International Journal of School & Educational Psychology

ISSN: 2168-3603 (Print) 2168-3611 (Online) Journal homepage: http://www.tandfonline.com/loi/usep20

Sexual knowledge acquisition and retention for

individuals with autism

Liza Pask, Tammy L. Hughes & Lawrence R. Sutton

To cite this article: Liza Pask, Tammy L. Hughes & Lawrence R. Sutton (2016): Sexual
knowledge acquisition and retention for individuals with autism, International Journal of
School & Educational Psychology, DOI: 10.1080/21683603.2016.1130579

To link to this article: http://dx.doi.org/10.1080/21683603.2016.1130579

Published online: 26 Feb 2016.

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 INTERNATIONAL JOURNAL OF SCHOOL & EDUCATIONAL PSYCHOLOGY
http://dx.doi.org/10.1080/21683603.2016.1130579

ARTICLE

Sexual knowledge acquisition and retention for individuals with autism

Liza Pask, Tammy L. Hughes, and Lawrence R. Sutton
Department of Counseling, Psychology and Special Education, Duquesne University, Pittsburgh, Pennsylvania, USA

ABSTRACT KEYWORDS
Healthy Relationships & Autism is a developmentally sequenced, manualized intervention intended autism; ASD; sexual
for children and adolescents with an autism spectrum disorder (ASD). The curriculum is designed knowledge; sex education
to facilitate healthy interpersonal relationships; three modules cover personal hygiene, sexual
knowledge, and a variety of productive interpersonal relations. The current study investigates the
effectiveness of the strategies used to increase sexual knowledge for individuals with ASD.
Downloaded by [University of California, San Diego] at 02:29 08 March 2016

Specifically, short step-by-step concrete explanations that are paired with visual modeling and
repeated practice accompanied by corrective feedback were delivered to six adolescents who
showed a wide range of functional abilities. Pre, post, and one month follow-up measures show that
the HR curriculum was effective in increasing sexual knowledge acquisition and retention regardless
of the child’s level of difficulties.

Adolescence is a critical period when youth learn the
developmentally and socially appropriate behaviors
needed to manage the physical and emotional changes
that occur as they mature. Sexual development is especially
important because it is closely linked with the basic human
needs such as acceptance, feelings of worth and
attractiveness, and the sharing of thoughts and feelings
(Haffner, 1995; Koller, 2000). Also, it is an essential factor
in bonding with others, developing relationships, and
building and maintaining an overall pleasurable life
(Murphy & Elias, 2006). Healthy sexual development not
only involves physiological development, but also the
knowledge, beliefs, and attitudes surrounding sexuality
(Gabriels & Van Bourgondien, 2007; Haffner, 1995).
Adolescents with developmental disabilities, including
autism spectrum disorder (ASD), are no different from
their neurotypical peers in their desire to understand
and develop a healthy sexuality. Although children and
adolescents with ASD experience normal physical
developmental changes, and the associated increased
interest in romantic relationships, they are often unable
to understand these changes and relationships in a typical
way. That is, the defining traits of ASD, which include
difficulties in socialization and communication as well as
the presence of repetitive and stereotyped behaviors
and interests, interfere with healthy sexual development
(Haracopos & Pedersen, 1992; Konstantareas & Lunsky,
1997; Ousley & Mesibov, 1991). The mismatch between
physical and social developmental levels can lead to
inappropriate relationship pursuit strategies (e.g., obses-
sive following, lurking in public places, displays of
unwanted attention, nonconsensual physical contact;
Stokes & Kaur, 2005; Stokes, Newton, & Kaur, 2007).
Inappropriate strategies may lead to unsatisfying social
outcomes, social isolation, or in a small number of cases,
illegal acts committed by individuals with ASD (Walters
et al., 2013). Acquiring accurate sexual knowledge and
accompanying relationship development is especially
important for this group (Chan & John, 2012).
There is a wide variety of methods used to deliver
sexual education curricula. Unfortunately, many pro-
grams rely heavily on euphemisms and innuendo (e.g.,
the birds and the bees, going all the way, doing it, etc.).
Given the difficulties in understanding pragmatic
language (e.g., the varied skills needed for adequate
social communication) routinely evident in individuals
with ASD, the method of delivering curricula content
requires adjustment to include communication tech-
niques and strategies useful for an individual with ASD
to learn and retain pertinent information. Although
individual needs differ, well-researched teaching tech-
niques include the use of repetition, reinforcement,

CONTACT Tammy L. Hughes hughest@duq.edu Department of Counseling, Psychology and Special Education, Duquesne University, 600 Forbes Ave,
Pittsburgh, PA 15282, USA.
Color versions of one or more of the figures in the article can be found online at www.tandfonline.com/usep.

