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The Son-Rise Programme: an intervention to improve social interaction in

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Article  in  International Journal of Therapy and Rehabilitation · May 2020

DOI: 10.12968/ijtr.2018.0148

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The Son-Rise Programme: an intervention to
improve social interaction in children with autism
spectrum disorder
Mina Ahmadi Kahjoogh1
Ebrahim Pishyareh2
Fatemeh Fekar
Gharamaleki3
Ahmad Mohammadi1
Abbas Soltani Someh4
Sahar Jasemi2
Mahdieh Mahmoudzadeh
Zali1
Author details can be found
at the end of this article
Correspondence to:
Sahar Jasemi;
saharjasemi@yahoo.com
How to cite this article:
Ahmadi Kahjoogh M,
Pishyareh E, Gharamaleki
FF, Mohammadi A, Someh
AS, Jasemi S, Zali MM. The
Son-Rise Programme: an
intervention to improve social
interaction in children with
autism spectrum disorder. Int J
Ther Rehabil. 2020. https://doi.
org/10.12968/ijtr.2018.0148
1
Research
Abstract
Background/Aims Communication problems are a core feature of autism spectrum
disorder. These problems usually lead to challenges in social interactions. The aim of this
study was to assess the effectiveness of the Son-Rise Programme on improving social
interaction and communication in children with autism spectrum disorder.
Methods Thirty children with autism spectrum disorder (aged 4–6) were involved in
this study. The children were assigned randomly to one two groups, either the 1-week
intensive Son‑Rise Programme or the control group. They were evaluated using the
Gilliam Autism Rating Scale before and after the study.
Results The participants in the group of the Son-Rise Programme showed a significant
improvement in their social interaction skills compared to the control group (P=0.001).
Conclusions The Son-Rise Programme could improve social interaction in children with
autism spectrum disorder.
Key words: Autism spectrum disorder; Communication; Social interaction
Submitted: 15 December 2018; accepted following double-blind peer review: 31 July 2019
Introduction
Autism spectrum disorder, with the prevalence of 1.14% (Baio et al, 2018), is a
neurodevelopmental disorder that can be distinguished by two important groups of symptoms.
One group includes social interaction and communication impairments, comprising
complications in verbal and non-verbal language skills and difficulties in understanding
relationships (Schroeder et al, 2010). Social interaction impairments have been defined as
difficulties with making eye contact, initiating interaction with other people, and understanding
gestures and facial expressions (Bohlander et al, 2012). According to the American
Occupational Therapy Association, social interaction skills are occupational performance
skills used during a social exchange (American Occupational Therapy Association, 2014).
Communication is a process in which information is transmitted from one person to another.
Non-verbal and verbal language skills are two important parts of communication skills
(Alokla, 2018).
The second group of symptoms comprises behavioural impairments. These behaviours
include repetitive physical stereotypic movements, excessive interest in objects and sensitivity
to sensory stimulations, leading to emotional reactions (Schroeder et al, 2010). As there is
a reciprocal relationship between social and academic achievements (Miller et al, 2017),
these problems can result in failure in work and educational activities (Smith et al, 2005).
Children with autism spectrum disorder also experience psychiatric comorbidities such as
anxiety and depression. These comorbidities are likely to exacerbate the core symptoms
(White et al, 2007; Strang et al, 2012). Estes et al (2011) reported that there is a significant
© 2020 MA Healthcare Ltd
difference between the level of academic achievement in children with autism spectrum
disorder and their mental abilities. They stated that these children do not acquire the academic
achievement which would be expected given their cognitive functions (Estes et al, 2011).
Children with autism spectrum disorder are also exposed to social isolation in their adulthood
(O’Brien, 2013). Given the importance of social skills in life, increasing the social skills of
these children is an essential component of therapeutic interventions (Shiri et al, 2015).
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Occupational therapy in children with autism spectrum disorder deals with all areas of
occupation, including social participation (Wallace et al, 2016). Participation in society
can be achieved through the proper social interaction skills and communication (Baio
et al, 2018). Applied Behaviour Analysis (Lovaas, 1987), Social Stories (Gray, 1998;
Sansosti et al, 2004), Social Skills Training and interventions based on the theory of
mind skill (Otero et al, 2015) are a number of various intervention approaches typically
implemented for these children. Therapists may also use other methods such as imitation,
parent education, peer education and social skills training as a group (Parr, 2010; Naeeimi
Darrehmoradi et al, 2013).

