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Original Article
Using psychodrama to relieve social barriers in an
autistic child: A case study and literature review
Jing Li, Dangyang Wang, Ziqiu Guo, Kun Li
*
School of Nursing, Jilin University, Changchun 130021, China
article info
Article history:
Received 8 June 2015
Received in revised form
17 July 2015
Accepted 21 August 2015
Available online xxx
Keywords:
Autism
Psychodrama
Social barriers
Case study
Role-playing
abstract
Objective: To review and update the evidence for the effect of psychodrama for children
with autism, and evaluate the effect of psychodrama on an autistic child with severe social
barriers, using the theory of mind and psychodrama methodology as the analytical
frameworks.
Methods: A 5 year-old boy, the research object, was diagnosed as severe autism using
behavior observation and autism screening tools, with an DSM-Ⅵcriteria. Autism symptom
severity was usually measured by Childhood Autism Rating Scale (CARS) and Autism
Behavior Checklist (ABC) in research of autism. In this study, the autistic boy accepted
psychodrama training and was measured with CARS before and after the entire training
program. The ABC was adopted to evaluate him after each intervention program. Mean-
while the entire training process was recorded. The evaluation criterion consists of four
aspects including eye contact, following instructions, focusing attention and imitation
ability. Finally, all live records and changes presented in volume tables were analyzed.
Results: The patient's social barriers were relieved at the end of the third month of the
training program. The CARS data shows a shift from the severe to moderate level of autism.
Conclusions: It was possib le for autistic children to relieve social barriers by implementing
psychodrama training, then to improve the social cognitive ability and enhance the social
function of the autistic children. These results provided basic Clinical implications for
exploring a new intervention technique to reduce autistic symptom severity.
Copyright © 2015, Chinese Nursing Association. Production and hosting by Elsevier
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1. Introduction
Autism is a kind of extensive developmental disorder; its core
symptoms include social barriers, narrow interests and ste-
reotyped behaviors. This kind of disease, resulting from nerve
dysfunction, tends to appear in early childhood, generally
around the age of 2 [1e3]. Autism was generally considered to
be a lifelong condition. However, recent research demon-
strated that, with the help of various interventions, some
patients proved to lose their symptoms and the autistic
diagnosis as they grew up [4]. Namely, the intervention in
*
Corresponding author.
E-mail addresses: lj689392@sina.com (J. Li), lik@jlu.edu.cn (K. Li).
Peer review under responsibility of Chinese Nursing Association.
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Please cite this article in press as: Li J, et al., Using psychodrama to relieve social barriers in an autistic child: A case study and literature
review, International Jour nal of Nursing Sciences (2015), http://dx.doi.org/10.1016/j.ijnss.2015.08.008
social function is of far-reaching significance for autistic
children.
Theory of mind (often abbreviated as “TOM”) is the ability
to attribute mental statesdbeliefs, intents, desires, pretend-
ing, knowledge, etc. to oneself and others and to understand
that others have beliefs, desires, and intentions which are
different from themselves [5]. In 1981, Simon Baron-Cohen
identified the infant's understanding of attention in others, a
social skill found by 7e9 months of age, as a “critical precur-
sor” to the development of TOM [6]. In 1985, together with
peers, he published a research article suggested that children
with autism did not employ a TOM [7]. Individuals who
experience a theory of mind deficit have difficulty deter-
mining the intentions of others, lack understanding of how
their behavior affects others, and have a tough time with so-
cial reciprocity. This deficit is caused by their specific cogni-
tive defects stemming from the executive function defects in
the brain's frontal lobes, rather than general learning difficulty
[8,9].
Psychodrama is a therapeutic discipline, which uses action
methods, role training, and group dynamics to facilitate a
constructive change in the lives of participants [10,11].