q 2016 International School Psychology Association

 2 L. PASK ET AL.
concrete instruction, role-plays, video modeling, and so
forth (Murphy & Elias, 2006). Given the need to deliver
sex education for children and adolescents with ASD and
the requirement to modify the delivery of the curricula,
the current study examines the usefulness of the Healthy
Relationships & Autism (shortened and denoted as HR)
intervention, which is designed to meet the needs of
individuals with ASD.
Autism spectrum disorders and sexuality
Autism is a neurodevelopmental disability that has
increased in its prevalence in children to 1 in 68 live
births (Centers for Disease Control, 2014). The core
features of autism include persistent difficulties in social
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interaction and communication across multiple contexts
and the presence of restricted, repetitive patterns of
behavior, interests, or activities. Since traits of autism
differ in number and intensity across individuals, those
differences are described as occurring on a spectrum.
Children and adolescents with autism experience
physical development at a typical rate with the emergence
of secondary sex characteristics (e.g., pubic hair growth,
breast development) during puberty (Gabriels & Van
Bourgondien, 2007; Sullivan & Caterino, 2008). However,
the emotional changes and increasing sexual urges that
also accompany adolescence can be delayed in the ASD
population (Gabriels & Van Bourgondien, 2007; Sullivan
& Caterino, 2008). According to Eaves and Ho (1996),
about 10 –30% of adolescents with ASD have increased
behavioral problems during adolescence. Engaging in
inappropriate sexual behaviors may become a concern
for adolescents with ASD because the development of
sexual drives is not accompanied by an ability to
understand the social norms that govern appropriate
behaviors (Henault, 2005).
Most typically developing adolescents learn how to
deal with the maturational changes that occur naturally
by gathering information from a variety of sources in
their daily environment such as peers, parents, teachers,
and the media (Chan & John, 2012). Social skills are
necessary to manage the information gathered during
adolescence as well as to manage peer pressure, new
relationships, unfamiliar sexual feelings, and romantic
desires (Chan & John, 2012). The ability to understand,
communicate, and interact in a socially appropriate and
reciprocal way is necessary in the pursuit of relationships
and in the clarification of sexual knowledge. ASD by its
nature is characterized by difficulties in social inter-
actions, and therefore, children with ASD lack the
necessary skills for healthy growth and development
during adolescence (Chan & John, 2012; Gabriels & Van
Bourgondien, 2007).
Researchers suggest that individuals diagnosed with an
ASD are less likely to acquire appropriate social skills
such as courting and romantic behaviors through
interactions with family, peers, observation, and media
as compared to their neurotypical peers. As such, the
adolescents with ASD are disadvantaged, as they are not
able to benefit from that same social learning as their
peers (Stokes & Kaur, 2005; Stokes et al., 2007). For
example, Stokes et al. (2007) found that irrespective of
age, young adults with ASD differed significantly from
typically developing peers on their ability to benefit from
social learning interactions with peers and friends as
sources. In addition, this same group differed in their
romantic learning, as individuals with ASD had less
access to romantic and social knowledge and skills from
their peers and friends than their neurotypical peers.
These social deficits are of particular importance to
sexual development because impairments negatively
affect peer acceptance, communication skills, psychosex-
ual development, relationship building, and intimacy
(Sullivan & Caterino, 2008). Social deficits not only
interfere with an individual’s ability to form friendships
and romantic relationships, but also may impede social
judgment, such as the distinguishing between private
versus public activities, who is appropriate to speak with
about sexuality, and how and why to manage personal
hygiene (Gabriels & Van Bourgondien, 2007).
Early misconceptions: ASD and sexuality
There is a commonly held misconception that, due to the
nature of autism traits, children and adolescents with
ASD are uninterested in sexuality, and that they are
sexually immature, or even asexual (Konstantareas &
Lunsky, 1997; Murphy & Elias, 2006; Sullivan & Caterino,
2008). Specifically, early research suggested that those
with ASD, and males in particular, had no interest in
sexual intercourse (DeMyer, 1979) and therefore,
experienced few sexual problems (Dewey & Everard,
1974). Often, the incapacity to learn social skills through
informal interaction, as typically developing individuals
do, is incorrectly perceived as the preference for being
isolated (Stokes & Kaur, 2005). Researchers have found
that when sexual interests and behaviors were noted in
individuals with ASD, they were generally viewed in a
negative manner by caregivers, teachers, and peers due to
social ineptness, inappropriate courting actions, and
related stereotypes usually associated with the disorder
(DeMyers, 1979; Dewey & Everard,1974). Therefore,
historically, inquiring into their attitudes, beliefs, and
knowledge of sexuality was thought to be impractical and
unnecessary (DeMyers, 1979; Dewey & Everard, 1974;
Konstantareas & Lunsky, 1997).
 INTERNATIONAL JOURNAL OF SCHOOL & EDUCATIONAL PSYCHOLOGY
Current conceptions: ASD and sexuality
As stated previously, more current research suggests that
social impairments associated with ASD do not translate
to lack of interest in relationships and intimacy with
others (Koller, 2000; Kontstantareas & Lunsky, 1997;
Sullivan & Caterino, 2008). Researchers find that
individuals with autism are endorsing, expressing interest
