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Why Work When You Can Play:

A Literature Review on Theatre-based Interventions for Autism Spectrum Disorder

Few disorders are as complicated or as debated as autism spectrum disorder (ASD). It has

a broad and heterogenous disorder; it has multiple etiologies with a combination of polygenetic

and environmental factors; it’s very nature as a diagnostic category has changed within the last

iteration of the DSM-V (Beauchaine & Hinshaw, 2017). The one fact that everyone seems to

agree on is that ASD manifests largely through social communication impairments. These

impairments often manifest in toddlerhood, during a developmental period in which typically

developing children begin to display signs of joint attention (shared focus with another person on

a stimulus), self-concept, and emotion regulation (Siegler et al., 2020). Any developmental

deficit in these areas leads to cascading effects throughout childhood and adolescence, often

adversely affecting one’s adult life. Early intervention is therefore vital; but it isn’t always

possible due to resource limitations. Also, given the chimeral nature of the disorder, choosing

and implementing an intervention can be daunting.

The National Clearinghouse on Autism Evidence & Practice currently cites 27 different

evidence-based practices and hundreds of non-evidence-based interventions being practiced at

this time (Steinbrenner et al., 2020). Many interventions that have yet to be determined as

evidence-based are not necessarily ineffective interventions but lack rigorous scientific studies to

support their claims of efficacy. Again, this comes down to resources. However, it also has to do

with the difficulty in operationalizing experiments for treatments that are often as heterogenous

as the disorder they hope to help. One such intervention is theatre-based or socio-dramatic play.

This paper will illuminate some of the successes and struggles of theatre-based interventions.

First, I will provide further background on the components of autism spectrum disorder that
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many interventions hope to address. I will briefly discuss the approach taken by some of the

more well-known interventions, before explaining how theatre-based interventions have the

potential to improve upon previous methods. I will then discuss the few experimental studies of

theatre-based interventions, underlining their respective strengths and weaknesses. Finally, I will

discuss future directions for both the research and treatment opportunities in a promising, if

complicated, intervention.

ASD as a Series of Social Skills Deficits

To be diagnosed with ASD according to the DSM-V, one must display at least two

restricted and repetitive behaviors, while also showing evidence of deficits in socio-emotional

reciprocity, nonverbal communication, and relationship development/maintenance (American

Psychiatric Association, 2013). These impairments often appear through a child’s struggles with

joint attention (JA), play behavior, and facial/emotional recognition (Siegler et al., 2020). While

the outward manifestations of such deficits are often obvious through an inability to understand

and respond appropriately to other people’s emotions and actions, the underlying causes can be

less straightforward. Typically, the disorder is seen as a combination of affective and cognitive

deficits.

Prevailing theories tie these communication deficits together under a banner of Theory of

Mind (ToM), meaning the ability to take on the perspective of another person (Baron-Cohen,

1995). A classic measurement of ToM is the false-belief task in which a person must recognize

that another person can believe something even if it is counterfactual. Children with ASD find

this task especially difficult (Siegler et al. 2020). A nativist viewpoint is that an individual with

ASD struggles with ToM tasks due to atypical brain size and activity in areas such as the

prefrontal and temporal cortices, amygdala, and temporoparietal junction; these brain regions
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relate to selective attention, face-recognition, empathy, and interpersonal information processing

(Beauchaine & Hinshaw, 2017). While this theory finds support through brain scans and post-

mortems of individuals with ASD (Arioli et al., 2021; Kennedy & Adolphs, 2012), the question

of whether the differences in brain volume etc. come from genetics or environmental impact

remains unclear. Empiricists argue that ToM deficits come from a dearth of learning

opportunities through interactive experience with other people (Seigler et al., 2020). In reality,

the ToM deficits experienced by children with ASD are probably a combination of both nature

and nurture. Early disruptions in brain activity lead to struggles with social interactions which, in

turn, discourage children from honing social skills through interpersonal interactions. Many

therapies (especially early interventions) aim to disrupt this cycle. Because of the complicated

etiology of ASD as well as its heterogenous nature, most interventions attempt to help through

addressing behavioral issues.