Developed by Jacob L. Moreno, psychodrama includes ele-
ments of theater, which is often conducted on a stage where
props could be used, and focuses principally on a single
participant, known as the protagonist [12]. Protagonists
investigate and gain insight into their lives by interacting with
the other actors and the leader, known as the director. This is
done by using specific techniques, including mirroring, solil-
oquy, role-playing and role reversal. Psychodrama can be used
in a variety of clinical and community-based settings. Com-
bined with cognitive behavioral intervention, the psycho-
drama process in behavior training can contribute greatly to
promote the social cognitive ability [13]. Moreover, TOM is an
effective social cognitive instrument, which enables children
to adapt to the social environment more effectively and is the
foundation of individual to exist in society. Therefore, psy-
chodrama intervention could be relied on to strengthen the
TOM ability and finally improve social skills of autistic chil-
dren. It is generally believed that the TOM ability of normal
children can reach a relatively mature state at the age of 4.
Namely, 4-year-old children can understand the behavior of
others according to one's wishes, beliefs, etc. [14e16]. This
case study demonstrated how the psychodrama intervention
was implemented on a 5 year-old boy with autism and
relieved his social barriers.
2. Methods
2.1. Study design
An autistic child was selected randomly as a research object
and accepted psychodrama training. According to the obser-
vation records and assessment outcomes, psychodrama plots
were designed to train the patient mainly in four aspects: eye
contact, following instructions, focusing attention, imitation
ability. Ranging from 90 minutes to 2 hours, a psychodrama
session typically was implemented once every 2 weeks, and
the whole training process lasted totally for 3 months (Patient
received intensive training in Special-Education Center for the
rest of the time). The entire training process was recorded.
The patient was measured with Childhood Autism Rating
Scale (CARS) before and after the whole experiment, and
Autism Behavior Checklist (ABC) was used to evaluate him
after each intervention program. Finally, all live records and
changes were analyzed to evaluate whether the psychodrama
therapy works. The study design was presented in Fig. 1.
2.2. Case presentation
Lan, male, the only son in the family, was born in Harbin City
Heilongjiang Province in February 2008. He was introverted
and had almost no active words. He spoke unclearly with few
social interaction behaviors and frequent rigid behaviors. Be-
sides, he had good pulley technology and loved strawberries.
An autistic child was selected
randomly as a research object.
The child accepted psychodrama
training twice a week
for 3 months.
Autism Behavior Checklist (ABC)
was adopted to evaluate the child
after each intervention. Meanwhile
the entire training process was
recorded on the site.
Before Intervention
After Intervention
The child was measured with
Childhood Autism Rating Scale
(CARS).
Records of eye contact, following
instruction, focusing attention
and
imitation ability
were analyzed.
Recruitment and Assessmen
t
Intervention and Record
Data and Material Analysis
Data changes presented in volume
tables were analyzed.
Interventions
1
Eye contact
2
Following instructions
3 Focusing attention
4
Imitation ability
Fig. 1 e Study flow diagram.
international journal of nursing sciences xxx (2015) 1e62
Please cite this article in press as: Li J, et al., Using psychodrama to relieve social barriers in an autistic child: A case study and literature
review, International Journal of Nursing Sciences (2015), http://dx.doi.org/10.1016/j.ijnss.2015.08.008
His parents both had college degree, creating a decent life with
good economic conditions and harmonious relationship. The
main care-giver was his mother, who suffered from severe
depression disorder from the first trimester of her pregnancy
to the third month after delivery. There was no similar family
history and other medical history. The patient was diagnosed
with severe autism in June 2009, through behavior observation
and autism screening tools, with an DSM-Ⅵcriteria [17].He
entered pre-school in September 2010, since when the
symptoms became more and more serious. He was receiving
rehabilitation training in Special-Education Center at that
time. He did not participate any other special training pro-
gram except the activities in the center. Informed consent to
the study was obtained from the parents of the patient.