Son-Rise Programme
One of the approaches to treatment of autism spectrum disorder focusing on social
interaction is the Son-Rise Programme. This developmental approach emphasises the positive
and responsible attitude of parents toward interacting with their child (Williams, 2001;
O’Brien, 2013). It consists of three parts; in the first two parts, families and therapists get
to understand how the programme works, what the principles and techniques are, as well
as the basic stages of the programme, specific methods and challenges. The last part is a
clinician-delivered intensive intervention, which lasts 40 hours in 1 week (Houghton et al,
2013). The approach is used to promote spontaneous and child-initiated social interaction
with the therapist or parent as a parallel imitator of the child’s activities (Otero et al, 2015).
Child-guided sessions, intensive interaction and non-directive of the approach are the
main features of a child-led approach such as the Son-Rise Programme. Treatment sessions
of Son-Rise are not directly guided by the therapist or parents. However, they usually
design the game room and choose the playing equipment (Thompson and Jenkins, 2016).
In the Son-Rise Programme, the child is intended to effectively participate in the treatment
sessions and finally guide them (Williams, 2001; O’Brien, 2013). Family education is
another major component of the programme. The parents learn to respond their child needs
at the right time. The therapist or the parent imitates stereotypic movements and never use
the word ‘no’ or ‘not’. Instead, the therapist or parent tries to make the child initiate the
interaction (Williams, 2001).
Studies on child-centred approaches have shown promising results in improving social
skills in children with autism spectrum disorder (Koegel et al, 1987; Norris and Hoffman,
1990; Williams, 2001). There is a lack of empirical research into the effectiveness of
the Son-Rise Programme; however, some preliminary studies have shown that Son-Rise
can promote social interaction in children with autism spectrum disorder (Davis, 2006;
Houghton et al, 2013; Thompson and Jenkins, 2016). Thompson and Jenkins disclosed
that children who received high intensity home-based treatment demonstrated significant
improvement in their communication, sociability, and sensory and cognitive awareness
(Thompson and Jenkins, 2016).

Aim
The aim of the present study was to examine the impact of the Son-Rise Programme on the
social interaction of children with autism spectrum disorder. The authors hypothesised that
children in the intervention group would make progress in their social interaction skills.

Materials and methods

The study was a randomised clinical trial with a pre-test/post-test design.

Participants
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Children with autism spectrum disorder ranging from 4 to 6 years of age, who were referred
to Tavanesh Centre for Occupational Therapy and Roshd Development Rehabilitation
Centre in Tehran, participated in the study, which took place in 2017. Based on convenience
sampling, 50 parents of children on waiting lists of the centres were telephoned and asked
if they would participate in the study. A total of eight did not answer and 12 declined as
they said that the procedure was too long and they could not cancel their other plans. The

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sample size of 30 children was calculated based on 95% confidence interval, 80% power
and 0.5% effect size, according to Houghton et al (2013).
Inclusion criteria were as follows: children aged 4–6 years with autism spectrum disorder
who lived with their parents and did not have any other mental or physical disabilities such
as cerebral palsy (according to their clinical records). Participation in similar intervention
programmes at the same time, lack of regular attendance for treatment sessions and seizure
during the course of treatment were considered as exclusion criteria.
According to the inclusion criteria, a total of 30 children were randomly divided into
two groups. Simple randomisation by tossing a coin was the method used to divide groups
in which every new participant had an equal chance of being assigned to the intervention
or control groups (Ferreira and Patino, 2016).

