“His inner-self must be good”: An ethnographic-vignette study of social interactions between children with autism spectrum disorder and typically developing peers

Abstract

Children with autism spectrum disorder (ASD) can benefit from greater social integration through positive peer relationships. The study aimed to understand children’s views toward autism as well as experiences of interactions between children with ASD and typically developing (TD) peers. After ethnographic observations in a mainstream primary school educating diverse students, interviews were conducted with 10 students with ASD and ten of their TD peers using open-ended and vignette questions about three hypothetical scenarios set in varied contexts: a classroom, a birthday party, and a public setting. Narrative analysis focused on how the children constructed their experiences in response to these vignettes. Children with ASD frequently experienced isolation in peer interactions. While their TD peers favored interactions with those with ASD, believing that their behaviors of concern are extrinsic and their intentions must be good, their lack of understanding of ASD and of social skills that could be used to facilitate more positive interactions could result in unintended harm and exclusion. Early school-based intervention would assist in increasing the acceptance of neurodevelopmental differences and diversity.

Keywords

Autism spectrum disorder disability ethnographic observation inclusive education primary school children qualitative study social interactions vignette methods

Introduction

Positive peer interaction is important for children’s well-being, especially for children with autism spectrum disorder (ASD). With a neurodevelopmental disability characterized by social and communication differences and behavioral atypicalities (American Psychiatric Association, 2013), children with ASD are highly vulnerable to social exclusion, which adversely affects their mental health, development and effective participation in education (Billstedt et al., 2007; Rotheram-Fuller et al., 2010). Thus, forming positive attitudes toward people with developmental disabilities and nurturing interactional skills are essential to improving peer relationships in childhood (Hay et al., 2004). The development of sociality and morality in childhood is dependent more on voluntary engagement in social interactions than specific activities or information presented in the classroom (Kim & Mahoney, 2004). Learning to understand social meaning and respond appropriately in social situations is gained through consistent interaction with others. Children with ASD often miss out on this “social education” from an early age, as they may be less exposed to interactions and have limited experiences with quality interactions with their peers (Anderson et al., 2004; Klin et al., 2003). This study aimed to understand social interactions among children with ASD and their typical peers to address the development of effective early interventions in school settings.

Some individuals with ASD without intellectual disability have reported a desire for social interactions and friendship despite difficulties in initiating and maintaining these friendships (Deckers et al., 2017; Hull et al., 2020; Jaswal & Akhtar, 2019; Livingston et al., 2019). Being aware of the discrepancy between their desire for social participation and their limited social skills and social differences can be particularly frustrating for students with ASD and may lead to feelings of loneliness. It is unclear to what extent self-reported preferences for being alone in children with ASD were related to past experiences of negative interactions (Calder et al., 2013; Nowicki & Sandieson, 2002). Similarly, among TD students, their avoidance of interaction or conflict with children with ASD may be due to a lack of mutual understanding and skills in how to initiate and respond to unfamiliar interactions (Tsang, 2013). Recurring interactions would allow children with ASD to develop friendships with their peers, contributing to better psychological and school adjustment (Cottenceau et al., 2012). Fostering positive interactions not only enables children with ASD to have greater satisfaction with friendships but also can contribute to acquiring a more diverse set of social and intellectual skills in the classroom and beyond. Removing some of the barriers to positive peer interactions in early school contexts would help children with ASD enhance their sense of autonomy and enjoyment of school. This process, in turn, would provide a positive foundation for the development of social relationships beyond the school years. Seeking the views of both ASD and TD children about social interactions assists our understanding of both positive and negative aspects of relationships between school peers and of how to encourage mutually beneficial relationships.

Inclusive education, where children with ASD and other learning differences are supported to fully participate in mainstream education settings, is an effective strategy to improve social integration. A large body of evidence supports the psychosocial and educational benefits of education inclusion for all students (Crosland & Dunlap, 2012; UNESCO, 2009), providing increased opportunities for social interactions and fostering improvements in adaptive social functioning (Crosland & Dunlap, 2012; Koegel et al., 2012; Tsao et al., 2008). However, given the social and communicative differences in ASD students, they are at an increased risk of social exclusion in classrooms even when physically included. Social networks of children with ASD have been reported as being weaker than those of TD children in terms of reciprocal peer relationships (Rotheram-Fuller et al., 2010). Children with ASD have also reported having fewer close friends and limited invitations to others’ homes or social events compared to TD peers (Ochs et al., 2002). They are often peripheral to social relationships, spending more time in solitary behaviors, and less time in cooperative interaction with peers (Knott et al., 2006). They may experience higher degrees of loneliness than TD peers (Bauminger & Kasari, 2000; Chamberlain et al., 2007). With difficulties in conventional social interactions and play, children with ASD may also be exposed to rejection, scorn, and bullying (Anderson et al., 2004; Lindsay, 2007; Symes & Humphrey, 2010). A recent review, for example, reported high rates of school bullying among youth with ASD, including the pooled prevalence of physical (33%), verbal (50%) and relational (31%) school victimization (Maiano et al., 2016).

Early intervention in promoting acceptance and companionship is important for social skills training of peer sensitivity about ASD (Chamberlain et al., 2007; Humphrey & Symes, 2011). Children of younger ages are generally more flexible to learn and adopt different attitudes and behaviors (Rotheram-Fuller et al., 2010). Friendships change throughout childhood in terms of both their functions and children’s expectations. Children have more success in developing friendships with those who are perceived to be “different” in early and middle childhood than in adolescence. In early and middle childhood, friendship is based more on shared norms, conversation and games rather than the intimate reciprocal relationship demanded in adolescence (Hojjat & Moyer, 2017). Studies have found that interactions between children with ASD and their TD peers are amenable to interventions improving their frequency and quality (Koegel et al., 2012; Trembath et al., 2009). While children with ASD often experience challenges in casual social activities, they can systematically learn to interact socially with peers and engage in more adaptive play behaviors by modeling, imitation, and observation (Sperry et al., 2010). Likewise, training TD peers to implement social-communication interventions in mainstream settings could generalize benefits for all children involved (Sperry et al., 2010; Tsao et al., 2008).

