AN EXAMINATION OF EMPATHY AND SOCIAL OUTCOMES FOR INDIVIDUALS WITH INTELLECTUAL AND DEVELOPMENTAL DISABILITIES By Cynde Katherine Josol A DISSERTATION Submitted to Michigan State University in partial fulfillment of the requirements for the degree of Special Education–Doctor of Philosophy 2022 ABSTRACT AN EXAMINATION OF EMPATHY AND SOCIAL OUTCOMES FOR INDIVIDUALS WITH INTELLECTUAL AND DEVELOPMENTAL DISABILITIES By Cynde Katherine Josol Empathy is generally described as a multidimensional construct, consisting of cognitive and affective components. Researchers demonstrate that a better ability to understand and express empathy toward others is associated with positive social outcomes such as strong communication skills and meaningful social relationships. For individuals with intellectual and developmental disabilities (IDD), the understanding and expression of empathy and its various components can be challenging. However, different etiologies can elucidate various strengths and weaknesses related to empathy. Given empathy’s critical role in various social domains and potential differences in empathy skills and social outcomes across different IDD groups, the purpose of this dissertation is to expand the current literature on empathy for three distinct and unique IDD groups to better inform current and future interventions. This dissertation consists of three independent, but related manuscripts presented in journal submission format. The first study was a systematic literature review of 169 studies conducted to identify the current research on empathy skills and social outcomes for individuals with autism spectrum disorder (ASD), Williams syndrome (WS), and Down syndrome (DS). Overall, the results of the systematic literature review indicate that individuals with ASD experience poorer empathy skills and these deficits relate to poor social skills. Further, there is a lack of research on empathy for other IDD conditions (e.g., WS and DS) and in relation to other social domains (e.g., social skills). As such, the second study examined the specific relationship of empathy and social skills for individuals with ASD, WS, and DS and examined for differences across groups and compared to a typically developing (TD) control group. The final sample (N = 120) included 30 students diagnosed with ASD (mean age = 10.73 years) and their caregivers, 30 students diagnosed with WS (mean age = 12.07 years) and their caregivers, 30 students with DS (mean age = 11.53 years) and their caregivers, and 30 TD students (mean age = 10.90 years) and their caregivers. Results demonstrate that, according to parent reports, students with ASD present with lower empathy skills compared to students with WS and DS and to students without disabilities. Differences between groups were also demonstrated regarding the relationship between empathy skills and social skills. More specifically, for students with WS, lower empathy skills were not significantly correlated with social motivation. The results of Chapter 3 highlight that differences in empathy and social skills should be accounted for in empathy-related interventions and underscore the importance of developing etiology-specific interventions. In response to the importance of developing interventions that account for the student’s disability, the third manuscript was written to guide special educators in addressing empathy skills for students with ASD. When assessing empathy skills, it is crucial that special educators obtain accounts from multiple informants including parent- and teacher-reports. The use of multiple sources will provide both a general picture of a student’s empathy skills along with information for specific areas of concern. Other general considerations for empathy assessment and intervention include incorporating elements of cognitive and affective empathy during assessment, adopting a developmental framework to guide both short term and long-term goals, and identifying additional social skills deficits to target prior to or during the empathy intervention, if applicable. ACKNOWLEDGEMENTS First, I would like to sincerely thank my PhD advisor and chair of my dissertation committee, Dr. Marisa Fisher. Over the past five years, she has provided thoughtful feedback and direction as I navigated my doctoral program through a pandemic- no less with kindness and grace. I could not have asked for a better advisor! I would also like to thank my dissertation committee members including Dr. Emily Bouck, Dr. Eunsoo Cho, Dr. Catherine Emily Durbin, and Dr. Marie Moore Channell. I was able to complete my dissertation due to their understanding and expertise throughout the entire process. I would also like to thank my parents, Crispa and Mario Josol, for their endless love and support. The decision to move across the country away from family and friends was not easy but thank you for all the encouragement in my moments of self-doubt and sending me Filipino food whenever I got home sick. Thank you to my siblings as well for coming to visit me, especially during the holidays so it would be a little less lonely. To all the friends I made in Michigan, I am so grateful to have met each and every one of you. The little family we created together will always be a source of happy memories and wild stories for me! To my friends in California, thank you for continuing to be supportive even with the time difference and distance. It meant so much to me that I was able to come home to wonderful friends during break. Finally, I would