Ethical approval
All families were informed about the goals of the study. The parents provided written
consent on behalf of the children. The Ethics Committee of Tehran University of Social
Welfare and Rehabilitation Sciences approved this study (approval number:IR.USWR.
REC.1395.326).

Instruments
Gilliam autism rating scale (GARS-2)
The Gilliam autism rating scale (GARS-2) was used to assess baseline skills of the
participants and also changes, if any, after the study. The GARS-2 scale is an autism
spectrum disorder screening tool for children of 3–22 years of age (Volker et al, 2016). This
screening scale consists of 42 questions and is composed of three subscales (stereotyped
behaviours, communication, and social interaction). The scale also has 14 questions about
developmental disabilities, but scores of this section, were not included in the analysis. Raw
scores of this scale are converted to an autism index, in which scores of 85 or higher indicate
that an individual is likely to have autism, while scores of 70–84 suggest that an individual
may have autism and 69 or less suggest it is unlikely that the person has autism (Volker
et al, 2016). The maximum score for each subscale is 42 and the minimum is 0. Thus, the
maximum and the minimum overall score for each person are 142 and 0 respectively. The
subscales are scored on a 4-point Likert scale of never observed to frequently observed.
According to Ahmadi et al (2011), Cronbach’s alpha coefficient of the stereotyped behaviours
is 0.74, communication is 0.98 and social interaction is 0.73. GARS’s Cronbach’s alpha
coefficient was 0.89. This coefficient indicates the high reliability of the scale, whereby
diagnostic and therapeutic procedures are facilitated (Samadi and McConkey, 2014). In
the present study, the test was used to measure the severity of autism in order to assess
social interaction and communication as well as a tool for entrance to the study. Note that
the third edition of GARS is available but it was translated to Farsi after starting the study.

Vineland Social Maturity Scale

The Vineland Social Maturity Scale score is obtained through interviews with informants.
This scale covers a range of ages from birth to 25 years and above and includes the following
eight aspects: self-help general, self-help dressing, self-help eating, communication,
self‑direction, socialisation, locomotion and occupation (Doll, 1947; Malin, 1971).
The test–retest reliability coefficient of Vineland Social Maturity Scale is 0.92. Similarly,
the Cronbach’s alpha coefficient for the 8 subscales is reported 0.92 (Fazel-Kalkhoran
et al, 2015). This questionnaire was used to compare social maturation only at the baseline
in the groups.

Procedure
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The diagnosis of autism spectrum disorder was established based on Diagnostic and
Statistical Manual of Mental Disorders, fourth Edition (DSM-IV, American Psychiatric
Association, 2000) criteria by a psychiatrist. The severity of autism, social interaction,
and communication were assessed by the GARS-2 test and the Vineland Social Maturity
Scale was completed at baseline by children’s mothers. The intervention group received the
Son-Rise intensive programme (Dawson and Adams, 1984) in accordance with its protocol

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(Houghton et al, 2013) for 30–40 hours in a week (5–7 hours each day depending on the
child’s tolerance) and the control group received traditional occupational therapy including
sensory integration therapy three times a week. Each session lasted between 45–60 minutes
with an average of 50 minutes. In total, all participants had the same treatment time. Before
the intervention, a meeting was held at the participants’ home in order to organise the
play room and coordinate the intervention hours. Families participated in the intervention
group were also given a translated version of the Son-Rise Programme booklet (Williams,
2001). The intervention was carried out by the researcher who had received the necessary
theoretical and practical training by attending the Son-Rise Workshop.
Imitating stereotyped movements, responding quickly and naturally to the interactive
behaviours of the child, communicating with the child, expanding the child’s responsiveness,
and engagement in new activities were the main techniques of the programme. First, the
therapist copied all the child’s behaviours and activities, imitating the child when they
showed stereotyped movements. The imitation continued until the child’s attention was
caught by the therapist and the interaction begun with her. Once the child initiated a
communicative act, the therapist immediately responded to him, praising his behaviour in a
way to increase the duration of the interaction. If the interaction was carried on by the child,
the therapist suggested a new activity based on his interests and abilities. If the interaction
was interrupted by the child and he engaged in repetitive activities again, the therapist did
not insist on communicating and resumed the imitation for further interaction. One week
after the intervention course, the assessor who was blinded to the groups examined the
progress by GARS-2.