The available literature on social interactions in children with ASD highlights the pivotal role of TD children compared with teachers or parents (Goldstein et al., 2007; Kalyva & Avramidis, 2005; McConnell, 2002). TD peers’ initiation plays an essential role in promoting social interactions (Corbett et al., 2014). Children with ASD generally make fewer initiations to form peer relationships and activities than TD peers, even compared to children with other developmental disabilities (Lord & MaGill-Evans, 1995; Orsmond et al., 2004). Difficulties in social cognition frequently hinder the ability of children with ASD to use pragmatic language in conventionally accepted ways (Hauck et al., 1995). While children with ASD engage in peer interactions, they usually respond to fewer initiations and may engage in shorter bursts of interaction (Kennedy & Shukla, 1995). Of course, interactions are two-way behaviors that occur within social contexts. For their part, TD peers may be less effective in interacting with their autistic counterparts in terms of information transfer (Crompton et al., 2019). Thus, TD peers could facilitate and increase interactions by learning simple steps for successful social initiations toward children with ASD (Corbett et al., 2014; McConnell, 2002).

Current study

Despite increasing awareness of ASD and recognition of the benefits of inclusive education for all children, there is a dearth of research on the social integration of children with ASD in Asia. Studies in the region have mostly focused on the clinical epidemiology of ASD etiology, risk factors, and assessment, the effectiveness of individual-based interventions, and parenting stress. In Hong Kong, under the Integrated Education Policy implemented in 1999, children with ASD who have an IQ of 70 and above receive mainstream education in public schools (Hong Kong Education Bureau, 2014). Notably, the number of children with ASD in primary school has increased from 4,150 in the 2012/13 academic year to 7,820 in 2016/17. The increase rate of 88% in children with ASD was significantly higher than the increase rate of 9% in all students (Hong Kong Education Bureau, 2018). However, the resources for supporting genuinely inclusive education for children with ASD are very limited in Hong Kong (Peters & Forlin, 2011; Wong et al., 2004; Yi et al., 2020). Most activities in mainstream Chinese schools are classroom-based. Students are each assigned a seat (often with a “next-desk” neighbor) and spend most of their time in their own classroom. Such extensive physical proximity highlights the salient role of peers in the adjustment of children with learning differences in local school settings (Lam & Yeung, 2005). While Hong Kong students identified themselves as having a shared responsibility to initiate interactions with their peers with developmental atypicalities, they reported multiple barriers: (1) feelings of incompetence related to unfamiliarity and lack of knowledge and skills in how to initiate and maintain interactions; (2) lack of mutual understanding, such as knowledge of the difficulties that their peers with developmental differences experience; and (3) lack of cooperative activities outside the classroom to foster interactions and mutual understanding (Tsang, 2013). Currently, there is limited educational intervention available in primary schools in Hong Kong to promote social skills for initiating and maintaining positive peer interactions with children with ASD.

This lack of effective intervention is, in part, due to limited knowledge of the social world of children’s friendships with peers with ASD. To gain contextual understanding of children’s views toward neurodevelopmental disabilities, particularly ASD, and their experiences of social interactions between children with ASD and their TD peers, we conducted an ethnographic-vignette study in a mainstream primary school addressing the following research questions. What views of neurodevelopmental disability and ASD are held by primary school-aged children with ASD and their TD peers? What are the social contexts of their peer-interactions? How do TD peers respond to social interactions with children with ASD in particular settings, including classroom activities, birthday parties, and public events? In these diverse contexts, what are the main concerns and problem-solving skills utilized by TD peers?

Methods

Ethnographic approach

We contacted five mainstream primary schools in a district of Hong Kong. One of the schools agreed to participate in the study. The school informed us that the enrollment of children with ASD had increased in recent years. The district the school is located in is one of the most populous in the city, with average rates of secondary school completion (48.3% vs. 50% across Hong Kong) and median monthly income (HK$ 12,000 (≈ US$1,530) vs. HK$11,000 (≈ US$1,400); Hong Kong Census and Statistics Department, 2015). The other schools contacted expressed concerns that their school would be identifiable, even though we assured them that they would remain anonymous.

We first had a series of meetings with the school principal and teachers. During the meetings, we introduced our study, including its aims, procedure, expected outcomes, and research ethics, and discussed our proposed methodologies for ethnographic observations and in-depth interviews using vignettes. Ethnographic approaches have been used widely in educational research (Walford, 2008). We learned about aspects of the policies and practices for education in the school and refined our study protocol based on their suggestions. Unlike structured observation techniques, we used ethnographic approaches employed in naturalistic settings (Delamont, 2002; Hammersley & Atkinson, 2007). There was no prefixed number of observations. We tried to make ourselves flexible in the school while interacting with teachers and students to gain a “quasi-membership” from the school community (Hammersley & Atkinson, 2007). Although the focus of observation was children’s behaviors, the unit of analysis in ethnography was the school setting as a whole. We engaged with teachers and special education specialists in the school conducting informal, open-text interviews to better understand their perspectives. All of these methods allowed us to explore children’s social worlds while developing rapport with school staff (Walford, 2008).