like to thank everyone involved in the completion of all three studies of my dissertation. Thank you to all the families and youth who participated in my study, especially in the midst of the pandemic. I could not be more grateful! A special shoutout as well to Katie Cwiakala, Emilie Cwiakala, and Eliza Guernsey for so graciously volunteering over their winter and summer breaks to help me review over 4000 articles for my dissertation. I could have not finished my very large literature review without you. iv TABLE OF CONTENTS LIST OF TABLES ........................................................................................................................ vii LIST OF FIGURES ..................................................................................................................... viii KEY TO ABBREVIATIONS ........................................................................................................ ix CHAPTER 1 ................................................................................................................................... 1 The State of Empathy in Individuals with Intellectual and Developmental Disabilities ............ 1 Empathy in ASD ..................................................................................................................... 2 Empathy in WS ....................................................................................................................... 3 Empathy in DS ........................................................................................................................ 4 Empathy and Social Outcomes ............................................................................................... 6 Assessment and Measurement of Empathy ............................................................................ 7 Interventions Addressing Empathy Deficits ........................................................................... 8 Purpose of Current Dissertation .............................................................................................. 9 Chapter 2: Empathy Systematic Literature Review .............................................................. 10 Chapter 3: Comparing Empathy and Social Skills across Individuals with ASD, WS, and DS ......................................................................................................................................... 10 Chapter 4: Development of Individualized Interventions ..................................................... 11 Chapter 5: Discussion ........................................................................................................... 11 REFERENCES ......................................................................................................................... 12 CHAPTER 2 ................................................................................................................................. 21 Empathy and Social Outcomes for Individuals with Intellectual and Developmental Disabilities: A Systematic Literature Review ........................................................................... 21 Social Outcomes for ASD ..................................................................................................... 21 Social Outcomes for WS ....................................................................................................... 22 Social Outcomes of DS ......................................................................................................... 22 The Role of Empathy in Social Outcomes ............................................................................ 23 Empathy as a Facilitator of Friendship Development........................................................... 23 Measurement and Assessment of Empathy .......................................................................... 24 Purpose of Current Study ...................................................................................................... 24 Method ...................................................................................................................................... 25 Information Sources and Search Strategy ............................................................................. 25 Study Selection ..................................................................................................................... 26 Data Extraction and Synthesis .............................................................................................. 27 Results ....................................................................................................................................... 28 General Study Characteristics ............................................................................................... 29 Research Question 1: Definition and Measurement of Empathy .......................................... 30 Research Question 2: Reported Empathy Skills ................................................................... 32 Research Question 3: Reported Social Outcomes ................................................................ 34 Research Question 4: Relationship between Empathy and Social Outcomes ...................... 35 Discussion ................................................................................................................................. 35 v Limitations ............................................................................................................................ 