in, and engaging in sexual behaviors including self-
stimulatory behaviors, sexual behaviors with others
including handholding, hugging, kissing, touching, and
attempted intercourse (Haracopos & Pedersen, 1992;
Hellemans, Colson, Verbracken, Vermeiren, & Deboutte,
2007; Konstantareas & Lunsky, 1997; Stokes & Kaur,
2005; VanBourgondien, Reichle, & Palmer, 1997). Ousley
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and Mesibov (1991) found that both males and females
had a greater degree of sexual interest than what had been
previously reported in the literature, with males being
more interested in sexuality than females. Also, although
interested, those with ASD engaged in a markedly less
amount of sexual activity than their intellectually
disabled peers.
Difficulties: ASD and sexuality
Despite the interest in and engagement in sexuality-
related matters, there are problems that arise for
individuals with ASD. For example, when compared to
typically developing peers, individuals with ASD engaged
in fewer social behaviors, had less education about sex,
and had fewer sexual experiences (Mehzabin & Stokes,
2011). Additionally, this group showed marked anxiety
for the future, including worries about finding a life
partner and concern that others would misinterpret their
behavior as sexual when it was not (Mehzabin & Stokes,
2011).
Due to the social difficulties (e.g., inability to recognize
affective cues, impaired communication skills, and poor
perspective-taking ability), adolescents with ASD may
naïvely engage in intrusive or inappropriate behaviors
while trying to initiate and pursue relationships with
others (Stokes & Kaur, 2005; Stokes et al., 2007). For
example, Stokes et al. (2007) describe the subtle differences
between appropriate courtship behaviors such as calling,
texting, writing, and meeting to get together and when
such behaviors become more intrusive behaviors that
might resemble stalking. In addition, Stokes and Kaur
(2005) found that due to a combination of the lack of social
understanding and the perseverative nature of some
individuals with ASD, behaviors may evolve into a
determined pursuit, harassment, or intimidation.
Another challenge is difficulty demonstrating propri-
ety. For example, adolescents with ASD do not always
3
seek privacy when undressing. This group may be less
aware of privacy norms, such as knocking on closed
doors before entering or refraining from touching private
body areas while in public (Haracopos & Pedersen, 1992;
Hellemans & Deboutte, 2002; Ruble & Dalrymple, 1993).
It is hypothesized that because of a resistance to change (a
trait that is common in individuals with ASD), adapting
to the physical changes of puberty is difficult (Hellemans,
Roeyers, Leplae, Dewaele, & Deboutte, 2010). Finally,
although less frequently reported, sexual problems noted
in the literature include masturbation in the presence
of others, deviant or harmful masturbation, unwanted
sexual touching, unwanted attempt at intercourse,
pedophilia, fetishism, and anxiety with regard to sexuality
(Hellemans et al., 2007; Ruble & Dalrymple, 1993).
Associated risks: ASD and sexuality
Associated risk factors that may contribute to individuals
with ASD being more inclined to demonstrate unac-
ceptable sexual behaviors include limited rewarding social
experiences during childhood and adolescence, little
exposure to erotic material during puberty, and failing to
encounter an adequate sexual partner. Researchers report
that children and adolescents with ASD are also more
likely to be victims of emotional, physical (Walters et al.,
2013), or sexual abuse (Mandell, Walrath, Manteuffel,
Sgro, & Pinto-Martin, 2005; Travers & Tincani, 2010) and
are likely to attempt to reenact the abuse experience.
In these circumstances, individuals with ASD might be
subject to, or perpetrators of, indecent or criminal sexual
behaviors (e.g., exhibitionism, voyeurism, frotteurism,
sexual assault, pedophilia) that are the result of several
risk factors accumulating including an aggressive nature,
history of sexual abuse, imitation of observed aggressive
behaviors, sexual dissatisfaction or hostility (Henault,
2005). Taken altogether, the high degree of interest in
sexuality, and engagement in sexual behaviors, among
individuals with ASD (Haracopos & Pedersen, 1992;
Koller, 2000; Kontstantareas & Lunsky, 1997; Ousley &
Mesibov, 1991; Sullivan & Caterino, 2008; VanBourgon-
dien, Reichle, & Palmer, 1997), suggests there is a strong
need to understand how to appropriately approach
sexuality education for this population.
Intervention: Sexual knowledge
Access to and delivery of sex education can be
controversial for many reasons. Although standards are
set by the Sexuality Information and Education Council
of the United States (SIECUS; 2012), some school
districts provide limited information to avoid complaints
from parents, school board members, or lawmakers.
 4 L. PASK ET AL.
As such, sex education curriculum can use indirect or
vague terms, relying on euphemisms (e.g., junk, flagpole)
and colloquial expressions (e.g., birds and the bees,
getting busy) to relay information and to describe
behaviors (Boehning, 2006; Tissot, 2009). Although this
may or may not suffice for a general population,
difficulties in understanding these inexplicit communi-
cations may arise for youth with ASD. Indeed, there are
few programs designed with the intention of conveying
sexual information to youth with ASD.
Effective teaching techniques
The literature regarding how best to provide information
to individuals with ASD about their sexuality is scarce.
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However, there is evidence these individuals can learn
and do benefit from thoughtfully prepared instruction
that is modified to meet their learning needs.
Similar to the way that academic concepts are taught,
there is a need to learn and master basic concepts of social