ASD Interventions: How They Can Hurt and Help

The most well-known ASD intervention is Applied Behavioral Analysis (ABA), a

predecessor to the many behavioral therapies on today’s evidence-based practice list. ABA

targets specific skills such as making eye contact or repetitive behaviors such as hand-flapping to

either enforce or extinguish through operant conditioning. The intervention involves long

sessions of exposing a subject to a repeated stimulus, traditionally using both reinforcement and

punishment to train the behavior of children with ASD. The use of punishment is less popular

now, but adults with ASD who received ABA in childhood intervention claim that it was not

only ultimately unhelpful, but abusive. ABA is seen by many in the ASD community as

compliance conditioning or obedience training (Devita-Raeburn, 2020). By targeting an

individual’s behavior alone, ABA often misses an opportunity to address underlying cognitive
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aspects of ASD, making it difficult for the individual to translate progress they made in therapy

to other people or environments. While ABA has been shown to be effective in eliminating or

encouraging certain behaviors, the intervention often struggles to generalize effects outside of

intervention conditions (Sandbank et al., 2020).

Failing to be able to generalize to real-world situations is a problem that many

psychosocial interventions for ASD encounter (Smith et al., 2007). However, a number of

interventions have found ways to overcome this methodological hurdle. In a meta-analysis of

ASD interventions for young children, Sandbank et al. (2020) found the largest positive effect

sizes for Developmental Interventions and Naturalistic Developmental Behavioral Interventions.

While only the latter employs the less punitive social skills training techniques of ABA, both

approaches emphasize Vygotsky’s principle of social interaction as a mechanism for learning

and development (Siegler, 2020). Setting the session in naturalistic contexts and using real life

relationships such as parent-child or child-peer, the interventions produce positive effects for

children with ASD that generalize to people and contexts in every-day life. The two

interventions are also administered almost exclusively through play.

The use of play as intervention technique is not only proven to be effective, but

importantly, creates conditions that allow for more agency on the part of the child. One of the

first points of entry in treating children with ASD is JA. In a systematic review of studies on JA

literature, White et al. (2011) found that the most effective interventions involved play as

primary component. Teaching JA through play provides a naturalistic environment with natural

consequences in which to learn, two key components of generalization. Moreover, White et al.

(2011) point out, the use of play is especially advantageous for children with ASD as play is a

critical part of one’s development of communication skills beyond JA. Finally, play provides the
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opportunity for the child to lead her own treatment, creating intrinsic motivation to learn and

practice social skills (Gupta, 2009). Putting more control in the hands of the child with ASD also

supports a growing need voiced by the ASD community for a neurodiversity conceptualization

of ASD (Sandbank et al., 2020). In accepting that ASD is simply a naturally occurring difference

of how to exist in the world, a play intervention provides opportunities for the child to learn

skills as they choose, rather than training them to comply with specific societal standards.

A study by Kasari et al. (2006) on JA and Symbolic Play (SP) found evidence to support

the integration of symbolic (in addition to functional) play in ASD interventions. Using a sample

of 58 children with ASD, the study randomly assigned participants to either a control group, a JA

behavioral training session, or an intervention involving SP. The researchers found that the SP

intervention was just as effective in teaching the children to initiate and be receptive towards

efforts of JA. Even more exciting, however, was the finding that the SP group improved

significantly more than the JA group in functional play (such as brushing a doll’s hair) and SP

(such as using a block in place of a brush) as well as sophistication of play (mastery level

overall). The study also found that the children were able to generalize treatment outcomes to

interactive play with their mothers at home. These results have encouraged further studies on the

effects of SP in interventions for children with ASD.

Socio-dramatic Play & Theatre-based Interventions

SP may be divided into three subtypes: substitution (eg. a child uses a block as a brush),

agent-directed (eg. a child has a doll brush its own hair), and imaginary (eg. a child brushes the

hair of an imaginary friend). Socio-dramatic play encompasses all three of these play behaviors

with the added component of interpersonal interaction (Siegler et al., 2020; So et al, 2020).

Children with ASD typically struggle with all three forms of SP and rarely participate in, let
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alone initiate socio-dramatic play. This play deficit has shown to be predictive of further deficits

in ToM, language development, social communication, and interpersonal relationships (Baron-

Cohen, 1995). Theatre, by naturally addressing aspects of these issues, seems to contain all the

components for an effective ASD intervention. Theatre encourages interpersonal communication

on a verbal and nonverbal level. It requires rehearsal of such skills in a controlled, but

naturalistic environment. Theatre exercises an individual’s empathy and understanding of

multiple perspectives. It also revolves around imaginary circumstances (while clearly

delineating the difference between reality and fiction). Importantly, theatre puts ownership of the

process in the hands of the participants and creates intrinsic motivation through its reliance on

play. Finally, theatre requires the formation of relationships through creation of ensemble (Gallo-

Lopez, 2012; Gupta, 2009). It’s no surprise, then, that several researchers have begun to

investigate the effect of socio-dramatic or theatre-based interventions on the ASD population.