39 Future Directions .................................................................................................................. 40 APPENDICES .......................................................................................................................... 42 Appendix A Data Extraction Form for Reviewing Full-Text Articles ................................. 43 Appendix B Table 2: Overview of Studies Examining Empathy and Social Outcomes for Individuals with Intellectual and Developmental Disabilities .............................................. 64 REFERENCES ......................................................................................................................... 99 CHAPTER 3 ............................................................................................................................... 124 Exploring The Relationship between Empathy and Social Skills for Individuals with Different Forms of Intellectual and Developmental Disabilities............................................................ 124 Purpose of Current Study .................................................................................................... 127 Method .................................................................................................................................... 127 Sample................................................................................................................................. 127 Measures ............................................................................................................................. 130 Procedures ........................................................................................................................... 132 Data Analysis ...................................................................................................................... 133 Results ..................................................................................................................................... 133 Preliminary Analyses .......................................................................................................... 133 Group Differences in Empathy and Social Skills ............................................................... 134 Relationship between Empathy and Social Skills Across Groups ...................................... 136 Discussion ............................................................................................................................... 145 Differences in Empathy Skills ............................................................................................ 145 Relationship between Empathy and Social Skills ............................................................... 146 Limitations .......................................................................................................................... 147 Future Directions ................................................................................................................ 148 REFERENCES ....................................................................................................................... 151 CHAPTER 4 ............................................................................................................................... 158 Improving the Empathy of Students with Autism Spectrum Disorder: Suggestions & Guidelines ............................................................................................................................... 158 The Importance of Empathy ............................................................................................... 158 Empathy Skills of Students with ASD ................................................................................ 159 Specific Guidelines and Suggestions .................................................................................. 161 General Considerations ....................................................................................................... 166 Final Thoughts .................................................................................................................... 168 REFERENCES ....................................................................................................................... 169 CHAPTER 5 ............................................................................................................................... 174 The Importance of Empathy for Individuals with Intellectual and Developmental Disabilities ................................................................................................................................................. 174 REFERENCES ....................................................................................................................... 180 vi LIST OF TABLES Table 1 Overview of Top Measures Used to Assess Empathy ..................................................... 31 Table 2 Overview of Studies Examining Empathy and Social Outcomes for Individuals with Intellectual and Intellectual Disabilities........................................................................................ 64 Table 3 Participant Characteristics ............................................................................................. 129 Table 4 Mean Scores and Standard Deviations for Each Group ................................................ 134 Table 5 Estimates and Confidence Intervals of Pathway Models Across Groups ...................... 