aptness before moving on to the more complex concepts
(Murphy & Elias, 2006). That is, an individual will need to
have mastery of basic self-care, hygienic expectations, as
well as a working knowledge of basic sexual education in
order to successfully initiate relationships. Techniques,
strategies, and modifications such as role-playing
scenarios, use of concrete visuals, use of explicit visuals,
social stories, repeating material, individual instruction,
video modeling, applied practice, delivery in a small-
group setting, the use of a structured routine, reinforce-
ment for desired behavior, as well as immediate
redirection or other behaviors and can be used across
various functional levels (Koller, 2000; Murphy & Elias,
2006) as long as treatment is also individualized at
developmentally appropriate levels for participants
(Koller, 2000).
Where sexual education content requires supplemen-
tal adjustments is when describing the subtle and implicit
rules that govern sexual behavior that are readily
understood by most typically developing individuals.
In this case, individuals with ASD require direct
instruction (Hattan & Tector, 2010; Sullivan & Caterino,
2008), and appropriate social expectations must be
explicitly taught. For example, a typically developing
adolescent male might understand that it is against social
convention to initiate conversation with others in private
areas such as restrooms; however, it may be necessary to
explicitly teach an adolescent with an ASD that this is not
an appropriate place to engage another in conversation.
Stokes (2012) suggests formal social practice may be
required.
The purpose of this study is to determine whether or
not Healthy Relationships & Autism (Sutton & Wesley
Spectrum Services, 2013) is effective in the knowledge
acquisition and knowledge retention of adolescents with
ASD. Since the HR curriculum uses strategies shown to
be effective with individuals with ASD, it is hypothesized
that the youth will show good knowledge acquisition and
retention of sexual knowledge. That is, regardless of
functioning ability, the HR curriculum will help
participants to acquire and retain sexual knowledge
over time.
Method
Setting
A nonprofit organization offering an array of services and
programs in Southwestern Pennsylvania participated in
this study. The agency provides partial care hospitaliz-
ation, outpatient services, and school-based programs to
at-risk youth and their families. For the purposes of this
study, only participants diagnosed with an ASD in the
school-based autism services program were examined.
Participants
Six White, male participants ranging from ages 15 to 17
(mean age ¼ 15.83 years) were recruited from grades 9
to 11 to participate in the study. One participant exhibits
minimal symptoms of autism, four participants exhibit
mild to moderate symptoms of autism, and one
participant exhibits moderate to severe symptoms of
autism. All participants were enrolled in the same self-
contained classroom.
Intervention
The HR curriculum is a developmentally sequenced,
three-module curriculum designed to assess and teach
Basic Hygiene, Basic Biological Sex Education, and
Relationship Development. A therapeutic staff team
comprised of one male and one female facilitator
delivered the intervention. Therapeutic staff received
40 hr of formal training on how to deliver the curriculum
with fidelity. To ensure consistency in the delivery of
sessions, the training meetings included demonstration
of the lessons to trainers and other trainees that was
paired with a performance review, constructive feedback,
and tips for the unexpected. Spot checks by trainers were
conducted throughout the intervention in addition to
regular feedback in weekly supervision.
For the child, each session lasts approximately 45
min (e.g., the equivalent of one class period) and is
presented in a small group format of at least 5 but no
more than 8 students. All students must demonstrate
mastery of the material (85% accuracy on posttest
 INTERNATIONAL JOURNAL OF SCHOOL & EDUCATIONAL PSYCHOLOGY
measures) before being able to move to the material in
the next module.
The first module of Healthy Relationships focuses on
basic hygiene. Upon completion of the pretest, there are
two introductory sessions designed to establish group
rapport and cohesion, develop rules for members to
follow, and review confidentiality. There are six lessons of
content following the introductory sessions. The next
six sessions include content related to hand washing,
showering and bathing, proper dental care, toileting,
bedroom organization, and privacy. The module
concludes with a posttest.
Once students have achieved mastery of module 1
material, they move to module 2, which is basic biological
sex education. Upon completion of the pretest, there are
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six lessons addressing basic biological sex education.
The six lessons of module 2 include an introduction to
puberty, male genitalia, female genitalia, intercourse, and
pregnancy and childbirth. Module 2 content is factual in
nature and clinical terms for anatomy and other
biological processes are presented. However, the HR
curriculum recognizes that social slang regarding sex-
related material is prevalent and used pervasively in
casual social conversation. As such, the use of slang
terminology is used to increase knowledge of nuanced
interactions. Module 2 includes a section on identifying
and matching currently popular social slang terms with
their clinical counterparts. The module concludes with a
posttest.
Upon achieving mastery of the information in
module 2, students move on to module 3, which has a
focus on developing relationships. The module titled
Developing Relationships includes 23 sessions that
address topics such as differentiating between friends,
acquaintances, and bullies, small talk, private talk,
