The past 30 years have brought greater support and understanding for people with autism spectrum disorder (ASD) with new interventions helping bridge some of the most challenging social challenges. We now know social skills can be taught through a diverse array of approaches, from group interventions and social stories to response training and problem-solving. Most of the methods are instructional, predictable and direct, with the goal of minimizing stress for the participants.
At The Ohio State University Nisonger Center, we recently ran the first clinical evaluation of a new type of intervention, one that is anything but direct or predictable. Called the Hunter Heartbeat Method, it is a fusion of activity, drama and humor based on the works of William Shakespeare.
At first glance, that approach might seem unlikely to work. If the routine, pragmatic language of daily life seems foreign to a child with ASD, how can the outsized emotions of drama help? The answer is in the playful execution and accessibility of one of Shakespeare’s most powerful tools: the rhythmic pulsing of iambic pentameter.
Acting in instead of acting out
One way children learn to acknowledge—and internalize—other perspectives is through play, especially through role playing. The Hunter Heartbeat Method builds on that theme. I was introduced to the technique by Ohio State Department of Theatre professor Lesley Ferris, who has been working with the developer of the method, actor Kelly Hunter of the Royal Shakespeare Company.
The technique uses a series of games that rely on the rhythm and repetition of lines from Shakespeare, building skills that are challenging for children with autism—such as improved eye contact, recognizing facial emotions, personal space and turn-taking—along with skills familiar to all students of drama, such as imitation, improvisation and comedy.
Despite Hunter’s training, the reliance on Shakespeare is not simply a reflection of her experiences. At the most critical moments of his plays, Shakespeare has his characters follow a specific rhythm, one with idiosyncratic properties that show advantages for working with children with autism. That rhythm is iambic pentameter, and it follows the beat of the human heart. You likely learned about it in school, but may not have realized it had this power. The steady pulse, the accented second beat—it is perhaps the most recognizable pattern in life, and it is inherently accessible.
Beginning and ending with the beating heart
The intervention, appropriately, takes place on a stage with each participant sitting in a circle next to other children and the actor-instructors. Every session begins and ends with everyone pounding their chest in rhythm with the beat of a heart, an exercise that aids the transition away from, and back to, the outside world.
Our intervention was based on the plot of Shakespeare’s “The Tempest” and focused on target skills. Two instructors would model the first of the day’s games in the center of the circle, and then the other instructors and children would break-off into pairs for one-on-one repeated practice and feedback. After practice, everyone returned to the circle to take turns performing the game for the other participants, with a heavy dose of humor. The process repeated for several games, all reflecting the play’s plot progression, until the session ended with a Goodbye Heartbeat. For the study, students participated in one after school session each week, for ten weeks.
While the activities are unpredictable, the format becomes familiar to each student and progresses in a quiet environment dominated by one-on-one guidance and support. Encouragement from the children and instructors in the circle—paired with spontaneous adaptation to each child’s ability level—provide stability, while imitation and observation, alongside free interpretation, drive creative expression.
To the untrained eye, the intervention may appear no different than a drama class or after-school activity in which a typically developing peer would participate. However, unlike other methods, each child does not learn one role that will be incorporated into a larger whole, but instead, all kids learn all roles without extensive rehearsal or attempts at perfection–each child can find comfort at the moment, without anxiety about performing at a certain level. It is an approach that allows kids to “try on” various social roles, emotions, and responses to build flexibility and spontaneity, and it can be adapted to children of all levels of functioning, including nonverbal participants.
Evaluating the heartbeat method
To capture the core elements of the approach, graduate student Maggie Mehling—the study’s lead author—traveled to New York City to work directly with Kelly Hunter, observing her during two weeks of sessions. Mehling crafted a manual from her notes, and on her return to Ohio worked with teams in our theatre department and Nisonger Center to develop a program targeting the skills we would measure.
We worked with a local school district to recruit 14 children with ASD, aged 10 to 14 years old, and recruited our facilitators from Ohio State’s Master’s of Fine Arts program, providing them with training in the Hunter Heartbeat Method and basic education in autism spectrum disorder.
This was the first pilot study to evaluate the effectiveness of the drama-based intervention with children with autism, and to eliminate bias, we recruited blinded evaluators for assessing the impacts on each child. The evaluators did not know what the project was about, or the purpose of the study and they assessed the children before the study began and at the end of the ten-week intervention.
What we found was ca lear improvement in social skills, communication and pragmatic language skills (the everyday communication with words and body that convey context). Some students even improved their recognition of facial expressions, one of the most challenging skills for children with ASD to master.
Highly verbal children, as well as children with a very limited verbal repertoire (expressing one- to two-word phrases), were able to successfully and meaningfully participate. One child who had a one-to-one aid was even able to slowly transition away from individualized prompting as the sessions progressed. Plus, our surveys confirmed what we could see in practice: everyone had fun. Parents observed that their children enjoyed the groups, left happy and spoke positively about the experience in the days between sessions. Many parents also reported, anecdotally, improvements in their child’s mood and social engagement at home.
Through their responses, parents revealed that they were some of the Hunter Heartbeat Method’s biggest fans. From a follow-up questionnaire, comments recounting the joy kids felt and new levels of participation were common–one student even said he wanted to become an actor.
A lasting impact
While carefully designed, our study is just the first of many that must take place to gain a better understanding of the benefits of the Hunter Heartbeat Method and where the method can fall short. To prove valid, the results need to be replicated through more robust research that includes a control group and additional independent assessments of outcomes.
Our group has two additional studies in process building on the outcomes from this experience.
The first will evaluate the Hunter Heartbeat Method in comparison to a control group, one that progresses over the same time period with students experiencing only their existing standard of care. The next will compare the Hunter Heartbeat Method to Skillstreaming, a more conventional intervention with strong evidence of impact. That study will include functional magnetic resonance imaging (fMRI) of the brain as part of the evaluation. We’re hoping to learn if improved behaviors and skills for recognizing facial emotion also improve efficiency in areas of the brain associated with those skills.
The Hunter Heartbeat Method is but one of many now working to break through autism’s barriers, and succeeding. Steeped in the dramatic arts, it is a testament to a promising future: As children with ASD are each challenged, each in his or her own way, for every child there appears to be interventions that can help.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing. http://www.dsm5.org/Pages/Default.aspx
Lord, C., Rutter, M., Goode, S., Heemsbergen, J., Jordan, H., Mawhood, L., & Schopler, E. (1989). Autism diagnostic observation schedule: A standardized observation of communicative and social behavior. Journal of autism and developmental disorders, 19(2), 185-212.
Sparrow, S., Cicchetti, D., & Balla, D. (2005). Vineland Adaptive Behavior Scales (2nd Edition). Parent/Caregiver Report Form Manual. Minneapolis: NCS Pearson Inc.
Gur, R.C., Ragland, J. D., Moberg, P. J.,Turner, T. H., Bilker, W. B., Kohler, C., Siegel, S. J., Gur, R. E. (2001). Computerized Neurocognitive Scanning: I. Methodology and validation in healthy people. Neuropsychopharmacology, 25, 766-776.
Test of Pragmatic Language (Second Edition.) (Phelps-Terasaki & Phelps-Gunn, 2007) Phelps-Terasaki, D., & Phelps-Gunn, T. (2007). TOPL-2 test of pragmatic language: Examiner’s manual. Austin, TX: Pro-ed Inc.
This article was featured in Issue 58 – The Greatest Love of All: Family