141 Table 6 Descriptive Statistics and Correlations for Empathy and Social Skills ......................... 144 Table 7 Summary of Different Measures Used to Assess Empathy ........................................... 162 vii LIST OF FIGURES Figure 1 PRISMA Flow Diagram of Systematic Literature Review ............................................ 28 Figure 2 Results from the multiple group path analysis for ASD group .................................... 137 Figure 3 Results from the multiple group path analysis for WS group ...................................... 138 Figure 4 Results from the multiple group path analysis for DS group ....................................... 139 Figure 5 Results from the multiple group path analysis for TD group ....................................... 140 Figure 6 Empathy Assessment and Intervention Considerations for Students with ASD .......... 160 Figure 7 General Considerations for Empathy Assessment and Intervention ............................ 167 viii KEY TO ABBREVIATIONS ADHD: Attention Deficit Hyperactivity Disorder ANOVA: Analysis of Variance ASD: Autism spectrum disorder AQ: Autism quotient DS: Down syndrome EQ: Empathy Quotient EQ-C: Children's version of Empathy Quotient ERIC: Educational Resources Information Center GEM: Griffith Empathy Measure HFA: High functioning autism IDD: Intellectual and developmental disabilities IEP: Individualized education plan IRI: Interpersonal reactivity index NIHTB-CB: NIH toolbox cognitive battery PDD-NOS: Pervasive developmental disorder-Not otherwise specified PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement SRS-2: Social responsiveness scale-2nd edition TD: Typically developing WS: Williams syndrome ix CHAPTER 1 The State of Empathy in Individuals with Intellectual and Developmental Disabilities Over the years, researchers have come to acknowledge the importance of empathy and its role in various social domains. While there is no consensus on a definition (Fletcher-Watson & Bird, 2020; Hall & Schwartz, 2019), empathy is generally described as a multidimensional construct, consisting of cognitive and affective components. Cognitive empathy refers to an individual’s ability to recognize their emotional state as well as the emotional states of others; whereas affective empathy describes an individual’s ability to share in another person’s emotional state (Mazza et al., 2014; van Noorden et al., 2015). Components of cognitive empathy include perspective-taking (i.e., the understanding that another person may have a different perspective than your own) and emotion recognition (i.e., the understanding of facial expressions; Blair, 2005; de Waal, 2008). Components of affective empathy include imitating another person’s emotional state (Hatfield et al., 1994) and responding to the emotional state of another person (Tone & Tully, 2014). While cognitive and affective empathy are distinct in definition, the two components are interrelated. That is, cognitive and affective empathy are interdependent with one component relying on the other and vice versa (Baron-Cohen & Wheelwright, 2004; Behrends et al., 2012). For individuals with intellectual and developmental disabilities (IDD), the understanding and expression of empathy and its various components can be challenging. Overall, individuals with IDD perform lower on empathy-related tasks and measures compared to individuals without IDD (e.g., Cebula & Wishart, 2008; Johnson et al., 2017); yet the empathy skills of individuals with IDD also vary across and within IDD groups (e.g., Kasari et al., 2003; Rueda et al., 2014). That is, different etiologies can elucidate various strengths and weaknesses related to empathy 1 skills (Dykens & Hodapp, 2001; Waite et al., 2014). As such, due to potential differences across and within various IDD groups, careful consideration must be taken when designing empathy- related tasks, measures, and even interventions. For example, differences in empathy skills have been observed across individuals with autism spectrum disorder (ASD), William syndrome (WS), and Down syndrome (DS). Empathy in ASD Individuals diagnosed with ASD exhibit impairments in various social domains, including challenges with social interaction, atypical or unconventional communication skills, and restricted and repetitive behaviors (American Psychiatric Association, 2013). Difficulties with displays of empathy have been observed across the autism spectrum for individuals of all ages. According to teacher reports, students with ASD between the ages of 3 and 12 display significantly fewer signs of empathy compared to their typically developing peers (Peterson, 2014). Qualitative interviews with adolescents with ASD further reveal that they perceive themselves as struggling to show empathy in their actions (Senland & Higgins-D’Alesandro, 2013). Finally, older individuals with ASD between 16 and 61 years old also report displaying lower empathy than those without disabilities (Trimmer et al., 2017). Researchers have developed several theories to explain the observed empathy deficit in individuals diagnosed with ASD. For instance, some researchers suggest that autism should be defined as a single-minded attentional system, often referred to as monotropism, that prefers to take in one information source at a time (Murray et al., 2005). Monotropism may explain why individuals with ASD (especially young children) are less likely to detect another person’s emotional cues, as this detection requires orienting towards other people (Mundy, 2018). This