showing appropriate affection, dating, and social media
and Internet safety. The module 3 posttest is given to the
students upon completion of the Developing Relation-
ships sessions.
Given the documented need to address sexual
knowledge in youth with ASD, as well as the need to
clarify the usefulness of the HR curriculum to provide
relevant sexual information, the current study examined
module 2 data.
Measures
CARS2-HF
The Child Autism Rating Scale, second edition, High
Functioning Version (CARS2- HF) was used to identify
and differentiate the level of ASD traits for each
participant. The CARS2-HF is a 15-item rating scale
5
that categorizes scores into one of three severity groups:
Minimal to No Symptoms, Mild to Moderate Symptoms,
and Severe Symptoms. Participants’ severity category is
designated low-, moderate-, or high-functioning for the
purposes of the study.
Pre- and posttest
A curriculum-based measure (CBM) designed to assess
knowledge related to basic biological sex education was
used for the pre- and posttest. CBM probes are the best-
known method for monitoring students’ progress and
achievement outcomes (McLane, n.d.) Eleven items on
the measure require participants to identify basic male
and female reproductive anatomy (matching terms to
pictures), 17 items are definitions of biological vocabulary
words (matching terms to definitions), 5 items require
the child to generate appropriate biological terms when
provided with slang terms, and 25 items are true or false
questions concerning module content covering infor-
mation related to such issues as sexual intercourse,
pregnancy, childbirth, and sexual health. The total
number of possible points is 58. The test was given prior
to receiving the intervention, immediately following the
conclusion of the sessions, and one month after the
module’s conclusion.
Research design
A quasi-experimental, repeated measures design was
used to compare youth learning. This design is common
when randomization of the participants is impractical
(i.e., participants requiring differential treatment for
basic biological sex education; McMillan & Schumacher,
2010). The independent variable in the study is the
second module of Healthy Relationships and the
dependent variables are the knowledge acquisition and
knowledge retention of the module 2 content, as
measured by the scores earned on the posttest. Knowl-
edge acquisition is measured by the scores earned by the
participants on the initial posttest, which is administered
at the immediate conclusion of module 2. Knowledge
retention is measured by probing the participants with
the same posttest at one month following the completion
of module 2.
Procedure
Participants progressed through the modules sequentially
in a cohort model and remained with the module until
mastery was achieved (i.e., 85% correct on the module
posttest) by everyone. Sessions were presented once or
twice a week lasting approximately 40– 50 min, or the
 6 L. PASK ET AL.
Table 1. Participants’ CARS2-HF severity and posttest scores.
Participant CARS severity
1 Mild to Moderate
2 Mild to Moderate
3 Severe Symptoms of Autism
4 Minimal to No Symptoms of Autism
5 Mild to Moderate
6 Mild to Moderate
Note. Mastery ¼ 49 questions correct.
equivalent of one class period per session. Modified,
differential instruction techniques (e.g., repetition,
rephrasing, supplementing with the use of relevant
videos or individual instruction) were used to help group
members progress at similar rates. Individual remedia-
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tion was provided, as needed, to assure minimum
competency (i.e., 85% correct on the module posttest), if
it was not achieved at the initial posttest time point.
No assumptions of prior knowledge were made; rather,
all participants completed all module content. Each
family had access to materials and the content taught in
each lesson. Upon completion of each lesson, a home
supplement outlining the material that was taught was
sent home to parents with encouragement to follow up,
practice new skills, discuss new content learned, and
provide opportunities to answer questions.
Results
A paired samples t-test was conducted to evaluate
whether there were significant differences between
participants’ pretest and initial posttest scores. The
results indicated that the mean of the initial posttest
scores (M ¼ 49, SD ¼ 4.86) was significantly greater
than the mean of the pretest scores (M ¼ 40.33, SD
¼ 7.84), t(5) ¼ 23.585, p ¼ .016, achieved power ¼ .92.
The standardized effect size index, d, was calculated using
d ¼ Mean/Standard Deviation, and is d ¼ 21.47, dash
before 1.47 is a minus sign indicating a large effect size.
The 95% confidence interval for the mean difference
between the two scores was 214.89 to 22.45.
Descriptive statistics were used to determine whether
the participants achieved mastery on the first posttest.
Results indicated that 3 (50%) participants achieved the
mastery criterion on the initial posttest, and 3 (50%) of
the participants did not reach mastery criterion on the
first posttest, thus needing individual remediation.
As required by the HR curriculum, participants 4, 5,
and 6 received individual remediation on module 2
content and were retested, as they are not permitted to
move to module 3 material without having achieved
mastery of module 2. After individual remediation, each
of the 3 participants achieved at least an 85% passing rate
Module 2 initial posttest Module 2 posttest score after
score (percent correct) remediation (percent correct)
57 (98) –
51 (88) –
50 (86) –
43 (74) 52 (90)
47 (81) 53 (91)
46 (79) 49 (85)
on their second posttest. Table 1 describes each
participant’s functioning ability and posttest results.
A one-way, repeated measures analysis of variance
(ANOVA) was conducted to investigate the hypothesis
that the HR curriculum would be effective in the
increasing and maintaining of knowledge acquisition, as