Data analysis
A paired t-test and the Wilcoxon sign ranked test were used to compare the mean values
of social interaction and communication within each group (pre-test/post-test comparison)
measured by GARS-2. Independent-t and Mann-Whitney test were used to compare the
two groups (comparing the decrease of GARS-2 score over time in the groups). Finally,
the data were analyzed by the Statistical Package for the Social Sciences (version 24). The
level of significance was considered as P=0.05.

Results
The baseline scores of two groups were compared in terms of gender and age, as well
as autism severity and social maturity as social developmental age by using the GARS-2
questionnaire and Vineland Social Maturity Scale respectively. The results are summarised
in Table 1. There was no significant difference between the two groups in the social
development and severity of autism scores.
The results of within group analysis showed that there was a significant difference
between the mean of pre- and post-test raw scores of social interaction (P<0.001) and
communication (P=0.027) in both groups. According to the GARS-2 questionnaire, the
reduction in the mean indicates improvement in the social communication and interaction
of the participants of the study.
According to Tables 3 and 4, there is a significant difference between the two groups in
terms of social interaction (P=0.001), while no significant difference was made regarding
communication (P=0.53). Social interaction scores decreased in the intervention group,
indicating that the intervention had a positive effect on social interaction.

Discussion
Participants in both groups did experience significant improvement in their social interaction
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score, but the improvement was significantly better in the Son-Rise group.
These results are consistent with the findings of previous studies (Houghton et al, 2013;
Thompson and Jenkins, 2016). In a similar study, Houghton et al made use of a Son-Rise
intensive programme implemented by a therapist to improve social interaction in children
with autism spectrum disorder. The results represented an increase in interactive behaviours
(Houghton et al, 2013). In the study by Thompson and Jenkins (2016), parents performed the

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Table 1. Participants’ demographic variables

Control
Intervention group
group Mean ± P t
Variable Mean ± SD SD value x2 statistics

Age (months) - 62.27 ± 8.94 62.80 ± 0.896 - -

8.06

Sex (n) Male 11 10 - 6.619 -

Female 4 5 -

Autism Index - 83.83 ± 19.18 83.80 ± 0.880 - 0.01

on GARS-2 19.02

Social - 2.43 ± 1.13 2.51 ± 0.740 - 0.20

developmental 1.18
age (year)
SD : standard deviation

Table 2. Pre-test and post-test GARS-2 scores in the groups

Pre-test Post-test
Variable (mean ± SD) (mean ± SD) P value

Communication Intervention group 33.47 ± 11.56 31.33 ± 14.30 0.027

Control group 33.20 ± 11.95 32.40 ± 12.93 0.024

Social interaction Intervention group 22.13 ± 8.22 15.27 ± 6.69 0.001

Control group 21.80 ± 7.98 19.40 ± 7.66 0.001

Table 3. Social interaction mean in the intervention and control

groups (GARS-2)
Mean ±
Variable Group SD t Statistics DF P value

Social Intervention 6.87 ± 1.85 8.13 22.26 0.001*

interaction
Control 2.40 ± 1.06

Table 4. Communication mean in the intervention and control

groups (GARS-2)
Statistical Mean ± Mean Mann-Whitney P
index /variable Group SD (n) rank statistics value

Communication Intervention 2.13 ± 2.92 16.50 97.5 0.530

(15)

Control 0.8 ±1.08 14.50

(15)
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programme with the interventions conducted over a 6-month period. The present study was
the same as Thompson and Jenkins’ study in terms of the programme being home‑based;
however, in the present study, the interactions were conducted by the therapist.
Improvement in social skills of the participants is also consistent with findings of other
child-centred interventions (Salter et al, 2016). According to the Son-Rise Programme,

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after building an acceptable interaction, the therapist extends the activities based on the
child’s interests and encourages the child to engage in them. In this way, Son-Rise can
be considered as a child-centred approach.

