain practical arrangements. Confirmatory letters were sent to staff and parents, outlining the purpose of the interviews and information about the interview process in order that school staff and parents could prepare children for the interview.

The researchers opted to conduct the interviews in the school setting as visitors to schools are a more common occurrence and it was considered that this would be less stressful for the children (Beresford et al., 2004). Through consultation with parents and school staff, all child participants were given the option of having a familiar adult present during the interview (Preece, 2002). Information sheets and consent forms were prepared for the participants. At the beginning of each interview, children were advised of their right to withdraw at any stage and it was agreed how this would be signaled to the interviewer. The researchers took the view that informed consent is an ongoing process (Cocks, 2006) and monitored the children throughout the interview, recognizing that despite being provided with a signal to end the interview some might this difficult.

During the first part of the interview, modules from IMS were used. Module Two (Emotions) was used to provide some insight into the child's ability to understand facial expressions and provide vocabulary to label the associated feelings. Module Three (Emotions and Scenes) was used to gain insight into the child's ability to understand and describe social situations. The child was then asked to choose a self-representational figure (Module One).

Module Five (People) served as a transition point from sole reliance on the modular content of IMS to integrating IMS with a more traditional semi-structured interview format. Questions were open-ended and the interviewers encouraged and facilitated free flowing comments rather than a question and answer format (Lightfoot & Sloper, 2003). It is acknowledged that this conflicts with Preece's (2002) recommendations; however the children in his study had more limited communication skills than those in the present study. Each child was asked to identify representations of people who help in school (e.g. peers, older or younger children, adults). As the child chose representational figures, the interviewer asked questions using the semi-structured interview schedule. This process was repeated to focus on people who help at home. Each child was then asked about being consulted about decisions, and experience of attending meetings. All interviews lasted up to one hour.

Both researchers were present throughout these interviews taking alternate turns acting as interviewer/transcriber, enabling one to focus on conducting the interview whilst the other took contemporaneous notes. These notes included what was said by the interviewer and interviewee as well as observations on non-verbal features, such as the verbal expression, tone of voice, and the general demeanour of the interviewee. Following each interview, the researchers checked the accuracy of their notes and reflected on other aspects of the interview process. The importance of a dialogic approach to criticality is recognized by Van der Riet (2008), who argues that in order to understand human action there is a need for both a distanciated (outsider) approach and an empathic (insider) approach. The researchers view the self-other confrontation in dialogic reflection as enabling a more effective approach to reflection on the process than could have been generated by a lone researcher. These reflections enabled a critical perspective on the use of IMS as a method to facilitate the consultation process with children with an ASD.

Data analysis

A deductive approach to data analysis was employed, with the coding system based on the research questions and prior reading of the extant literature in consulting with children with ASD and the use of CAI. This system was applied to the whole data set by the researchers working in a collaborative fashion. The researchers employed manifest analysis whereby the data was accepted at face value with minimal levels of interpretation (Newby, 2010). To enhance the rigour of the process, the researchers scrutinized the data for deviant cases (Silverman, 2010).

Results and discussion

Advantages of using IMS as a computer-assisted interviewing method to consult with children with ASD

An anticipated advantage of using CAI was using the computer as a tool (Wegerif, 2004) whilst also allowing the flexibility of a semi-structured or unstructured face to face interview. As found in other studies (Aubrey & Dahl, 2006; Berger, 2006; Greene & Hill, 2005), all the children responded positively to the introduction and use of a computer. At the outset, it appeared to have a relaxing influence and they showed obvious pleasure using this medium.