lack of social orientation displayed by individuals with ASD may lead them to miss social cues, 2 thereby affecting their ability to respond appropriately and empathically to another person’s emotional state. More recently, researchers have also turned to the ‘double empathy problem’ to explain observed challenges in empathy, particularly between individuals with and without ASD. The ‘double empathy problem’ suggests that individuals with ASD experience poorer social outcomes not just because they have challenges in social and communication skills but because they may also be misunderstood by individuals without ASD (Milton, 2012). As such, challenges in empathy skills come from both directions; both individuals with and without ASD may misunderstand each other’s social and communication skills (Mitchell et al., 2021). As a result, to better understand the empathy skills of individuals with ASD, researchers are now turning their attention to differences in how individuals with ASD socially interact with each other compared to social interactions between individuals with and without ASD (e.g., Crompton et al., 2019; Heasman & Gillespie, 2019). Empathy in WS WS is a rare genetic disorder caused by a deletion of ~26 genes on chromosome 7q11.23, affecting an estimated 1 in 7500 to 20,000 live births each year in the US (Hillier et al., 2003; Pober, 2010). Individuals diagnosed with WS present a unique adaptive behavior and cognitive phenotype which is characterized by mild to moderate intellectual disability with average IQ scores between 50 and 60 (Martens et al., 2008; Mervis et al., 2000). In contrast to individuals with ASD, individuals with WS are often depicted as having a sociable nature. In the literature, individuals with WS are generally described as friendly (Gosch & Pankau, 1997) and charming (Fryns et al., 1991) with a social desire to interact with others that is observed across the lifespan (Järvinen-Pasley et al., 2010). This is consistent with reports from parents rating their children 3 with WS higher on global measures of sociability and a lack of inhibition toward engaging with known and unknown individuals (Doyle et al., 2004; Haas et al., 2010; Järvinen-Pasley et al., 2010; Jones et al., 2000). Individuals with WS seem to display strong empathy skills and are described as compassionate and highly sensitive to the emotional needs of others (Jones et al., 2000). In fact, the literature suggests that individuals with WS may have high cognitive empathy. Storytelling and interview task studies have demonstrated that those with WS make rich use of empathic markers and evaluative comments when determining the emotional states of others (Jones et al., 2000). This high sensitivity to the emotional needs of others, however, may also result in a preoccupation with the suffering of others and overwhelming feelings of anxiety related to the well-being of family, friends, and even strangers (Semel & Rosner, 2003). Despite these relative strengths in sociability and cognitive empathy, individuals with WS often experience difficulties with anxiety, attention, and emotional regulation (Dykens, 2003; Leyfer et al., 2006), as well as difficulties in several social domains including social communication, social cognition (Fisher & Morin, 2017; Klein-Tasman et al., 2011; van der Fluit et al., 2012), and social reciprocity (Klein-Tasman et al., 2011). Struggles with these social domains may explain some of the social outcomes for individuals with WS including poor development and maintenance of friendships and experiencing feelings of loneliness (Sullivan et al., 2003; Thurman & Fisher, 2015), but it is unclear whether empathy skills are related to their social skills. Empathy in DS DS is the most common genetic cause of intellectual disability and, in 95% of cases, is caused by an extra 21st chromosome (i.e., Trisomy 21; Fidler & Nadel, 2007; Sherman et al., 4 2007). Described as a multisystem neurogenetic disorder, DS can affect development, growth, and participation in daily living activities across the lifespan (Krinsky-McHale et al., 2008). As one of the leading genetic causes of intellectual disability, many individuals with DS present with mild to moderate intellectual disability (IQ scores ranging from 40 to 70; Hodapp et al., 1999). Individuals with DS also present a unique learning profile that involves higher levels of off-task behavior compared to peers matched in mental age (Daunhauer & Fidler, 2011; Kasari & Freeman, 2001; Pitcairn & Wishart, 1994) and specific difficulties with some aspects of executive function (e.g., challenges in working memory; Jarrold et al., 2002; Lanfranchi et al., 2012). Individuals with DS are generally reported to have strong social and communication skills. Specifically, both younger and older children with DS demonstrate high levels of social engagement, social orientation, and social competency compared to other children with developmental disabilities (Dykens, 2006; Fidler et al., 2005; Kasari et al., 2003). As children with DS grow older, however, some researchers report observations of poorer interpersonal interactions with peers in general education classroom settings (Buckley et al., 2006). Empathy is a rather under-developed line of research for individuals with DS, as only a handful of studies have investigated empathy skills in this population (e.g., Sigman & Ruskin, 1999; Kasari et al., 2003). Among those studies that have been conducted, results indicate that individuals with DS are more attentive