Research on theatre-based interventions for ASD, while small in number, takes many

forms. From single case studies to random controlled trials (RCTs), from qualitative to

quantitative measures, from a focus on specific skills-training to the performance of a full play,

the ways in which researchers choose to operationalize theatre-based intervention research is

heterogenous to say the least. In the following section, I will first discuss the studies addressing

cognitive aspects of ASD. Next, I will examine the studies that measured behavioral indicators of

social comprehension. Finally, I will mention a third category of measurement loosely defined as

emotional well-being of child and family.

Social Knowledge: Cognitive Effects of Theatre-based Interventions

Development of ToM, which encompasses the cognitive aspects of social

communication, in a child typically follows in this order: 1) the ability to initiate, receive, and
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maintain joint attention, 2) the understanding that other people act on what they want, 3) the

understanding that other people have diverse beliefs, 4) the understanding that those beliefs may

be counter to reality, and 5) the understanding that a person’s desires and beliefs may not always

be readily perceivable through what they say or do (Baron-Cohen, 1995). Conceptually, this is a

very clear break-down of the growth of social comprehension; however, measuring such

concepts is not nearly as straightforward. Because of ToM’s many components, there are many

ways to measure it, some of which are discussed below.

A study by Goldstein & Winner (2012) on neurotypical populations has shown a clear

connection between acting experience and improved empathy and Theory of Mind. Though the

study does not focus on an intervention for the ASD population, it indicates the potential

effectiveness of theatre as intervention for cognitive-perceptual aspects of social deficits. In two

studies of different age groups (9 year-olds and 14 year-olds, respectively), the study examined

effects of a year-long acting program (involving improv games, character analysis, scene studies,

and physical activities) on children’s empathy and ToM. At the completion of the program,

researchers measured ToM and empathy through a series of established and novel tasks. The

study found significant improvement in empathy, but not ToM for the 9 year-old group;

however, it found significant improvement in both empathy and ToM for the 14 year-old group.

These results indicate potential age-related differences in a neurotypical individual’s ability to

improve empathy and ToM through acting. Moreover, they imply a potential for individuals at a

lower social-developmental level to increase empathic abilities, if not also ToM. It’s important to

note that the study was analyzing effects of a preexisting school program and not an intervention

of their own design. To compensate, researchers observed and coded the classes for content

material. They found ToM was addressed more explicitly than empathy in classes for the 14
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year-old group, suggesting that ToM may need to be more explicitly taught for younger (or less

socially-developed) populations.

While empathy and ToM are important components of social comprehension, they are

difficult to measure. This poses a clear hurdle for researchers hoping to assess the validity of

interventions for ASD. One established measure that has demonstrated sensitivity with children

with ASD is the DANVA2, a computer-based objective measure of nonverbal cue reading. Two

studies that have made use of this measure are Lerner, Mikami, Levine (2011) and Guli et al.

(2012). Lerner, Mikami & Levine tested a performance-based social skills curriculum that

utilized improv games and dramatic exercises against a waitlisted control group. While not

randomized, the study did ensure the control group was demographically matched. The study

found a significant difference between groups in the intervention group’s ability to detect

emotional cues in adult voices, but not in other measures of nonverbal cue reading. Guli et al.

(2012) also used the DANVA2 to measure effects of a similar theatre-based intervention on a

mixed population of children diagnosed with ASD, NLD, and/or ADHD. This study did not find

a significant difference in the intervention group’s ability to recognize nonverbal cues; however,

it did find significant effects across a number of behavioral measures, discussed in detail in the

following section. The discrepancy between significant effects in behavioral versus cognitive

measures may indicate the inability of certain cognitive measures to accurately capture change in

a child’s cognition. For instance, a computer-based test employing static pictures of faces is a

poor approximation of the flurry of emotional cues one receives from a person actively

communicating in real time.

A perhaps more easily measured component of social comprehension is face and emotion

recognition. These are commonly measured in ASD interventions through NEPSY subtests
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called Memory of Faces and ToM, respectively (Corbett et al., 2019). These two tests were used

in Corbett et al. (2016) and Corbett et al. (2019). Both studies were of the same peer-mediated

theatre-based intervention for children with ASD and both found a significant positive effect for

the face and emotion recognition tasks in the intervention versus the control group. The studies

also supported their findings through EEG scans of participants during a separate face-

recognition activity. The studies found heightened neural activity in children from the

intervention group during the activity compared to the control. Baseline EEG’s indicated

quantifiable deficits in children with ASD for face recognition and posttest EEG’s illustrated the

interventions ability to improve said deficits.