With the school’s permission, we conducted a series of observations of peer interactions and play behaviors among children diagnosed with ASD in physical education classes, lunch and break times, and during extracurricular activities (e.g., computer class) in March 2017. We conducted three observations per setting, with each observation taking one hour. We were introduced to students as staff who would observe students’ activities to enhance the school curriculum. As the school had a policy that teachers could not disclose which students had a developmental disability, the details of our primary study objective of understanding peer interactions between ASD and TD children were not given to the students. If we had informed students about our research objective, it might have influenced their actions, shifting them toward more overtly socially desirable behaviors.

The observations focused on how students diagnosed with autism interact with their TD peers, including spontaneous interactions during free-play activities and teacher-directed interactions during purposeful activities. With teachers’ informed consent, we video-recorded interactions and wrote observation fieldnotes. The data gathered from these observations were then used in the development of vignette cases and a topic guide for in-depth interviews based on these vignettes.

Participants and procedure

We used a purposive sampling strategy to recruit the interview participants (Creswell, 2013). During the observations, the school indicated the students with ASD, and we identified TD children who were in physical contact with them. Physical contact was determined by the frequency and distance of their contacts. We contacted the parents of both ASD and TD children and obtained their consent. We also obtained consent from their teachers. We then invited 10 students with ASD and 10 of their TD classmates to participate in an interview. The number of children was based on informed consent obtained from parents. The number of ASD-TD pairs of participants was relatively equally distributed across the grades: two students in each of grades one and five, three students in grade two, and one student in each of grades three, four, and six. Half of the students were from grades 1–3. At the interview, children were informed that they would share their school experiences with peers. The interviews were arranged during their lunch or break times in an office provided by the school to secure privacy and confidentiality. The interviews were conducted in Cantonese by the second author; the use of the local language helped to establish rapport with the children (Rubin & Rubin, 2005). The interviews lasted approximately up to one hour. The study was approved by the university research ethics committee. Our research ethics stated that if a student showed any distress during the interview, we would stop the interview and refer the child to the special education specialist in the school. We had no case of referral. After interviews with children with ASD, we had a brief debriefing with them to hear about their experience with the interview.

Interview domains

We developed interview topic guides separately for each group of children. The interview with the children with ASD (P1–10) focused on (1) their experience and feelings of inclusion or exclusion/loneliness in social interactions and (2) their understanding of ASD and developmental disability. Table 1 presents sample questions in the topic guide. There were challenges in the interviews with children with ASD, as some had difficulty with comprehension and communication. The quality of responses varied. Thus, the interviewers needed to adjust the flow of questions and probes. For example, the same questions might be asked more than once to ensure understanding. Children with ASD were more responsive to questions with a choice format (e.g., do you play inside or outside the classroom?) than open-ended questions (e.g., where do you like to play in school?). Probing questions were used to further explore the context of their responses.

Table 1.

Sample interview questions for children with ASD.

Experiences of friendship

1. Do you have friends? Can you tell me about them? What do you like doing together?

2. Do you have a best friend? Can you tell me about him or her? What do you like doing together?

3. What are the ways to make friends at school?

4. Do you find it easy or difficult to make friends and get along with them? Why?

5. Overall, how would you describe or summarize your friendship?

Views of friendship

6. What does a friend mean to you? How do you feel when you are being with a friend?

7. How do you know someone is your friend? How is a friend different from someone whom you just go to school with?

8. What do you like about having friends?

9. Are friends important to you? Do you like making new friends? Why?

Views of ASD

10. What does autism (the term referred by the interviewee) mean to you?

11. Does having autism affect your friendship with others?

12. Are there things that you wish your friends/classmates to know about autism?

The interview with TD children (P11–20) was constructed in two formats. Table 2 presents sample questions and vignette cases. First, we explored the children’s understanding and knowledge of ASD, peer interactions with classmates who were “different” and the meaning of friendship (Morton & Campbell, 2008; Swaim & Morgan, 2001). We clarified whether the peer who was “different” was the child with ASD by asking the peer’s name. The second part of the interview consisted of vignette questions (Finch, 1987; Jenkins et al., 2010).

Vignette approach: Development and validity

A vignette question describes an event, happening, circumstance, or another scenario, the wording of which is experimentally controlled by the researcher (Spalding & Phillips, 2007). The application of vignette questions has been previously validated in research with children (Barter & Reynold, 2000). We provided vignettes of social interactions with children with ASD and asked specific questions about how TD students would respond in terms of perceived problem-solving behaviors. Three vignettes scenarios were developed based on the type of social environments which children are mostly exposed to in school, social, and public settings: (1) a group project in the classroom, (2) a birthday party, and (3) a hypothetical event of children with ASD causing a disturbance on the street. The first case was drawn from our observations, and the other two cases outside the school setting were designed using knowledge from our previous studies of children with ASD (Ho et al., 2014; Yi et al., 2020). The cases were ordered based on expected exposure among TD children so they would find it easy to respond at the beginning. Under the major themes, we explored subthemes of perception toward ASD, peer pressure, social integration, social pressure, special needs, felt stigma, and perceived roles and responsibilities. In the vignettes, we used a local Chinese term for autism (“自閉症”) instead of the clinical term “autism spectrum disorder.”

The following procedures were performed to establish internal validity in the construction and development of the vignettes (Gould, 1996; Hughes & Huby, 2004). First, the scenarios were constructed based on our current observations or previous studies and informed by existing literature on the topic. The vignettes were then refined by experts in ASD treatment and special education and the schoolteachers, who evaluated the suitability of vignettes in terms of how the constructed scenarios were representative of situations relevant to our participants and research topics (Wilson & While, 1998). The timing of vignette questions affects the quality of responses (Gould, 1996). Our conversational interview was followed by the vignettes, so the children felt comfortable and found the vignettes relevant to explore. Children were assured that there were no right or wrong answers to reduce socially desirable responses. During the vignettes, the continuity of the setting of the vignette scenarios from school to home and then the street helped to keep the children interested and engaged.