measured by three points in time, including a pretest
prior to receiving the module, the posttest that indicates
initial mastery criterion knowledge acquisition, and a
second posttest given one month after completing
module 2 content. See Table 2 for summary. With regard
to the second posttest, it was hypothesized that
participants would maintain knowledge acquisition at
the mastery level (i.e., 85% passing rate). Results of the
repeated measures ANOVA indicated a significant main
effect, Wilks’ l ¼ .22, F(2,4) ¼ 7.08, p ¼ .049, partial
h2 ¼ .78, observed power ¼ .61.
Pairwise comparisons were examined to determine
between which specific time points there were significant
changes. Results indicated significant change between the
pretest to each person’s Mastery level posttest (Mean
difference ¼ 211.67, p ¼ .01). From the mastery time
point to the maintenance probe at one month out, there
was not a significant change. The mean difference of 3,
p ¼ .07, indicated that although some scores went down,
they did not decrease significantly. In other words,
participants retained their initial knowledge acquisition
at an average level that meets mastery criterion as
mandated by the HR curriculum. Figure 1 depicts each
participant’s results for each time point. Results indicate
that the Healthy Relationships curriculum is effective in
promoting the knowledge retention of participants
who present in a wide range across the autism spectrum,
as a group.
Discussion
The development of healthy relationships with others is a
central and critical experience needed for high quality of
life and for overall life satisfaction (Stokes et al., 2007).
Sexual development is a multifaceted process that related
to basic human needs such as acceptance and feelings
of value, worth, and attractiveness (Haffner, 1995; Van
 INTERNATIONAL JOURNAL OF SCHOOL & EDUCATIONAL PSYCHOLOGY
Figure 1. Module 2 Pre/Post Test Results. The figure displays number of questions correct at each time point for all 6 participants.
Downloaded by [University of California, San Diego] at 02:29 08 March 2016
Bourgondien, 2007). For individuals with ASD, inap-
propriate sexual behaviors may occur because the typical
development of sexual drives is not accompanied by an
ability to understand the social norms that govern
appropriate behaviors (Henault, 2005; Sullivan &
Caterino, 2008). The lack of programming aimed at
increasing sexual knowledge for youth with ASD was a
primary consideration for designing the current study.
Although there are several sex education curricula that
target adults with ASDs (e.g., the TEACCH program
by Schopler, 1997; the Devereux Centers’ curriculum by
Koller, 2000; the Benhaven School’s curriculum by
Melone & Lettick, 1985; and the Taking Care of Myself
curriculum by Wrobel, 2003), none have been empirically
investigated, nor has the relevance for children and
adolescents been considered.
Data from this study shows that the HR curriculum
can be effective for sexual knowledge acquisition and
retention in children and adolescents with ASD. Learning
is sustained for at least one month. The HR curriculum
attempts to fill several gaps in the literature in an effort to
improve the quality of life for children and adolescents
with ASD by increasing knowledge and skill via
theoretically sound teaching techniques. Results show
that the curriculum can be adapted for the needs of youth
with ASD.
Clinical significance
It was hypothesized that, regardless of functioning ability,
the sample of adolescents would retain the information.
Although this hypothesis was upheld, many of them
regressed slightly in their knowledge retention. Despite
the lack of statistically significant change in the
maintenance of the question items, there are important
clinical considerations for the items that were missed or
not retained by the participants. The pretest and posttest
questions were designed to mirror that of the lesson
7
content, and were chosen by the developers of the HR
curriculum due to the safety and social implications that
accompany a thorough understanding of the concepts
that the questions intend to address. For example,
understanding what sexual intercourse is, how pregnancy
occurs, and so forth are important concepts to under-
stand for an individual who is seriously considering a
sexual relationship with a partner. Therefore, it is
imperative that the HR curriculum and those caring for
individuals with autism who are at risk for socially inept
or unsafe behaviors to work to reinforce, reteach, and
consistently provide appropriate information so that the
information can be retained and used.
The HR curriculum was developed in order to be
administered in a manner that is consistent with best
practices for working with individuals with ASD, which
includes direct instruction, multiple reinforcers, and
repeated dosages of material to address the skill
regression that some individuals with autism experience.
In addition to this strategy, the HR curriculum is
intended to be administered in a timely fashion. That is,
the ages at which the adolescents are receiving the
intervention align with the period of development during
which they are actually experiencing the physiological
and psychosexual changes, urges, and desires (i.e.,
puberty, adolescence). Informal feedback from clinicians
serving youth in the facility who were not participants in
this study indicated that younger middle school aged
children who were not experiencing puberty tended to be
too socially and physically immature to benefit from the
information in a productive way or meaningful way.
Relatedly, older adolescents enrolled in adult transition
programs indicated dissatisfaction with the curriculum;
anecdotal complaints predominantly centered on reports
of unsuccessful relationships pursuits and therefore a
general feeling of hopelessness, apathy, and a disbelief
that they could be successful regardless of information