Social Performance: Behavioral Effects of Theatre-based Interventions

While arguably less quantifiable than cognitive measures due to their reliance on self and

parent-reports, behavioral analyses of theatre-based interventions show robust treatment effects.

Most of the studies previously mentioned employed measures of behavioral outcomes to some

degree. For instance, Lerner, Mikami & Levine (2011) relied on both a parent report on their

child’s nonverbal communication skills as well as a parent report on their child’s social

impairment. Using these measures, the study found that the children in the intervention improved

significantly in increased social assertion as well as decreased social problems. In a follow-up

analysis 6 weeks post-treatment, those effects were maintained. Using post-hoc analyses, the

study was able to confirm the observed maintenance was associated with change during the

intervention. It should be noted, however, that this intervention was a part of an established

summer program and, as such, was not provided for free to participants. Positive parental reports,

therefore, may reflect their desire to see a return on investment as much as indicate true

behavioral changes.
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Lerner & Mikami (2012) conducted a follow up study comparing the effects of the

aforementioned summer program to a more didactic skills-training program. The use of a

comparison intervention in addition to a control group is useful for beginning to establish

specific mechanisms of change in an intervention (Smith et al., 2007). This study used

exclusively behavioral measures and improved upon the previous study’s methods by measuring

behavior throughout the intervention and by enlisting feedback from the children’s teachers. The

study found that both the theatre-based and direct skills-training interventions led to significantly

improved social skills. However, the theatre-based intervention produced effects almost

immediately, whereas the social skills group took longer to warm up. In terms of time and

financial resources allocated to interventions, this study indicates increased feasibility for the

theatre-based intervention as it appears to work faster (Smith et al., 2007).

Another study that employed both cognitive and behavioral measures is Guli et al.

(2012). While the study did not find significant results according to the DANVA2 cognitive

measures, it found significant effects in social functioning that generalized to other environments

and people. Interestingly, the behavioral assessments that were measured on a scale did not

produce significant effects, whereas the observed and coded behavioral reports did. This may

indicate that the scaled measures of cognitive and behavioral change lack sensitivity to social

behavioral nuances that are more readily caught by observers in situ. This study involved

children with social difficulties not limited to just a diagnosis of ASD. However, the majority of

participants in the study had received a prior ASD diagnosis and the study’s inclusion criteria

required proof of social competence difficulties through scores on the SSRS (a widely used

parent-report measure employed by many ASD interventions). Also, the inclusion of participants
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with comorbidity diagnoses may actually get closer to generalizability, as real-world ASD and

ADHD populations overlap considerably (Beauchaine & Hinshaw, 2017; Guli et al., 2012).

Of the many studies mentioned already, the most comprehensive in terms of number and

variability of measures are those of Corbett et al. (2016) and Corbett et al. (2019). Not only did

the studies assess cognitive and neural outcomes of their theatre-based intervention, but they also

included a battery of behavioral measures, including multiple parent reports and coded

observations. Combined findings included significantly increased social communication

(especially in cooperative play and verbal interactions) for the intervention versus control group

that generalized to other environments and were maintained 2 months post-treatment. These

findings are especially exciting as the 2019 study was the largest sample size of any study found

yet. Also, the parents did not pay for the theatre-based intervention and, thus, were less likely to

inflate perceived effectiveness.

Another study that builds on the findings of Corbett et al. (2016), is that of Ioannou et al.

(2020). Using the same theatre-based intervention, the study found a significant increase

compared to a control group in group play behavior as observed through a natural play paradigm

that innovatively uses age-matched peers as confederates. This finding is indicates theatre-based

interventions’ ability to generalize to peers outside of the intervention program and illustrates the

potential effectiveness of a trained peer-mediated program in heightening reading and response

to nonverbal cues coming from individuals other than adults. This study also measured comorbid

conditions that will be elaborated on in the following section.

Perhaps the most innovative and certainly most interesting study on theatre-based

interventions has come out of Hong Kong. So et al. (2020) also measured intervention effects on

play behaviors but took a page from Kasari et al. (2006) in juxtaposing play behavior with
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measure of JA. The most unique aspect of the study, however, lies in the method of

administering the intervention. They used robots. Specifically, the study employed two NAO

(Aldebaran Robotics Company) robots that are widely used in autism interventions (So et al.,