Studies of vignettes use different perspectives from the view of the vignette characters, their peers, or from their own personal viewpoints. It is inconclusive about which perspectives are more effective in response and how different perspectives play a role in participants’ socially desirable patterns of responding (Hughes & Huby, 2004). However, for children, playing the role of the vignette character might be perceived to be a difficult task and therefore frustrating (O’Dell et al., 2012). Thus, we constructed the vignettes from their own personal viewpoints with the children using “I” to express their views (Jenkins et al., 2010; O’Dell et al., 2012). Prior to their application, the final version was evaluated by a local special education psychologist. We piloted the vignettes with three TD children who had social interactions with children with ASD, asking them if the vignettes were interesting and seemed realistic. No adjustment was made in the vignettes. We did not use vignette questions for children with ASD for several reasons. First, we were concerned that the hypothetical settings might evoke unfavorable past experiences and psychological distress. Second, we were primarily interested in TD peer-led initiation as an effective strategy to develop and maintain positive social interactions with children with ASD (Corbett et al., 2014). Thus, the vignette interview focused on the responses and concerns of TD children.

Table 2.

Sample interview questions and vignette questions for TD children.

Views of ASD
1. Have you heard of autism? Do you remember where did you first hear of autism?
2. When you hear about the word, autism, what are the first thoughts that come to your mind?
3. What are the similarities and difference do you think children with autism have?
Experiences of children with ASD
4. Have you interacted with someone with autism? What was it like?
5. Do you have a friend who has difficulty with getting along with others? Can you tell me more about the friend? How do you get along with him/her?
6. Any specific skills you have? How did you start and keep play with them?
7. Based on your experience what are the simple ways to make friends of children who have difficulty with getting along with others?
Views of children with ASD
8. What aspects of the friendship do you like most? Why?
9. How about challenges? What do you think you can play a role to overcome?
10. Based on your experience, what do you think is important to be aware of when getting along with them? Why?
Vignette 1—School setting: Group work in the classroom
At class, your teacher asks all of you to work in pairs. You do not have a particular classmate whom you want to work with. It seems everyone is pairing up with other “popular” kids but avoiding your classmate with autism, Sam. Although Sam is polite and friendly, the class has labelled him as the “weird” kid. Perhaps because that Sam shows a rigid smile on face all the time, and overly talks about his cat and likes to echo “meow” in his speech. You know that this is part of his condition of autism.
Questions (Subthemes: peer pressure, special needs, problem solving)
Would you consider to pair up with Sam? Who would you pair up with at the end? Why?
Do you expect any positive and negative aspects if you work in pair with Sam?
Do you think Sam should do anything to help himself being more accepted by his/her classmates?
What would you or the class do to help Sam become more integrated into the class?
Vignette 2—Social setting: Birthday party

You have invited your friend with autism (suppose Sam) to your birthday party. At the party, Sam acts politely but rarely talks or plays with your other friends. When the others try to talk to him, he starts to talk excitedly and like a tape about the gadgets that he has at home even that they show no interest. He sometimes refuses to join the group games too. Your friends who are not familiar with his condition of autism seem to start avoiding him and telling you that Sam is “weird”, “difficult” and “unfriendly”.
Questions (Subthemes: social integration, problem solving)

Why do you think Sam act like this? Why do you think some of your friends feel negatively towards him? Do you think Sam is responsible for that he is poorly accepted by the others?

What benefits and risks would you expect from having, Sam, your friend with autism in your birthday party?

How would you introduce Sam to others if they do not seem to have a good understanding of autism?

What would you and your friends do to make Sam feel at home?

Vignette 3—Public setting: Disturbance on street
You and your friend with autism, Sam, walk home together after school. You enjoy times with him at school, while you find that sometimes he acts inappropriately in the public. He keeps staring at strangers whomever wear hats. He also likes to tap on glass windows with his fingers, or randomly yells out your nickname on street. Such acts often draw people’s attention and with weird or offended look, however you know that these behaviours are part of his condition of autism.

Questions (Subthemes: social pressure, perceived stigma, problem solving)

How would you feel about hanging out with Sam? (like embarrassed/frustrated?)

Would you avoid hanging out with Sam to public places again? Why?

What impact may there be if you decide not to hang out with him again?

How would you become more comfortable with these situations when hanging out with Sam?

Data Analysis

All the interviews were tape-recorded, transcribed verbatim and translated into English for analysis. The transcripts were imported in NVivo (QSR International Ltd., 2020) and codes were generated inductively by analyzing content domains that emerged from the narratives and then clustered to form broader categories (Smith, 2008). The first and second authors read transcripts repeatedly and broke them down into meaningful units of texts independently. Overall, the children’s narratives consisted of two domains: (1) the realm of experience and (2) the realm of narrative or how meaning was conferred onto the specific situations. In the vignette cases, narrative analysis was used to explore the reasons for particular reactions focusing on explanatory (“why”) narratives in terms of decision-making for specific cases and the rationale informing solutions to problems, including interpretations, values, and beliefs (Lieblich et al., 1998). Vignettes are not intended to simulate a complete reality. Rather, they are used to simulate partial elements of situations (Hughes & Huby, 2004). Although the participants’ judgments occurred in relation to hypothetical situations, the aim of our analysis was not to identify model behaviors. Rather, our focus was on identifying the challenges and dilemmas TD peers would experience in the hypothetical scenarios.