2.3. Assessment measures
The Childhood Autism Rating Scale (CARS) and Autism
Behavior Checklist (ABC) were used to screen and diagnose
autism in this study. CARS was developed by Eric Schopler as a
diagnostic assessment method [17]. The original version of
this test, the Autism Diagnostic Interview (ADI) was published
in 1989 and was correlated to the ICD-10 definition of autism
[18e20]. CARS was considered a good screening instrument for
adolescents and adults [17]. The scale consists of fifteen items:
relationship to people, imitation, emotional response, body,
object use, adaptation to change, visual response, listening
response, tasteesmelletouch response and use, fear and
nervousness, verbal communication, non-verbal communi-
cation, activity level, level and consistency of intellectual
response, general impressions. Grading method is based on
the severity of each item and distributed “1”, “2”, “3”, “4” points
from light to severe. Patient who scores more than 30 points
can be considered as autism, 30e36 points can be considered
as moderate autism and over 36 points as severe autism.
The Autism Behavior Checklist (ABC) is one of the most
commonly used screening devices. Previous researches indi-
cated that ABC was a useful screening instrument in the
identification of children with autism in clinical and educa-
tional contexts [21]. ABC was introduced and revised into
Chinese with 57 items grouped into the following five sub-
scales: Sensory, Relating, Body and Object Use, Language, and
Social and Self-Help skills [22]. Grading method was based on
the severity of each item and distributed “1”, “2”, “3”, “4”
points. For example, one item is marked 3 points, which
means once the autistic children have this behavior, we must
write 3 regardless of its severity.
2.4. Interventions
2.4.1. Eye contact
Children with autism tend to have defects in eye contact,
which is the premise skill for social interaction [23]. Taking the
initiative to maintain eye contact could directly influence the
development of concentration and social skills. Therefore, the
basic training goal of eye contact was to encourage the patient
to take the initiative to make eye contact with people, and to
prolong the time of eye contact. Psychodrama training could
maintain eye contact through good social interaction between
trainers and the patient. For example, in plot “The Elder Sister
Comes to Visit My Home”, the sister knocked at the door,
mother reminded Lan of the loud knock at the door and guided
him to open the door. After entering the door, the sister said
hello to Lan actively, shook hands with him, and maintained
eye contact, keeping eye contact as long as possible. The sister
also gave him the appropriate verbal praise or material re-
wards to establish good relationship with him. At the end of
the training, mother guided Lan to take the initiative to shake
hands with sister and say goodbye. The purpose of the
training was to cultivate the initiative to maintain eye contact
with people in social contact.
2.4.2. Following instructions
Following instructions was a basic ability to associate with
people, but autistic children rarely follow instructions given
by others. The goal of this intervention was to help the patient
build the consciousness of understanding others' willingness
in linguistic or non-linguistic competence, and then to pro-
mote the development of social skills. Training methods were
as follows: trainers gave instructions and guided Lan to
complete them. If he needed someone's assistance, an inten-
sive training would be given immediately. In psychodrama
training program, the same instruction could be repeated in
each training program, whereas instructions would become
more and more difficult to understand, and the assistance was
gradually reduced as well. For example, in the first training,
the sister was thirsty and asked Lan for some water. The
mother guided and taught him how to pour the water
repeatedly until he completely mastered this skill. Then the
mother was thirsty and reminded Lan of pouring water to
drink. In the second training, the sister demanded Lan to pour
water for her, mother said to Lan: “What does the sister want
you to do, to pour water?” In the third training, the mother
asked Lan “The elder sister is very thirsty, what will you do?”
We could cultivate and strengthen patient's sense of self-
identity, and then promote the training effect under the
good relationship between the patient and trainers.
2.4.3. Focusing attention
Because of the lack of ability to “filter” irrelevant stimulus, it
was difficult for autistic children to focus on a simple opera-
tion. Psychodrama, integrating music, games and other ele-
ments could strengthen the ability of concentration of autistic
children. For example, in the process of psychodrama
training, we made Lan play with his mother in the game of
tossing basketball back and forth, preparing for the later
training. Then, two professional trainers joined them, sitting
together in a circle, about half a meter away from each other.