2020) to perform 3 scripted short dramas of varying realism and familiarity for participants. In

using robots, So et al. (2020) were able to sidestep the often confounding factor of human

variability in administering interventions. Whereas other interventions and studies must rely on

human (and thus variable) researchers to model and respond to children during theatre activities,

robots provide a consistent and reliable series of performances and interactions. This may sound

disconcerting on the outside (and certainly has implications for generalizability to human-human

interactions), but studies have found that children with ASD often prefer the lower stimulus level

afforded by robots. The study also used human experimenters to take part in role-play scenarios

related to the 3 previous dramas enacted by robots. So et al. (2020) found that children receiving

the intervention as opposed to the control group increased significantly in functional play and SP

as well as JA. Interestingly, when comparing the roleplay with robots to the roleplay with human

experimenters, researchers found a significant increase in gestures used and decrease in prompts

required for the human experimenters. Effects also seemed to generalize as the differences in

play behavior and join attention were measured 1 month post treatment and involved human

experimenters. This indicates that the use of robot-based interventions may increase social

behaviors, if not necessarily affect underlying cognitive processes.

Social Feelings & Impressions: Emotional Effects of Theatre-based Interventions

Ironically, many studies of ASD -a disorder based in the struggle to understand others’

emotions- do not study the emotional states of their participants. While this seems like an

obvious oversight, it is understandable, as reading the emotions of a child with ASD can be
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particularly difficult. Some studies, however, have attempted to get at this important question

through parent and child questionnaires and interviews.

Perhaps because of theatre’s immediate emphasis on emotion and empathy, many of the

theatre-based interventions have endeavored to measure the emotional well-being of participants.

Lerner, Mikami & Levine (2011), Lerner & Mikami (2012), Guli et al. (2019), and So et al.

(2020) all employed post-treatment parent and child-reports in an attempt to elicit such

information. All studies found enthusiastic and positive responses to the interventions, indicating

that parents not only observed post-treatment effects on social comprehension, but also on

overall positive mood changes in their children mid and post-treatment. Participants, themselves,

reported positive change in emotional well-being with comments like the following from Guli et

al. (2012): “I’m a bit calmer. I can understand people now. I have a social life now,” and “I

learned that I could handle myself a lot better than I thought I could” (p. 42). Two studies

(Lerner, Mikami & Levine, 2011; Ioannou et al., 2020) directly addressed depression and anxiety

through CBCL and STAIC self-reports. While Lerner, Mikami & Levine found no significant

change in depressive symptoms post-intervention, Ioannou et al. (2020) reported significant

decreases in trait anxiety post-treatment. These improvements in emotional well-being and self-

esteem may seem insignificant in comparison to the more targeted behavioral changes, however

they are important indicators of protective factors that could improve outcomes for these children

later in life (Beauchaine & Hinshaw, 2017). Also, participants who enjoy the intervention are

much more likely to continue it, thus preventing against recidivism, a common problem for

intervention studies (Smith et al., 2007; Sandbank et al., 2020). Participants are more likely to

form the motivation to practice acquired skills outside intervention conditions when the form of

learning is fun (Gupta, 2009). Finally, struggles with mood and internalizing behaviors are
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exceedingly common for children with ASD (Beauchaine & Hinshaw, 2017). Therefore, any

intervention that can address comorbid conditions such as depression or anxiety in the

participants is worth a second look.

Future Directions

While many of the results from the aforementioned studies are promising, they must be

taken with a grain of salt. Most studies addressed in this literature review had very small sample

sizes (the largest being 77 children) as well as homogonous participant pools (primarily

Caucasian males). Also, many studies differed in administration of the interventions both in

terms of duration of treatment as well as content covered. Next, as shown above, there are many

different forms of measurement used, not all of which have established validity. Finally, the

study designs often lacked a comparable intervention and, if they did have a control group, were

typically unable to randomize participants. These are all significant blows to the integrity of the

results. However, the potential benefits of an intervention that may be administered over a

relatively short period of time by practitioners aside from certified therapists and that show

promise for generalizability and maintenance through their use of naturalistic play are difficult to

ignore.

Aside from addressing the clear research-related issues in theatre-based interventions,

there are also several factors to consider in formulating future interventions. The majority of the

studies on socio-dramatic play were on high-functioning children in ages ranging from middle to

high school. It will be important moving forward to assess if and how interventions may help

younger and lower-functioning children with ASD. The Vygotskyian concept of scaffolding may

be especially important in this regard (Siegler et al, 2020).

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Overall, theatre-based interventions are a promising new approach to helping children

with ASD develop skills that they may apply as they choose to everyday social interaction.

Rather than directly training children in set behaviors, theatre-based interventions provide

children with opportunities to experiment, and practice set skills in a variety of circumstances, all

the while allowing and encouraging children to play.

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