Imitation
One of the most pivotal techniques of the Son-Rise Programme is the use of imitation
as an element playing a foundational role in the development of social interaction skills
(Uzgiris, 1981; Rogers and Pennington, 1991). The therapist first imitates the child’s
behaviours and then the child enters into the activity by imitating the therapist. In this
study, all the stereotypical behaviours of the child were imitated during the treatment
session by the therapist, and this was done by maintaining an appropriate distance from
the child, yet paying full attention to the child (Ingersoll and Lalonde, 2010). Imitating
the physical and verbal movements of the child, it implies to the child that the therapist
knows which type of play he/she is interested in. By creating a reciprocal interaction,
the opportunity is given to teach the child physical movements, speech and language and
more appropriate types of play. For example, if the child throws the ball, the therapist
encourages the child to throw the ball in a basket. When it is successful, the child is
given a reward..
Furthermore, the imitation of the child’s playing increases the child’s attention and
social responsiveness (Ingersoll, 2007). As Levy (1999) said, imitation of the stereotypic
movements is a way to assure the child that he is accepted enough to take the role as a
guide. In addition, the first communicative experience between the child and the adult
occurs during imitation (Levy, 1999).

Communication
The results of this study showed that the Son-Rise Programme did not significantly
improve the communication of the participants compared to those who received usual
occupational therapy. These results are consistent with the study of Houghton et al (2013).
In that study, no statistically significant change was reported in verbal behaviours of the
intervention group compared to those of the control group. On the other hand, the study
by Thompson and Jenkins (2016) in which the Son-Rise Programme was conducted by
parents for 6 months was inconsistent with the results of this study. Children who had
more than 1 hour of intervention a day had better communication skills compared to
those who had received a lower intensity treatment intervention.
In the present study, the GARS-2 questionnaire was used to measure children’s
communication abilities. In this tool, only verbal communication is considered as a
desired response; if the child uses gestures, however, they are given the complete score
of the item (the higher the score in this questionnaire, the lower the function expected)
(Samadi and McConkey, 2014). In children with autism spectrum disorder, non-verbal
communication skills are assumed as a predictor of language development at later stages
of life. Long-term interventions seem to have better effects on communication and word
use in interactions (Alokla, 2018). The results show that the Son-Rise Programme has
more impact on non-verbal behaviours in short-term interventions than verbal behaviours.

Limitations and future research

There was no follow-up in the study to address the stability of the intervention effects.
Future research should consider a follow-up phase of the effects. Moreover, a bigger
sample size in future studies could make the results more generalisable. It is also
suggested to conduct comparative studies to compare the effects of different treatments
in reducing the symptoms of autism spectrum disorder. Children with autism spectrum
disorder have the most interaction with their parents; as a result, the parents carrying
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out the programme should be considered as another suggestion.

Conclusions
The Son-Rise Programme could be used as an effective programme to improve the social
interactions of children with autism spectrum disorder. According to the results, this

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approach has a positive effect on the social skills of children. Social interactions can
be improved over a short time span, but communication skills likely need more sessions
and long-term treatment.

Author details
1Department of Occupational Therapy, Faculty of Rehabilitation Sciences, Tabriz University of Medical

Sciences, Tabriz, Iran

2Department of Occupational Therapy, University of Social Welfare and Rehabilitation Sciences,
Tehran, Iran
3Department of Speech Therapy, School of Rehabilitation Sciences, Tabriz University of Medical
Sciences, Tabriz, Iran
4Department of Physical Therapy, Faculty of Rehabilitation Sciences, Tabriz University of Medical
Sciences, Tabriz, Iran

Conflicts of interest
The authors declare that there are no conflicts of interest.

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