We triangulated the data from ethnographic observations, informal open-text interviews with teachers and semi-structured interviews with the children in the data interpretation and discussion phase. In addition to triangulation, we used several methods to enhance the trustworthiness and credibility of data analysis (Lincoln & Guba, 1985). We randomly selected five interviews and conducted independent translations to check the quality of the two translated transcripts in terms of similarity and comprehensiveness. Throughout the data collection, we exercised reflexivity about how our personal views were influencing the interview process (Creswell, 2013). The interviews were conducted in Cantonese by the second author, who was trained in psychology and involved in local ASD assessments. Her clinical work with children with ASD gave her experiential expertise. The first author, who is an expert in ethnographic qualitative research, held regular meetings with the interviewer and together they discussed her personal assumptions and reflections on the interviews. Remaining aware of the interviewer’s subjectivity and positioning helped to ensure an empathetic yet neutral interview stance. We also conducted “member-checking” with a special education psychologist as a validation technique to ensure credibility and trustworthiness (Birt et al., 2016). In the presentation of findings, the authors selected representative quotes that were recurrent in children’s narratives.

Results

Understanding of ASD in TD Children

Although TD children interacted with their peers with ASD in the same classroom (without specific knowledge of their diagnosis), they had limited understanding of the heterogeneity of the autism spectrum. All children responded that their immediate knowledge of autism was mainly from the word itself in Chinese (自閉症), which means “confining oneself.”

Autism? Does it mean lock yourself in the house? They do not want to know others and always stay at home. They do not go to school or talk to others. (P13, grade 5)

I think they are quite unfortunate because people with autism do not like playing with others but just playing with themselves (P15, grade 4).

Some children perceived people with autism as engaging in “voluntary unsocial behaviors,” refusing social interactions, and did not know that it is a neurodevelopmental disability. Their perceptions of ASD were mainly influenced by the media, such as TV documentaries.

A TV program showed how people with autism lived. They cannot walk properly due to a lack of learning ability. They needed to be fed by mothers. (P11, grade 6)

A person with autism gave a guitar performance [on a TV program]. People with autism were not like us, not normal. They are born geniuses. They learn faster, so they do not need to make friends with others. They do not have such worries (P14, grade 4).

These representations portray individuals with ASD diagnoses in highly stereotypical ways as either severely impaired or exceptional. A salient theme of “they are not like us,” as one child described, repeatedly emerged during the interviews.

Children with ASD’s Interactions with TD Peers

We observed that the amount of social interactions between TD students and their peers with autism was limited largely due to negative responses to atypical behaviors, such as shouting and kicking desks and chairs. Their interactions were mostly led by teachers in the context of physical education or extracurricular activities. Thus, the opportunity to initiate and develop friendships tends to be limited to teacher-led activities.

I do not spend time with my classmates. I have two in the same group of extracurricular activities, but I forgot their names. I only played with them once. (P10, grade 5)

At other times, such as lunch, we observed that children with ASD were usually alone. Although most of the children with ASD reported having a number of friends who they have known for years, their understanding of these friendships was predominantly based on the “who plays with me” and remote from “true” friendship. They were unclear about how to make friends.

I do not have a best friend. I usually play with others in school, but they are not my friends. They are not willing to make friends with me. I do not know why. (P6, grade 3)

One of the main reasons for the social exclusion of children with ASD is due to their difficulties with understanding the rules of games and limited play skills. A child with ASD expressed both his wish to make friends and his difficulty doing so.

When we play a “shark” game, the one who loses from the paper, scissors, and stone cannot touch something in a specific color. The game is very difficult…I do not know what to talk about or how to play. I do not talk and keep quiet. (P9, grade 4)

A few children with ASD reported that they were physically abused by their peers. When we asked a child with ASD about the reasons for being alone in the school, he talked about his experience of being bullied by others.

They hit me. I told no one about it, even my mother. I did not hit them back. I do not like to play with them. I feel lonely. (P9, grade 4)

Another child with ASD spoke about his traumatic experience of being bullied surrounded by many classmates.

There are two whom I do not like because I was beaten by them. They are boys who are taller than me. Others said I should hit them back, but I did not. There was only me surrounded by others. (P8, grade 5)

The school policy of nondisclosure of ASD contributes to a school culture in which there is minimal intervention by teachers in peer interactions and conflict. This lack of adult intervention places vulnerable students at risk of harm. Some children with ASD said that their behavior is sometimes interpreted as rude by their classmates. Such a situation evokes distress and further social isolation in these children.

Those who are studying in the same school with me are not my friends. It is not good. I prefer staying at home to going to school. It is difficult to make friends with others because I am often rude to them and they become outraged. I want to be less rude. (P8, grade 5)

At the end of the interview, we asked about their understanding of ASD. Most of the children with ASD had limited knowledge about their diagnosis. However, one grade 6 student clearly understood autism as a stigmatizing category, comparing it to an “illness.” He firmly stated that he had autism and stressed that he did not want to disclose his condition as it is not “normal.”

I do not want my friends and teachers to know about my autistic condition because I want to be a normal person. It is better to be a normal person than a person with things that cause nuisances to people. I do not want them to know that I have an illness. This illness is troubling me. There is no point in letting others know about my problem. (P6, grade 6)

TD Children’s Interactions with Peers with ASD

We asked TD students about whether they had any classmates who were “different” and asked for the classmate’s name. By doing so, we were able to identify the student being spoken about and understand the views of TD students toward students with ASD. Their views toward their peers with ASD were generally not favorable. They described them using phrases such as “strange, rude, mean, and often losing their temper.”

My classmate always loses his temper. When he is angry, he will usually kick others’ school bags out of the classroom. He is too mean and speaks coarse languages. The whole class tried to stop him, but he did not listen and continued. (P16, grade 3)

These negative descriptions of the atypical behaviors of their peers with ASD were similar among all the TD children we interviewed.

