APROXIMACIÓN A LA REALIDAD DE LAS VÍCTIMAS DE LA VIOLENCIA

between imagination and RRB. Several researchers have argued for the existence of a relationship between generativity and RRBs, and between imagination and RRBs (e.g. Hanson & Atance, 2013). Indeed, it has been suggested that executive dysfunction, such as generativity and inhibition, are the cause of RRBs; although the evidence for this is mixed (e.g. Leekam et al., 2011). Generativity is particularly relevant here as I have identified it is a key component of imagination, although they are not

synonymous. Generally, it is argued that there is a negative relationship between imagination and RRBs, in that imaginative difficulty results in high rates of RRBs. Early observations of autistic children noted the limited behavioural repertoires coupled with lack of spontaneous imaginative activity (Wing & Gould, 1979). Turner (1999b) later drew a more direct link between high rates of RRBs and dislike of change in autistic children with difficulty in spontaneously generating novel ideas and behaviours. Happé (1999) noted that children with ASD tended to engage in obsessive, repetitive sensory and motor actions with toys and objects rather than playing pretend; she argued that these obsessive rituals give way to obsessional interests in autistic adults. As such a link was made between a lack of early pretend play and restricted interests in both childhood and adulthood. Similarly, Boucher (2007) argued that difficulty with memory results in difficulty with generativity and imagination, which in turn leads to a reliance on routines. Furthermore the majority of this work suggests that it is specifically the routines, rituals and restricted interests of autistic people that is related to imagination. This suggests that this relationship is specific to IS rather than RSMBs; although Happé’s (1999) suggestion that RSMBs

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replace pretend play suggests some degree of relationship between imagination and RSMBs. Regardless, this relationship has received very little empirical attention (Honey et al., 2007; Leekam et al., 2011). In typical populations, there is little evidence related to this relationship; although Kloosterman, Keefer, Kelley, Summerfeldt, and Parker (2011) noted that imagination as measured by the AQ correlated with

communication/mindreading abilities but not resistance to change in an undergraduate NT population.

Honey et al. (2007) compared RRB, play and communication in children with and without ASD aged between two and eight years old. They examined these using the Activities and Play Questionnaire Revised, an original parental questionnaire based on the RBQ and DISCO, which assesses RRB and play behaviours (including symbolic play) in children. Although there were two age groups for both TD and ASD children, the older TD children were excluded as their language reached ceiling level, and the ASD groups were collapsed into one due to a lack of variation in language ability. For children with ASD, there was a significant negative correlation between total RRB and total play, and both expressive language and RRB significantly predicted play.

However, for the TD children RRB was not a significant predictor, nor did it correlate with play; the latter was only predicted by expressive language. The authors

interpreted this as a three-way relationship between RRB, imagination and communication specific to ASD.

This finding lends some support to the argument that difficulties with

imagination are reflected by excessive RRB. However, Honey et al.’s (2007) results also support the placement of imagination with communication in the DSM; a three-way relationship is difficult to reconcile with the distinction between RRBs and social interaction/communication, although these two are somewhat related. It may be that imagination is related to both but this association is stronger with either RRBs or communication. The finding that expressive language predicts play in TD children supports Kloosterman et al.’s (2011) later finding that imagination and

communication/mindreading are associated in a large NT population (N=222). There are some limitations to Honey et al.’s (2007) work. Most notable is the fact that different types of play and sub-types of RRB were not separately measured and

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analysed. The different sub-types of RRBs may associate markedly differently with other variables, such as age and IQ (e.g. Militerni et al., 2002; Richler et al., 2010; Moore & Goodson, 2003). In terms of imagination, this is especially important given that it is specifically symbolic play which is thought to be an indicator of imagination, and these findings assess all play behaviours but have been interpreted in terms of imagination. Honey et al. also used a questionnaire to assess play and RRB, which has inherent limitations, and just two DISCO questions to measure language. In addition, there was also no information about specific ASD diagnosis or symptom severity for the participants. Nevertheless these findings provide preliminary evidence of the relationship between imagination and RRB, which may be expanded by using more detailed measures of both RRB and imagination.

A later study (Harrop et al., 2014) of TD and autistic children (aged between two and five years) assessed the developmental trajectory of RSMBs, measured observationally by coding the frequency of RSMBs in a free play session; however, the authors also assessed correlations between the ADOS algorithm measures and

frequency of RSMBs at the first time point. Harrop et al. found a significant positive association between frequency of observed RSMBs and the ADOS-G imagination algorithm, which is primarily based on a structured play scenario as well as free play. As higher scores on the ADOS indicate more difficulties with imagination, this indicates that a higher level of RSMBs was associated with more imagination difficulties,

supporting the findings of Honey et al. and demonstrating convergence across different methods while having the advantage of confirmed diagnoses of ASD for all the participants. Harrop et al.’s finding also supports the suggestion by Happé (1999) that RSMBs may replace pretend play in autistic children. This observational study specifically measured only RSMBs, and while an association was found, it is not possible for this method to assess IS behaviours. The study also focused on younger children who mostly engage in RSMBs rather than IS (e.g. Militerni et al., 2002; Moore & Goodson, 2003).