The first part, mother threw a basketball to Lan, and reminded
him to focus on the movements of the basketball, and
instructed Lan to pass the ball to the trainer who was next to
him by the same method. The second part, the ball was firstly
passed from Lan, who was offered the freedom to toss the ball
to whomever he was interested in (research shows that: In
most cases, child would like to throw the ball to his mother).
Others could try to induce Lan to throw the ball to them. The
third part, when Lan began to toss the ball, others could
reminded him by saying “throw the ball to the sister in white
clothes” or “throw the ball to the girl in red”. During the whole
course, trainers could use vocal language or body language to
international journal of nursing sciences xxx (2015) 1e6 3
Please cite this article in press as: Li J, et al., Using psychodrama to relieve social barriers in an autistic child: A case study and literature
review, International Jour nal of Nursing Sciences (2015), http://dx.doi.org/10.1016/j.ijnss.2015.08.008
guide the patient to focus on the basketball, as well as his eye
contact with others. When patient performed better, trainers
could use exaggerated language or facial expressions, even
material rewards, to encourage him, thereby creating a
relaxing atmosphere and improving training efficiency.
2.4.4. Imitative ability
Imitation is to imitate the behavior of others consciously.
Previous research in developmental psychology suggested
that the infant's ability to imitate others depended on the or-
igins of both a theory of mind and other social-cognitive
achievements like perspective-taking and empathy [24].
Many studies have shown that autistic children had impair-
ment in imitation. Since imitation is essential in establishing
and advancing children's social skills, the imitation defects
directly affect the development of their social mentality of
individuals [25]. Imitative ability training in this study was
supposed to progress gradually from simple to complex step
by step. As imitative ability training in psychodrama involved
more psychological elements, children could easily accept it
and concordantly cooperate with trainers. For example, in plot
I “My Sister Taught Me How to Origami”, firstly, in order to
attract Lan's interest, a trainer displayed various kinds of
flowers and animals made in paper, helping him to identify
their colors and shapes. Other trainers were allowed to teach
him to recognize the colors and shapes until he could judge
correctly, and then a trainer said: “You're pretty smart and this
flower is for you. Do you want to fold a beautiful flower by
yourself?” Subsequently, the trainer divided the process of
folding paper flowers into several simple steps. While teach-
ing step by step, the trainer tried to encourage him to recall the
whole procedure (Before this period of intervention, we knew
that Lan had a profound and pleasant memory of folding
paper lanterns with his grandmother before, and he had a
grounding in technique before setting to training). Plot II
“Warm Winter”, in a cold winter, Lan with his mother
encountered a friendly sister and exchanged greetings while
walking on the road. The sister covered her ears with hands,
staring at Lan, and said, “It is so cold. Let me help you to cover
your ears to keep warm!” Then, trainer could begin teaching
him how to cover ears and face with his hands. According to
the findings of our study, after mastering the basic skills, Lan
would like to warm his mother's ears, but not his own. Act III,
Lan did a simple dance with trainers accompanied by light
music, the mother functioned as a guide and assistant (Before
training, we learned that Lan had a natural interest in light
music).
2.5. Participants and site
The training team consisted of a psychologist, an associate
professor engaged in nursing teaching and research for many
years in XX University, the dean of Special-Education Center
who was a mother of an autistic child and had 11 years rich
experience in special education, four undergraduates of XX
University, four special education teachers and the mother of
the patient.
Protagonist: Lan, playing his own role in real life and
focusing on a particular situation to enact on stage [26].
Auxiliaries: the patient's mother and other members of
training group, supporting the protagonist by playing other
significant roles in the scene.
Audience: the members of training group, other autistic
children and their parents.
Director: the leader of training group, controlling the
progress of the plot and guiding the leading actor to explore
his own problems through psychodrama intervention
training.
Stage: a music classroom in Special-Education Center,
about 15 square meters.
3. Results
3.1. Patient assessment before training
Before the intervention, Lan was measured with Childhood
Autism Rating Scale (CARS), and was observed naturally for a
week without any intervention. The result of CARS demon-
strated that Lan was a severe autistic patient before psycho-
drama intervention, the data were shown in Table 1.