He is very troublesome. He is very noisy and naughty and sometimes runs out and into the classroom. He often shouts. When the teacher stops him, he is obedient but then becomes noisy again for days. He always bangs on the table when he is in a rage and forcefully pushes the chairs, making sounds like bang, bang, bang. In physical education lessons, he is alone rather than in the group with us. (P12, grade 5)

When we asked them about friendships with their atypical peers, their responses varied. Some students expressed concerns about unpredictable behaviors from peers with ASD.

I am worried that he might hit me suddenly. He does whenever I unintentionally say something he dislikes. Some avoid interactions with him worrying that unstable interactions might end up with fighting due to unsolved communication issues. (P15, grade 4)

The unfavorable experiences were mostly based on misconceptions. While children were aware of problem behaviors in their peers of ASD, they did not understand the underlying reasons motivating their behaviors or “losing their temper.” As most children responded, “I do not know. Maybe because he is…I cannot think of any”. Their confusion was prevalent.

Friendship with Peers with ASD

Although students often expressed disapproval of autistic peers’ behaviors, most were willing to make friends. Their motives related to positive conceptualizations of all friendships:

Interviewer:

What are the feelings when you make friends with him?

Student:

I feel happy that I have a friend. People need friends (P19, grade 2).

Statements such as the one above suggest tolerance toward their peers’ behaviors, which they saw as episodic and situational.

Children learned how to get along through repeated interactions. As one student remarked: “Just play with them with more patience.” Another stated, “Don’t refute. Don’t argue. Don’t make them angry.”

I only talk to him after he has calmed himself down. I tend to tolerate him because he seemed gentle when I knew him at the outset. (P14, grade 4)

They learned that their friends with ASD were vulnerable to external stimuli, and good relationships come from focusing on strengths and positivity.

We talk more about things that he is good at, and I never say something that he dislikes. Once there was a person saying he was very stupid, then he hit that person. He is very sensitive about how others talk negatively about him. (P12, grade 5)

A student shared her experiences of changes in a friendship with a student with autism over time. Their friendship has developed based on shared interests and trust.

I do not know why he has become more sociable, but I know one thing. When I played with other classmates before he would not play with me. But now, if I play with others, he plays with me and others. The situation actually has improved. (P11, grade 6)

Vignette 1—Classroom

TD children expressed both positive and negative attitudes toward interactions with their classmates with ASD. As they had peers who “act differently” in the classroom, they were reasonably confident in responding to this vignette about group work. TD children anticipated some disadvantages of working with ASD peers in terms of academic performance.

If a teacher asks us to come up and explain to the class, he might say strange and incomprehensible words. (P16 grade 3)

To encourage classmates with ASD to participate in projects actively, TD students said that frequent interactions and a commitment over time are critical to assisting ASD students with social skills.

I will teach him to be polite. I can play with him frequently and teach him to be brave. We tell him we can be friends with him if he is polite. We play with him more often. So, others will treat him better after they know his problem. (P13, grade 5)

To the last question, “what to do to help peers with autism be more integrated in class,” a student gave a good example of how to approach ASD from a strengths-based perspective.

Not to think about him in the same aspect, like from others. Everyone has his own strengths and weaknesses. Maybe this is his weakness, but maybe he has some strengths. But you just focus on his strengths and ignore his weakness. (P11, grade 6)

Vignette 2—Birthday Party

TD children were favorable to inviting a friend with ASD to their party. However, they worried that their friend with ASD might be isolated from the party by inappropriate behaviors such as “destroying a birthday cake” and “not getting along with other friends.”

If I invite a person with autism to my party, others will not understand why the person and I are friends. I am worried that they will not befriend him. (P15, grade 4)

While all agreed that friends should not exclude the friend with ASD, the major concern was whether or not and how they needed to disclose autism to the party. For children who were opposed to the disclosure of ASD, their reason was that friends would have inaccurate information about autism and therefore, might behave based on prejudicial ideas.

Do not tell them he has autism. If everybody thinks my friend with autism would be hard to get along with, they will not play with him. (P12, grade 5)

For those who would introduce the friend with ASD by disclosing the condition, they said they would not say much about autism in detail but give some words of caution.

I would avoid talking about negative things. I would tell them not to say things that he dislikes. They need to not talk about some sensitive issues. (P14, grade 5)

One student (P11) who maintained an ongoing relationship with her friend with ASD proactively spoke out for social interaction.

If they said that my friend is strange, they should apologize for saying that word. (P11, grade 6)

However, most TD students said that their friend with ASD should share responsibility for making friends during the party to ensure social interactions.

I would ask him to play together. I invited him. Therefore, everyone should play together. If he is not playing with others, it is meaningless for me to invite him. Why doesn’t he play with others? If he wants to have friends, he should play with them. He should have a good attitude. He needs to share food with others first and then chat with them. He must apologize if he collides with others accidentally. (P15, grade 4)

Vignette 3—Public Scene

This scenario was found to be the most difficult situation for TD children. Unlike the previous vignettes, most worried about how their friend with ASD would behave in public space. Their perceived lack of control was a cause for concern.

I will not go out with him. I cannot control him. I will not go to shopping malls. If he suddenly screams, I would feel ashamed and annoyed. (P12, grade 5)

They also worried that others might perceive themselves as having ASD if they were seen with their friend with ASD in public. As one student said, “I feel very embarrassed because others may think I have a problem as well.” Their solution for dealing with their friend’s problem behaviors was to isolate and ignore him.

If he continues his inappropriate behaviors, I would isolate him and do nothing. I would ignore him for a while to let him know he should not behave in this way. (P16, grade 3)

A few TD students who reported maintaining and supporting positive relationships with their peers with ASD during the interviews expressed willingness to go out with them. While expecting “sudden strange behaviors” and embarrassment, their friendship with them extended to public settings.