Use of the computer allowed a three-way interaction process which appeared to facilitate communication. The participants could choose to give the interviewer eye contact with the computer screen providing a shared point of reference. This seemed to be important during the initial part of the interview when relationships were being established. During the structured questions phase, transcripts indicate free-flowing conversation in the majority of the interviews, as illustrated by the following examples:

‘Any clubs?’ (I) ‘Saturday club. Disabled club for people with disabilities and disorders. Just like playing outside or playing inside’(C) ‘Do you go every week?’(I) ‘Yeah. Don't always go. Sometimes I just want to stay and play with my friends’ (C)

‘Think of someone who helps you in school’ (I) ‘George’ (C) ‘do you know how to spell George? (I) ‘(types in name)’ (C) ‘who's he?’(I) ‘He's my friend … he helps me when I'm stuck on heaps of games and lets me borrow his and if I get past the level he's on I help him … I help him and he helps me’ (C) ‘how does that make you feel?’(I) ‘happy’ (C)’ is that home or at school?’(I)’ both’ (C)

‘Is he in your class?’(I) ‘He's coming this year’ (C) ‘Is he younger?’ (I) ‘Yes. He's 8 or 9’ (C) ‘How does he feel when you help him?’(I) ‘He's practically mentally happy’ (C) ‘Is that good?’(I)’(smiling): Yes' (C)

Mrs X. She helps us outside and inside … all staff in this school are ladies (C) ‘Mrs X helps in class?’(I) ‘she helps us inside and she helps outside like if there’ s a fight or takes people inside if they're injured’ (C) ‘does she help you?’ (I) ‘she helps me outside cos I'm autistic … I know that sometimes people say things and I don't take it as a joke cos I'm autistic’ (C)

Particular features of IMS enabled the interviewer to be sensitive to each child's responses. The facility to alter the number of emotions addressed variability in children's verbal ability enabling a more tailored approach. There was evidence that the use of IMS allowed the children to take some control over the direction of the discussion. In the first part of the interview, which relied solely on the use of IMS, a number of the children expanded the discussion beyond the representational scenes to include reference to their own experiences as illustrated by the following examples:

‘Angry … my brother is always like that’(C)

‘I hate spiders! My mum has a friend and he let a tarantula out of a cage by accident’ (C)

‘What did you want it to be?’ (I) ‘Feeling not happy because someone wouldn't let her go to the cinema with her and she wanted to see it too. Boy said sorry “I just want to go on her own” Maybe her brother’ (C) ‘Sometimes people just want to be on their own’ (I) ‘Maybe someone wouldn't let her go to the theatre or go out to play or just take a look at things’ (C)

These quotes complement and validate the researchers’ reflections that the interview allowed space for the children to direct aspects of the conversation. The authors suggest that being encouraged to use their own vocabulary, a feature of IMS, personalized the process and enabled the children to feel involved from the outset although it is not possible to demonstrate this empirically. The children continued to speak freely about their own experiences during the second part of the interview as illustrated by the following extracts:

‘I remember my old teacher. I won't mention her name. If you don't behave good you will get lines for it. I probably did provoke it. We did play up. We thought this isn't fair. You should be believing me’(C)

‘She helps me when I'm stuck or if I don't understand or she asks me if I'm ok … I like her because she helps other children … because she's a teacher she's got to love all the children in the school … sometimes when I've got an expression on my face like I'm sad or I'm stuck, she come over and asks if I'm ok’ (C)

The visually mediated feature of IMS appeared to be useful in the first part of the interview. It might have been expected, given the difficulties associated with ASD, that participants might have found distinguishing between visual representations of themselves and others confusing. However, a number of the participants indicated that they were able to distinguish between self and other representations as illustrated in the following quotes: ‘That's just a girl. Not me … It could be one of my friends. It looks like X’ (C) and ‘Think he might be afraid of spiders as I would be’ (C).

Given the difficulties with theory-of-mind found in the majority of individuals with ASD (Begeer et al., 2011), it seemed reasonable to predict that the children would have problems appreciating the feelings of a third party in Module Three (Emotions and Scenes). As illustrated in the preceding examples, a number of the participants talked about their personal experiences. It should be noted that during the accredited training in IMS the researchers were advised that it is not uncommon for children to respond in this fashion.

Disadvantages of using IMS as a computer-assisted interviewing method to consult with children with ASD

IMS incorporates the facility of a ‘guide’ who gives advice and instructions on how to use the programme during the various modules. The researchers opted to have the guide switched on (and used the Mary guide option) thus providing supplementary auditory support. On reflection, it was apparent that the children found this guide irritating, as the following quote illustrates: ‘How do you get rid of her … probably some editor will say “get rid of the girl”’ (C).