Several studies have examined the relationship between generativity – as measured by fluency tasks - and RRB (Turner, 1997; Bishop & Norbury, 2005; Dichter et al., 2009). Although generativity is just one aspect of imagination, and fluency tasks

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have their methodological flaws, these studies may provide some insight into the relationship between imagination and RRBs. Turner (1997)6 _{assessed four groups of}

individuals (ASD, ASD with LD, LD only and non-ASD clinical control participants7_{) using}

the UOT, PMT, a design fluency task and the RBI. A significant negative association was observed between performances on both ideational fluency tasks with sameness behaviour and CI for both ASD groups, but not for the clinical control groups. This was supported by median split comparisons; autistic individuals who produced few novel responses on the UOT showed significantly more extreme sameness behaviour and CI. Importantly, there were no significant correlations between ideational fluency and stereotyped movements or repetitive use of language, suggesting that generativity is only associated with certain sub-categories of RRB, which are equivalent to IS. Performance on design fluency tasks was also related to CI. This study is somewhat limited by the large age range of participants (between six and thirty-two years) within relatively small group sizes (N=21/22). Moreover, an online study of ASD traits and divergent thinking reported a significant negative correlation between fluency score on the PMT test and the rigidity subscale of the SATQ (Best et al., 2015). However, they did not find a relationship between rigidity and the Alternate Uses task, and their sample included both NT and autistic participants.

Turner’s (1997) findings have not always been replicated. Bishop and Norbury (2005) compared children with different language impairments with children with ASD. In particular, children with pragmatic language impairment share some of the

communicative difficulties of children with an ASD but fewer social difficulties and fewer RRB. Bishop and Norbury found that children with pragmatic language impairment performed at the same level on the UOT and PMT as children with ASD; they interpreted this to mean that the poor performance on fluency tasks was not due to RRB. Furthermore, generativity (percentage correct) on both tasks was significantly related to the pragmatic language composite (measured by the Children's

Communication Checklist; Bishop, 1998) and the ADOS communication scale, but not

6 _{NB Participants performance on these fluency tasks were also reported later by Turner (1999b), but}

the latter paper did not include the RRB results.

7 _{These were participants referred to psychiatry services for reasons other than ASD, including}

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RRB. Bishop and Norbury treat their own results with caution as they did not use a complex measure of RRB, which was assessed using the ADOS and the Social

Communication Questionnaire (Berument, Rutter, Lord, Pickles & Bailey, 1999), and did not distinguish sub-categories of RRB which may have masked any relationships. Finally, levels of RRB were generally low, even within the ASD group. Dichter et al. (2009) assessed ASD and TD children using an Animals Fluency task, UOT, the

Children’s Communication Checklist and the RBS-R. When controlling for non-verbal intelligence, there were significant relationships between communication and the number of total and correct responses on the Animal Fluency task for participants with ASD but not TD participants. In contrast to Turner’s (1997) findings, there was no significant correlation between measures of generativity and RRB or its sub-scales. Dichter et al. argue these findings support those of Bishop and Norbury (2005) while using a more detailed measure of RRB. These findings are not entirely consistent however, as UOT was not significantly related to communication. In another domain of imagination, Lind et al. (2014) did not find evidence of a significant relationship between EFT and RBS-R total scores; although they did not report correlations from the subscales.

The studies considered thus far have looked at generativity, the frequency of different play behaviours (Honey et al., 2007) and the imagination algorithm from the ADOS (Harrop et al., 2014). Therefore this research has focused only on the fluency aspect of imagination rather than other aspects such originality, flexibility and elaboration; although fluency is important to imagination, it is just one component according to my definition of imagination (page 12). Liu et al. (2011; see page 27) measured these dimensions in boys with AS and found that they scored significantly higher than matched TD boys in terms of originality and elaboration. The authors noted that boys with AS tended to draw pictures within idiosyncratic restricted interests; for example one child was interested in biology so only drew microscopic organisms such as dust mites, viruses and bacteria. Liu et al. suggested that the tendency to draw within unusual special interests contributed to the ASD group’s significantly higher score on originality compared to the TD group. Conversely, this also may have negatively affected their flexibility score, as it reduced the number of

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categories that the ASD group used. This pattern of findings illustrates how RRB - in this case CI – could both positively and negatively affect imagination. Unfortunately Liu et al. did not include a measure of RRBs so this relationship cannot be evaluated from these results. However, the suggested relationship between restricted interests and originality contrasts with the more common hypothesis that imagination and RRBs are negatively associated in ASD. Therefore Liu et al.’s study highlights the importance of considering different types of imagination, such as originality, as they may be

differentially associated with RRBs in ASD. In a similar vein, some previous research has indicated a positive relationship between the level of RRBs and the presence of “savant” skills or special talents in both ASD and non-ASD populations (e.g. Lyons & Fitzgerald, 2013; O’Connor & Hermelin, 1991; Vital, Ronald, Wallace & Happé, 2009), although it should be noted that such abilities are not always creative.