Before setting off from home or school, I would ask him to keep hold of his unusual behavior for a while along the way. I will ask him not to behave like this. I will still go out with him because he is my friend. (P14, grade 6)

The children who supported public interactions believed in the importance of socially including children with ASD and were hopeful about behavioral self-management.

I know his inner-self must be good. He will be able to control his temper. He will be very happy about this every day. (P11, grade 6)

Discussion

The findings from the study highlight challenges and the need for positive peer interactions between children with ASD and TD in primary school settings with inclusive policies. The school, similar to most of the schools in Hong Kong, has a policy of nondisclosure of developmental disabilities due to possible harm, including labeling, separation, exclusion, and stigmatization (Humphrey & Symes, 2010; Lauchlan & Boyle, 2007). Accordingly, no explicit norms or policies about ASD exist, and no direct educational programs to address developmental disabilities are in place. We noted that teachers’ interventions in interactions between TD and ASD children were minimal. Students with ASD, who often exhibited external problem behaviors more frequently than TD children, received minimal assistance.

Children were first introduced to autism by social media with its local term of 自閉症, meaning a disease of confining oneself. There is a significant impact of such labeling of autism and media portrayal on children’s understanding of ASD (Tang & Bie, 2016). Special caution is needed when and how the word is used in public to avoid misconceptions of ASD. Stereotypical ideas that individuals with autism are highly solitary or very dependent increase prejudice. The media portrayal of individuals with ASD as either geniuses or severely cognitively impaired is very limiting. Media representations need to focus more on the diversity of individuals with ASD, including their strengths and capacities.

While children with ASD and TD both valued the need for friends, the views toward friendship among children with ASD were limited because of their lack of opportunities for peer interaction. Friendship is learned by continuing interactions with peers and built on mutual engagement and reciprocity. Children with ASD can benefit from exposure to such social development. Their narratives showed that few knew how to initiate, maintain and develop a friendship with peers with ASD. First, offering school-wide education on knowledge of developmental disabilities, without necessarily using the diagnostic term ASD, would help students to accept differences and acknowledge the support needs of children with ASD. Neutral terms such as “challenges” or “difficulties” could be employed in the school to describe the externalizing behaviors of children with ASD. Learning programs to increase social skills in how to initiate and respond to behavioral characteristics and communication difficulties could be helpful (Crosland & Dunlap, 2012; Koegel et al., 2012; McConnell, 2002). Such interventions may also help reduce the burden on teachers as children may gradually take on increased responsibility for supporting and assisting students with developmental disabilities.

The findings from the vignettes highlight the challenges TD children experienced when they interacted with peers with ASD. For the first scenario, TD children were familiar with the case of group activities in the classroom as the vignette scene was part of their daily class activities. All children agreed to form a group with a classmate with ASD, expecting that unforeseen situations can be managed by teachers. However, their concerns about the disadvantages of having a peer with ASD, including poor performance, lack of collaboration and physical disturbance, need to be addressed by the school in the context of inclusive education. Teachers need to create an enabling environment by providing fair opportunities for all students considering individual differences in communication, traits, and problem-solving ability.

From the case of the birthday party, children were not certain about what knowledge of ASD needs to be given to others if ASD is disclosed and how to encourage peers with ASD to socially participate. It is suggested that there are degrees of information about ASD that should be shared at each age (Kerr, 2011). Primary school-aged children might not understand “diagnosis” itself. Instead of focusing on the diagnosis, children could approach aspects of strengths, such as attention to detail and honesty and difficulties, including pragmatic language use and repetitive behaviors in children with ASD (Kerr, 2011). Sharing such information will create a mutually understanding atmosphere. Inclusive education needs to develop locally specific standardized scripts for sharing ASD information to ensure that the diagnosis is explained in a non-stigmatizing manner (Gus, 2000).

The last case of going out in a public space addressed a lack of perceived ability and anxiety about controlling unexpected behaviors in their peers with ASD. The connection between parental stress and anxiety about some of the atypical behaviors of children with ASD are well-reported (Gray, 2002). As some of the participants experienced, continuing interactions with their peers with ASD help reduce stress and anxiety because they can identify the specific stimuli that trigger particular behaviors. A notable finding was that TD children were concerned that they would be subjected to courtesy stigma (Birenbaum, 1992). This finding is congruent with another report by older students in Hong Kong that they were worried about rejection by other peers if they interact with their peers with special needs (Wong, 2008). Experiences of marginalization, shame, and devaluation because of their close social or physical proximity to children with ASD have been reported in the literature (Ali et al., 2012). This finding further underlines the importance of better public education about developmental disabilities.

Implications

The findings indicate the need and potential benefits of early peer-led intervention in the social integration of children with ASD. The most salient theme from the interviews was the TD students’ view of friendship, which was simple but clear: human beings need friends. This view reflects the literature on early child development of friendship (Hojjat & Moyer, 2017). It allowed them to approach and interact with peers who frequently showed problem behaviors as these behaviors were perceived as episodic and situational. They believed that the real intentions of their friends with ASD were good.

Self-esteem and identity are highly embedded within explicit conceptualizations of “face” and a family-oriented context in Chinese culture. Chinese children have a high level of social-evaluative fears and concerns, which extend from oneself to one’s family (Dong et al., 1994). Peer conflicts and poor school adjustment may threaten how children with ASD evaluate themselves (e.g., guilt related to parents being judged by other parents and extended families). For example, three children with ASD in this study were concerned that they or their parents would be “laughed at” if their ASD was publicly disclosed. One of them linked the disclosure of developmental differences with an anticipated feeling of embarrassment “because it (learning disability) is not a cool thing.” This finding essentially highlights the need for school and community collaboration toward improved understanding and values that promote empathy and acknowledge individual differences. Such values are likely to be undermined in a collectivist culture with examination-orientated education. Psychoeducation about individual differences, including strengths and difficulties, will potentially help protect children with ASD from maladaptive masking (Mandy, 2019). On the other hand, public respect for teachers in Hong Kong may facilitate behavioral change and self-esteem in all students if the school shows leadership in inclusive education.