provided in the curriculum. This anecdotal information,
 8 L. PASK ET AL.
Table 2. Descriptive statistics: Module 2 pretests, posttests,
remediation, maintenance probes.
N Minimum Maximum Mean Std. deviation
Module2_Pre_Total 6 29 51 40.33 7.840
Module2_Post_Total 6 43 57 49.00 4.858
Module2_Rem1_Total 3 49 53 51.33 2.082
Module2_Maint1_Total 6 45 55 49.00 4.517
taken alongside the positive results from the current
study, highlight the importance of the timely delivery
of the HR curriculum, ensuring that the session content
matches child and adolescent interest, engagement, and
learning needs. Therefore, it is suggested that pertinent
life experiences are identified from a reliable data source.
A way to formally increase communications among
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school, youth, and family should be developed.
Since individuals with ASD have difficulty translating
social events and social nuances in real time, there is
also a need to measure real-life social actions. That is,
although the HR curriculum material provides a solid
foundation for sexual education knowledge, the material
does not account for how individuals continue to learn or
understand new events as they continue to grow, develop,
and engage in relationships. How to measure the
management of these real-life implications is a future
need. At present, the role and responsibility of school
safety is left unconsidered (Stokes & Kaur, 2005; Stokes
et al., 2007; Walters et al., 2013) in the sex education
curriculum available for adults; covering safety issues is a
significant strength of the HR content.
Limitations
Study results are obtained from a very small sample of
male (only) participants with ASDs that are from the
same class in a single school facility. This limits the extent
to which the results can be generalized to other
adolescents with ASD. Although an ASD diagnosis is
more prevalent among males than females, there may be
significant variation between acquisition and retention of
sexual knowledge that differs across gender, race, and
regional demographics. Of note, the small size of the
sample had the potential to lower the overall power and
increase the likelihood of a Type II error. However, power
in the current study was not compromised, as evidenced
by the large effect sizes.
Future studies should incorporate additional main-
tenance probes beyond 1 month. Individuals with ASDs
regress in their skill development for a variety of reasons,
including (a) learning differences (e.g., failure to rehearse
or encode, memory deficits, emotional dysregulation),
(b) schedule disruptions (e.g., vacations, school breaks,
etc.), (c) difficulty identifying how to generalize learned
skills in new situations (e.g., when social rules must be
slightly modified to apply to different but similar
situations), or (d) when social situations are of little
interest or relevance to the adolescent’s life (Koller, 2000;
Stokes & Kaur, 2005; Travers & Tincani, 2010).
Continuing to assess knowledge retention over time
will improve understanding of the effectiveness of HR
curriculum as well as indicating when booster sessions
would be required. Replication studies are needed to
determine if the learning observed in this sample is
applicable to other samples and settings.
About the authors
Liza Pask, PhD, is a graduate of the School Psychology program
at Duquesne University and is currently completing her post-
doctoral residency assessing and treating children with complex
mental health needs. Her research interests have included
facilitating the healthy sexual development and appropriate
interpersonal interactions of children and adolescents with an
Autism Spectrum Disorder. Other areas of professional interest
include the assessment and intervention of children who present
with social-emotional difficulties and those who have experienced
complex trauma.
Tammy L. Hughes, PhD, is the Chair of the Department of
Counseling, Psychology and Special Education at Duquesne
University. She is a licensed psychologist and certified school
psychologist. Her writing is in the area of child violence,
differentiating emotional disturbance and social maladjustment,
and understanding the relationship between emotional dysregula-
tion and conduct problems in children. Her clinical experience
includes assessment, counseling, and consultation services in
alternative education and juvenile justice settings focusing on
parent – school – interagency treatment planning and integrity
monitoring. She is currently funded by the ASERT Collaborative
through a grant from the Pennsylvania Department of Human
Services, Bureau of Autism Services to train juvenile justice service
providers to address the needs of youth with autism who are
adjudicated delinquent.
Lawrence R. Sutton is a licensed psychologist, employed as a
psychologist working with individuals with autism. Prior to
working with the Bureau of Autism Services, he worked as Chief
Psychologist for the Bureau of Juvenile Justice Services, supervising
psychological services in the 14 sites/Centers. He focused his work
in part on those individuals who had a developmental disability
and who were being housed in the sexual offender programs.
In this work, he attempted to identify service, treatment, and
rehabilitation gaps of adolescents, which may have led to their
involvement in the criminal justice system. He developed methods
to fill some of those gaps by identifying treatment practices both
within the criminal justice system as well as within the community
(to help to prevent the need for criminal justice involvement/
confinement of similar individuals).
References
Boehning, A. (2006). Sex education for students with
disabilities. Law & Disorder, 1(1), 59– 66.
Centers for Disease Control. (2014). Prevalence of autism
spectrum disorder among children aged 8 years—Autism and
8 Developmental Disabilities Monitoring Network, 11 sites,