A related issue is how the different subtypes of RRBs are associated with imagination. Two of the above studies examined the relationship between

imagination (as measured by generativity or play) and RRBs without taking subtypes into account (Bishop & Norbury, 2005; Honey et al., 2007). When there is evidence that a construct is multi-dimensional, it is misleading to only assess a composite of said construct, as this obscures which dimension accounts for any effects (Briggs & Cheek, 1986; Strauss & Smith, 2009). As described in section 1.2.3 (page 42), there is

evidence that RRBs divide into at least two subtypes, RSMB and IS. There is scarce empirical evidence showing how the subtypes of RRBs relate to imaginative ability. Only two studies to my knowledge have assessed a full range of RRB subtypes, and these only measured generativity rather the whole construct of imagination (Dichter et al., 2009; Turner, 1997).

Turner (1997) identified significant relationships between generativity and sameness and CI, but not stereotyped movements. This supports the hypothesis that relationship between RRBs and imagination is specific to IS. Similarly, Best et al. (2015) found a significant association between one of their creativity measures and the rigidity subscale of the SATQ. However, the rigidity subscale of the SATQ is the only subscale that corresponds to RRBs and does not include any RSMBs and so no conclusions can be drawn from this study about the specificity of the relationship. It

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should be noted that Harrop et al. (2014) investigated RSMBs in ASD and discovered a significant positive association with imagination on the ADOS, although the authors did not test IS. In contrast, Dichter et al. (2009) found no association between any RRB subscale and generativity. This inconsistency may be partially explained by the fact that the sub-grouping of RRBs varies across measures (see Appendix 2, Table 8.2, page 243). Given the existing conflicting evidence, it is important to consider the different subtypes of RRBs when investigating the relationship between RRB and imagination. Theoretically, it is specifically IS that drives the potential relationship between imagination and RRBs rather than RSMBs; this is supported by evidence from Turner and Best et al. This is not supported by the finding that RSMBs are also related to imagination (Harrop et al., 2014). Turner’s participants were aged from six to thirty- two and Best et al.’s participants were all adults, whereas the children in Harrop et al.’s study were aged from two to five years. As Happé (1999) argued, pretend play is replaced by RSMBs that may become obsessive rituals, and in adults this may be replaced by restricted interests. Therefore in younger children the relationship with imagination may be driven by RSMBs, and in older children and adults it may be driven by IS.

1.3.1 Conclusion: Imagination and RRB

In summary, the precise nature of the relationship between RRB and

imagination in ASD has not been definitively established. The empirical evidence is equivocal; there is some evidence that related constructs – generativity and play – are indeed associated with RRB (Best et al., 2015; Harrop et al., 2014; Honey et al., 2007; Turner, 1997); however, this is not a consistent association (Bishop & Norbury, 2005; Dichter et al., 2009). There is some evidence that this relationship is specific to IS (Turner, 1997), although this is not definitive (e.g. Harrop et al. [2014] found a

relationship between imagination and RSMBs). Furthermore, there is some evidence that imagination is related instead to communication (Dichter et al., 2009; Honey et al., 2007; Kloosterman et al., 2013), reflecting the placement of imagination in

international diagnostic manuals. Part of the difficulty in establishing this relationship lies within methodological issues, particularly in terms of assessing subtypes of both constructs. So far, most of the studies have focussed on fluency and generativity,

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rather than other aspects of imagination such as originality and flexibility and

researchers do not always take into account the different sub-types of RRB. Therefore the potential relationships between imagination and RRB may be ‘masked’ by using composites of variables. This issue is exacerbated by the fact that the imagination literature is relatively underdeveloped and has not satisfactorily established whether or not imagination is a multi-dimensional construct. Little consideration has also been given to the potential positive effects of RRBs on imagination, in particular restricted interests (e.g. Liu et al., 2011; Vital et al., 2009). Importantly for this thesis, only two out of the six studies investigating this relationship in ASD included adults (Best et al., 2015; Turner, 1997). Furthermore, what we can conclude from these studies in terms of the relationship between imagination and RRB in autistic adults is limited by the fact Best et al. did not separate out ASD participants from NT participants in their analyses, and Turner tested generativity only. Therefore the relationship between RRBs and imagination has yet to be fully explored in an adult ASD population.