When students were uninformed about ASD, there was a coherent narrative that “friendship is good; any problems are extrinsic, but we cannot figure out why.” If TD children understand some of the preferences and difficulties of their peers with ASD in social communication, this situation can be improved. Schools need to provide appropriate information on neurocognitive developmental disabilities and social skills, such as how to interact with children with ASD and develop positive relationships with them (Gus, 2000; Kalyva & Avramidis, 2005). Delivery of such information facilitates perspective-taking and benefits from being framed in a wider social context (i.e., the difficulties manifest when atypical cognition and behaviors in autism meet social conventions). Encouraging a school ethos that values differences and diversity is essential. The need to share both strengths and weaknesses emerged as a salient theme in our study and in other studies of Hong Kong students interacting with children with special needs (Tsang, 2013; Wong, 2008). Education programs need to highlight the improvement in peer relationships between TD students and students with ASD.

Incorporating peer-mediated strategies would increase the self-efficacy of TD children in positive social initiation and interaction with their peers with ASD. Teachers are role models for students and can play an important role in modeling appropriate social skills. Training for teachers and professionals in delivering evidence-based information on ASD and psychoeducation on how TD peers play a unique role in facilitating positive social interactions with children with ASD collaboratively with school staff is needed (Harper et al., 2008). Didactic teaching in discipline-based (e.g., silence during class) Chinese classrooms can be an additional hurdle. Other strategies, such as peer tutoring and collaborative learning, provided by community organizations (e.g., ASD advocacy and support groups), can be used to establish opportunities to learn more about the life-course of individuals of ASD. The premise is to improve the overall quality of peer interactions, providing a compatible environment in which children with ASD and their TD peers feel comfortable exploring interactions.

Implementation should aim at multilevel collaboration between schools and the communities in which they are embedded. The physical environment and social structure of mainstream Chinese classrooms are unlikely to promote social interactions. Large classes, noisy classrooms, and free play during recess and lunchtime can be overwhelming for children with ASD (Wing, 2007). Schools can provide various semi-structured environments to accommodate different preferences for social interactions and recreational activities among students. For example, rotating recreational clubs (e.g., Lego), library zones (quiet and discussion zones), and playground facilities (e.g., chess field and garden) would encourage active participation in recess and lunchtime. The stress placed on academic achievement and adherence to social norms in Chinese society can reinforce elitism and peer hierarchy. Class rankings may do more harm than good by promoting interindividual competition and comparison. TD children can be reluctant to interact with children with ASD who are academically weak or socially peripheral. These factors may hinder children from developing insights and the initiative to relate to others perceived to be “different.” Widespread restructuring in inclusive education, including changes to the curriculum, the physical environment, and teacher supports, are all needed to create a compatible school environment for positive peer interactions.

Limitations

There are several limitations. This study was limited to the views and experiences of TD and ASD children from a public primary school in Hong Kong. Differences may exist for children from other schools in terms of school policy on disability and inclusion, overall resources (e.g., public and private school), and resources for children with additional learning needs. Children’s attitudes toward peers with ASD are closely affected by teachers and parents. Additional interviews with parents, teachers, and school administrative staff are needed to better understand the study topic. Due to the interview settings, it is plausible that children’s statements may be oriented to what they believe is socially desirable. To reduce such bias, we did not use the term autism, and the children were informed that they would be talking about friendship in general. A larger sample than 20 students may reveal a greater variety in attitudes. Gender is known to be an important factor when examining attitudes toward children with ASD, with girls often displaying more positive attitudes toward children with disabilities than boys (Rosenbaum et al., 1988). Due to our small sample size, this study was not able to explore gender roles. The differences in child development across primary school years are significant. Further sampling would increase our knowledge of the dynamics informing peer interactions between TD and ASD students. The hypothetical vignettes could be considered artificial or less authentic. However, it is important to note that vignette contexts were selective rather than hypothetical. In this study, selective representations of reality allowed children to engage with concrete examples, and their responses were diverse.

Conclusion

Social acceptance and inclusion can be fostered through positive social interactions between children with ASD and TD children during early social encounters in school. Despite the recognition of differences and diversity, little effort has been made to develop evidence-based interventions to increase positive social interactions for children with ASD. We suggest that early educational interventions in student’s knowledge of ASD and social skills training would assist in developing more positive interactions between TD and ASD children, helping to embed the values of a genuinely inclusive school culture that would benefit all students.

Footnotes

Acknowledgments

The authors thank the students and their parents who participated in the study and the teachers and principal who helped us to conduct the study. We thank Lok-kei Sum, who produced an educational video of autism in the project. We would also like to thank the anonymous reviewer whose comments and suggestions helped improve this manuscript. This research was supported by the Health Care Promotion Fund, Food and Health Bureau, Hong Kong SAR, China. The study sponsor had no role in the study design, collection, analysis, and interpretation of the data; or in the writing of the article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Huso Yi

Open research statement

As part of IARR’s encouragement of open research practices, the authors have provided the following information: This research was not pre-registered. The data used in the research are available. The data can be obtained by emailing: ephyh@nus.edu.sg. The materials used in the research are available. The materials can be obtained or by emailing: ephyh@nus.edu.sg.

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