to facial expressions and engage in positive affect compared to other developmental disabilities (Kasari et al., 1990; Kasari et al., 1995). However, general cognitive slowing (which is characteristic of DS) may affect empathy skills over time. In a study of emotion recognition, children with DS (with observed mental ages of 3 years old) 5 performed similarly to neurotypical children of the same mental age but showed lags in emotion recognition over time (Kasari et al., 2001). Empathy and Social Outcomes Deficits in empathy skills have been linked to poor social outcomes. For those with IDD, social outcomes are often reported to be poor or lacking compared to individuals without IDD. In fact, many individuals with IDD have trouble forming and maintaining relationships, and, as a result, have few close and meaningful social relationships in comparison to individuals without IDD (Fulford & Cobigo, 2018). Difficulties in developing and maintaining the social relationships necessary for a healthy quality of life have prompted families and advocates of individuals with IDD to urge policy makers and researchers to increase focus on improving our understanding of and interventions to support social outcomes for individuals with IDD (Turnbull et al., 2000). In fact, leading national organizations for IDD, including the American Association on Intellectual and Developmental Disabilities, have called for an increase in research, practice, and policies that focus specifically on social outcomes for individuals with IDD (Bogenschutz et al., 2015). As a result, several factors that can improve social outcomes have been identified, including the ability to empathize with others. Researchers demonstrate that a better ability to understand and express empathy toward others is associated with stronger positive social communication and interactions such as higher quality and more meaningful relationships with friends and romantic partners (Chow et al., 2013; Cramer & Jowett, 2010) and better social engagement (Bailey et al., 2008) throughout the lifespan (Tone & Trully, 2014). Higher empathy skills are also associated with the inhibition of aggressive or anti-social behaviors (Björkqvist et al., 2000; Eisenberg & Miller, 1987; Roberts et al., 2014). Therefore, the impact of higher levels 6 of empathy may extend beyond day-to-day social communication to also affect social outcomes and overall long-term social development positively for individuals with IDD. Assessment and Measurement of Empathy Given its role in positive social outcomes, empathy has become the primary dependent variable in many research and intervention studies. Due to its multi-dimensional nature (i.e., cognitive and affective empathy), however, several methods exist to measure empathy. For instance, methods to measure or assess affective empathy in children with ASD include the use of pictures and stories, self-reports with hypothetical situations, or experimental procedures designed to elicit an empathic response from the child (Miller & Eisenberg, 1988). For older individuals with ASD, self-report measures (e.g., surveys or questionnaires) of their empathy skills are often a popular method used by researchers (Baron-Cohen & Wheelwright, 2004). Among the various measurements and assessments for empathy, the Empathy Quotient (EQ; Baron-Cohen & Wheelwright, 2004) has been widely distributed, frequently used by researchers, and recognized as one of the leading standardized measures for assessing empathy (Fletcher-Watson & Bird, 2020). Developed by Baron-Cohen and Wheelwright (2004), the EQ is a 60-item (or a shorter 40-item) self-report measure that provides a summed total EQ score. The EQ consists of items concerning components of cognitive and affective empathy; however, the items are not separated into sub-scales because Baron-Cohen and Wheelwright (2004) determined that both components actually co-occur and cannot easily be disentangled from each other. Whereas the EQ is validated primarily with samples of participants with ASD without intellectual disability (Lawrence et al., 2004), it is unclear if the EQ (or other measures of empathy) is valid for use with other IDD groups (e.g., DS and WS). Further research is warranted to evaluate the assessment and measurement of empathy across different IDD groups. 7 In addition to variations in assessment and measurement, the definition of empathy can vary widely based on the type of empathy being targeted. In fact, thus far, there is no standard or agreed-upon definition of empathy in the research literature (Fletcher-Watson & Bird, 2020; Hall & Schwartz, 2019). Operational definitions of cognitive empathy can include the number of times an individual correctly identifies the emotion of a person shown in a picture (Baron-Cohen et al., 2001) or coding the accuracy of an individual to predict the emotions, thoughts, or inner states of another person through personal diary entries (Sened et al., 2017). Operational definitions of affective empathy can include the expression of listening statements and follow-up questions (Koegel et al., 2016) or a response that must exactly match the emotional state of an individual (e.g., expressing sadness if the individual is feeling sad; Hall & Schwartz, 2019). These various approaches only reflect the difficulties and challenges of defining and consequently testing empathy (Decety & Cowell, 2014) and the variability of definitions and corresponding methods to assess empathy could have important implications for the