It is possible that the guide had a distracting quality which may be particularly relevant for children with ASD who can experience difficulties with sensory integration (Iarocci & McDonald, 2006). One interesting comment in relation to the guide relates to Wegerif's (2004) notion of the ‘ambivalent ontological status’ (p.180) of the computer. When typing in names of people who help her, one child asked ‘Does Mary know the names?’ This suggests some level of uncertainty about the status of the computer as an interactional partner.

Conclusion

There is a limited literature in the area of consulting with children with ASD and attempts to develop practice in this area must be tentative and exploratory. It is the authors’ contention, supported by evidence from this exploratory study involving a small sample, that CAI offers potential as a consultation tool with children with ASD. CAI provided a shared focus from the outset of the interview and removed the pressure of immediate eye contact. Specific features of IMS provided flexibility enabling a tailored approach to be taken to each child interviewed. IMS allowed the interviewee to use his or her own vocabulary for feelings, people and places as he/she worked through the programme and provided useful visual supports at the early stages of the interview process.

The authors acknowledge a number of limitations in this study. The interviews were neither video nor audio recorded. Video recording of interviews, whilst potentially more intrusive, would have enabled an accurate and complete record facilitating fuller analysis of the non-verbal communication. By focusing on the researchers’ analysis of the data and reflections on the process, the study does not provide empirical evidence of the ‘value added’ dimension of IMS. Future research comparing the effectiveness of IMS with other approaches to consultation is indicated. This should take account of the active role of the child (Westcott & Littleton, 2005) and the co-constructed nature of the interview process, such that the emphasis would be on the interaction rather than the ‘quality’ or quantity of data obtained. The use of video recording would allow comparative micro-analysis of interactions using the different consultation approaches. Reflecting on wider aspects of the research methodology, the researchers recognize that the emphasis in this study was on finding the most appropriate tool for eliciting children's views and this may have been to the detriment of genuine participation in the research process.

Notwithstanding these limitations, it is suggested that these findings will be of interest to academics, researchers, and a wide range of professionals and practitioners, including school psychologists. Globally, school psychology practice is diverse reflecting the influence of external (e.g. geography, culture) and internal factors (e.g. legal status of profession) (Cook, Jimerson, Begeny, & Oakland, 2010; Oakland & Jimerson, 2007). However, a common and core feature is the application of psychology to bring about positive changes for clients. School psychologists employ a wide range of approaches and techniques in their direct work with children. Technological advances offer exciting opportunities for school psychologists to broaden their skill base. Computers have been used effectively for assessment (Ozonoff et al., 2004; Rajendran et al., 2005), instruction (DiGenarro Reid et al., 2011; Kodak et al., 2011) and intervention (Rajendran & Mitchell, 2000) with children with ASD. Future developments in school psychology should take account of the potential use of CAI in supporting consultation with children with ASD about significant aspects of their lives.

Footnotes

Acknowledgements

The authors would like to acknowledge the team who developed In My Shoes, namely Rachel Calam, Antony Cox, David Glasgow, Phil Jimmieson and Sheila Groth Larsen. They also wish to thank all the children who took part in the study, their parents and school staff.

Wilma Barrow is an Academic and Professional Tutor on the DAppEdPsy Programme at Newcastle University and is an Educational Psychologist with Scottish Borders Council. Address: School of Education Communication and Language Science, Newcastle University, King George VI Building, Victoria Road, Newcastle-upon-Tyne, NE1 7RU, UK. Email: w.barrow@ncl.ac.uk

Dr Elizabeth F. Hannah is a Senior Lecturer in Educational Psychology and is the Programme Director for the DEdPsy and MScEdPsy programmes. Address: School of Education, Social Work and Community Education, University of Dundee, Carnelley Building, Nethergate, Dundee, DD14HN, UK. Email: e.hannah@dundee.ac.uk

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