The above performances reflected that Lan's response to
the social interaction was very indifferent, indicating that he
had severe social barriers.
3.2. ABC data after training
It was approved by his mother and teachers that Lan achieved
obvious advancement in social skills after psychodrama in-
terventions. After-training analysis of ABC data showed a
shift from the severe to moderate level of autism. The data of
ABC after training were shown in Table 2.
3.3. The after-training evaluation
He could smile to person and maintain eye contact with
others occasionally when he was excited.
He could focus on one thing for 8 s, which is longer than
before.
He did not take the initiative to avoid eye contact with his
parents, teachers and trainers.
He could turn to voice after hearing his name was called
and had a short eye contact.
3.4. The continuous evaluation
After three months of psychodrama intervention training, Lan
made obvious progress in social skills. Firstly, in the fifth
week, the eye contact duration could last for 8 s, significantly
longer than before. Besides, he was able to follow the re-
quirements of trainer to focus attention on a certain thing.
Secondly, following instruction training obtained the good
effect as well. Lan was capable of listening to a majority of
simple instructions issued by trainers, such as opening the
door, shaking hands, pouring water, passing the ball, covering
ears and so on, which were quite different behaviors from the
beginning when he had no reaction to others' orders. At the
end of training, he could throw garbage by himself, but still
need some assistance when it came to other instructions. He
international journal of nursing sciences xxx (2015) 1e64
Please cite this article in press as: Li J, et al., Using psychodrama to relieve social barriers in an autistic child: A case study and literature
review, International Journal of Nursing Sciences (2015), http://dx.doi.org/10.1016/j.ijnss.2015.08.008
could be very obedient to trainers and his mother, and strictly
followed the orders. Finally, among the whole training period
of imitative ability, Lan could understand the instruction
immediately and concentrated on imitating folding papers,
ending up with a decent product. While dancing with the
music, Lan failed to adapt to it in the beginning and couldn't
follow the steps. However, due to the interest in music, he
could concentrate on study consciously and carefully. Under
the guidance of his mother, Lan gradually began a regular
dance, presenting a better sense of coordination.
As can be seen from the above continuous evaluation for 3
months, it was obvious that Lan had made great progress in
social skills after psychodramatic intervention.
4. Conclusions
There are several ongoing efforts to improve social cognitive
ability using psychodrama across the world, as alluded to in
our introduction. From our review we found that psycho-
drama had some beneficial effects on social cognitive ability.
However, few had the kind of strong empirical evidence base
for autism treatment that we need. It is not clear whether
these interventions have a lasting impact and there is a need
to conduct further studies.
Through this case study for 3 months, we concluded that it
was possible to use psychodrama intervention for autistic
children to improve the social cognitive ability, then relieve
the social barriers and enhance the social function.
Given the short three-month training time, we were not
sure whether the intervention effects were sustainable, and
what impact it may cause in the future. Due to the limitations
of our own professional knowledge about psychodrama, there
may be irregularities in role division, which need improve-
ment. In addition, our on-site records may ignore valuable
event. It is recommended that researchers should improve the
operability of psychodrama training in further studies, such as
setting the best training time and training duration.
With regard to psychodrama training, we found several
benefiting advices, according our experience, which could act
as references for later researches. Training contents should
keep pace with real life. Training them to learn daily life skills,
such as opening the door, saying hello to others and so on,
could efficiently help them survive in the world. Additionally,
training model was advised to put sufficient emphasis on
communicating with their parents, who could be helpful in
guiding autistic children to perform and also release their own
pressure by participating in the drama. Finally, the whole
training should be implemented in gentle and clean environ-
ment, avoiding objects children are excessively interested in.
Acknowledgments
This study belongs to the National-level scientific research
item of Jilin University innovative research plan, numbering
2012B74249.
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international journal of nursing sciences xxx (2015) 1e6 5
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review, International Jour nal of Nursing Sciences (2015), http://dx.doi.org/10.1016/j.ijnss.2015.08.008
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