United States, 2014. Morbidity and Mortality Weekly Report,
63, 1 – 21.
 INTERNATIONAL JOURNAL OF SCHOOL & EDUCATIONAL PSYCHOLOGY
Chan, J., & John, R. M. (2012). Sexuality and sexual health in
children and adolescents with autism. Journal for Nurse
Practitioners, 8(4), 306– 315.
DeMyer, M. K. (1979). Parents and children in autism.
Washington, DC: Winston.
Dewey, M. A., & Everard, M. P. (1974). The near normal
autistic adolescent. Journal of Autism and Childhood
Schizophrenia, 4(4), 348– 356.
Eaves, L. C., & Ho, H. H. (1996). Stability and change in
cognitive and behavioral characteristics of autism through
childhood. Journal of Autism and Developmental Disability,
26(5), 557– 569.
Gabriels, R. L., & Van Bourgondien, M. E. (2007). Sexuality and
autism: Individual, family, and community perspectives and
interventions. In R. Gabriels & D. Hill (Eds.), Growing up
with autism (pp. 58– 72). New York, NY: Guilford Press.
Haffner, D. W. (1995). Facing facts: Sexual health for America’s
adolescents: The report of the National Commission on
Downloaded by [University of California, San Diego] at 02:29 08 March 2016
Adolescent Sexual Health. SIECUS Report, 23(6), 2.
Haracopos, D., & Pedersen, L. (1992). Sexuality and autism:
Danish report. Northamptonshire, United Kingdom: Society
for the Autistically Handicapped.
Hatton, S. & Tector, A. (2010). Sexuality and relationship
education for young people with autistic spectrum disorder:
Curriculum change and staff support. British Journal of
Special Education, 37(2), 69 – 76.
Hellemans, H., Colson, K., Verbracken, C., Vermeiren, R., &
Deboutte, D. (2007). Sexual behaviour in high functioning
male adolescents and young people with Autism Spectrum
Disorder. Journal of Autism and Developmental Disorders, 37,
260 –269.
Hellemans, H., & Deboutte, D. (2002, November). Autism
spectrum disorder and sexuality. Paper presented at the
Inaugural World Autism Congress, Melbourne, Australia.
Hellemans, H., Roeyers, H., Leplae, W., Dewaele, T., &
Deboutte, D. (2010). Sexual behavior in male adolescents and
young adults with autism spectrum disorder and borderline/
mild mental retardation. Sexuality and Disability, 28(2),
93 –104.
Henault, I. (2005). Asperger’s syndrome and sexuality: From
adolescence through adulthood. London, England: Jessica
Kingsley.
Koller, R. (2000). Sexuality and adolescents with autism.
Sexuality and Disability, 18(2), 125 – 135.
Konstantareas, M. M., & Lunsky, Y. J. (1997). Sociosexual
knowledge, experience, attitudes, and interests of individuals
with autistic disorder and developmental delay. Journal of
Autism and Developmental Disorders, 27(4), 397– 413.
McMillan, J. H., & Schumacher, S. (2010). Research in
education: Evidence-based inquiry (7th ed.). New York, NY:
Pearson.
Mandell, D. S., Walrath, C. M., Manteuffel, B., Sgro, G., &
Pinto-Martin, J. A. (2005). The prevalence and correlates of
abuse among children with autism served in comprehensive
community-based mental health settings. Child Abuse &
Neglect, 29(12), 1359 – 1372.
McLane, K. (n.d.). Fact sheet: Benefits of curriculum based
measurement. National Center on Student Progress
9
Monitoring. Retrieved from http://www.studentprogress.
org/family/factsheet.asp
McMillon, J. H., Schumacher, S. (2010). Research in education:
Evidence-based inquiry (7th ed.).
Mehzabin, P., & Stokes, M. A. (2011). Self-assessed sexuality in
young adults with High-Functioning Autism. Research in
Autism Spectrum Disorders, 5(1), 614– 621.
Melone, M. B., & Lettick, A. L. (1985). Sex education at
Benhaven. In E. Schopler & G. B. Mesibov (Eds.), Autism in
adolescents and adults (pp. 169 – 186). New York, NY:
Plenum Press.
Murphy, N. A., & Elias, E. R. (2006). Sexuality of children and
adolescents with developmental disabilities. Pediatrics,
118(1), 398 – 403.
Ousley, O. Y., & Mesibov, G. B. (1991). Sexual attitudes and
knowledge of high-functioning adolescents and adults with
autism. Journal of Autism and Developmental Disorders,
21(4), 471 –481.
Ruble, L. A., & Dalrymple, N. J. (1993). Social/sexual awareness
of persons with autism: A parental perspective. Archives of
Sexual Behavior, 22(3), 229 – 240.
Schopler, E. (1997). Implementation of TEACCH philosophy.
In D. J. Cohen & F. R. Volkmar (Eds.), Handbook of autism
and pervasive developmental disorders (pp. 767 – 795). New
York, NY: Wiley.
Stokes, M., & Kaur, A. (2005). High-functioning autism and
sexuality: A parental perspective. Autism, 9(3), 266 – 289.
Stokes, M., Newton, N., & Kaur, A. (2007). Stalking, and social
and romantic functioning among adolescents and adults with
autism spectrum disorder. Journal of Autism and Develop-
mental Disorders, 37(10), 1969– 1986.
Sullivan, A., & Caterino, L. C. (2008). Addressing the sexuality
and sex education of individuals with autism spectrum
disorders. Education and Treatment of Children, 31(3),
381 – 394.
Sutton & Wesley Spectrum Services. (2013). Healthy
relationships and autism: A guide into adulthood. Pittsburgh,
PA: Author.
Tissot, C. (2009). Establishing a sexual identity: Case studies of
learners with autism and learning difficulties. Autism, 13(6),
551 – 566.
Travers, J., & Tincani, M. (2010). Sexuality education for
individuals with Autism Spectrum Disorders: Critical issues
and decision making guidelines. Education and Training in
Autism and Developmental Disabilities, 45(2), 284– 293.
Van Bourgondien, M. E., Reichle, N. C., & Palmer, A. (1997).
Sexual behavior in adults with autism. Journal of Autism and
Developmental Disorders, 27(2), 113– 125.
Walters, J. B., Hughes, T. L., Sutton, L. R., Marshall, S. N.,
Crothers, L. M., Lehman, C., & Huang, A. (2013).
Maltreatment and depression in adolescent sexual offenders
with an autism spectrum disorder. Journal of Child Sexual
Abuse, 22(1), 72 – 89. http://dx.doi.org/10.1080/10538712.
2013.735357
Wrobel, M. (2003). Taking care of myself: A hygiene, puberty
and personal curriculum for young people with autism.
Arlington, TX: Future Horizons.