development and application of interventions (van Noorden et al., 2015). Interventions Addressing Empathy Deficits Interventions addressing empathy deficits for ASD, WS, and DS vary greatly. Compared to the research literature of WS and DS, there appears to be a much larger focus on addressing empathy deficits for individuals with ASD. Historically, much of the focus has primarily been on cognitive empathy, as the observed empathy deficits in individuals with ASD has largely been explained by various cognitive theories (e.g., monotropism; Mundy, 2018) using a medical model approach (Mitchell et al., 2021). However, more recent research has also focused on examining the empathy skills of individuals with ASD as differences rather than deficits. For the example, the ‘double empathy problem’ suggests that challenges in empathy skills may be due to 8 differences in the understanding and expression of empathy between individuals with and without ASD (Mitchell et al., 2021). For individuals with WS, the development and evaluation of interventions is only beginning to emerge (Mervis & John, 2010). Past research in the WS literature suggests that this population may struggle with cognitive components of social and communication skills (similar to their ASD counterparts) and, therefore, has been a primary focus of intervention for individuals with WS as well (Laws & Bishop, 2004; Tager-Flusberg & Sullivan, 2000). As such, some researchers postulate that interventions already used for other IDD groups may also be beneficial for individuals with WS, such as applied behavior analysis (Klein-Tasman et al., 2009) and social skills training (Mervis & John, 2010). There are also few empathy interventions that have been developed specifically for individuals with DS. One promising approach, however, is responsive teaching. Responsive teaching is an early intervention curriculum designed to address the cognitive, language, and social-emotional needs of children with developmental delays, particularly children with DS (Mahoney et al., 2006). Responsive teaching includes empathy as one of 16 behaviors that children should learn in order to gain skills and competency across the developmental domains of cognition, communication, and social emotional functioning (Mahoney et al., 2006). Purpose of Current Dissertation Given empathy’s critical role in various social domains, potential differences of empathy skills across different IDD groups, and the variability observed in defining and measuring empathy, the purpose of this dissertation is to expand the current literature on empathy for three distinct and unique IDD groups (i.e., ASD, WS, and DS) to better inform current and future interventions. Three independent but related manuscripts presented in journal submission format 9 follow this introduction as chapters two through four. Chapter two is a systematic literature review of the current research on what is generally known about the empathy skills and social outcomes of individuals with ASD, WS, and DS. Using a group comparison research design, chapter three then collects direct data on the specific factors that may relate to any similarities and/or differences in empathy skills and social skills across the three diagnostic groups. Finally, chapter four combines the findings from chapters 2 and 3 to provide recommendations on how to address empathy deficits for individuals with ASD. Chapter five consists of a comprehensive discussion of the findings from all three studies. Chapter 2: Empathy Systematic Literature Review Given the relationship between empathy skills and social outcomes, there is a need to more closely examine whether empathy skills in individuals with ASD, WS, and DS are related to their social outcomes. Identifying these relationships may inform current and future interventions. Therefore, the primary purpose of this study is to generally examine the current research on empathy skills of individuals with ASD, WS, and DS and how these skills are related to their social outcomes. Chapter 3: Comparing Empathy and Social Skills across Individuals with ASD, WS, and DS Chapter 3 examines similarities and differences in empathy skills and social skills across individuals with ASD, WS, and DS using standardized measures. If empathy and social skills are different across these groups, it is critical to identify such differences for consideration in current and future interventions. Therefore, in this study, measures of empathy and social skills were administered to compare skills across individuals with ASD, WS, and DS and to individuals without IDD. Identifying differences in empathy skills in relation to social skills provides a 10 deeper understanding of what to address in interventions for each diagnostic group. 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The importance of understanding the behavioural phenotypes of genetic syndromes associated with intellectual disability. Paediatrics and Child Health, 24(10), 468-472. https://doi.org/10.1016/j.paed.2014.05.002 Yirmiya, N., Erel, O., Shaked, M., & Solomonica-Levi, D. (1998). Meta-analyses comparing theory of mind abilities of individuals with autism, individuals with mental retardation, and normally developing individuals. Psychological Bulletin, 124(3), 283–307. https://doi.org/10.1037/0033-2909.124.3.283 20 CHAPTER 2 Empathy and Social Outcomes for Individuals with Intellectual and Developmental Disabilities: A Systematic Literature Review The research literature generally classifies social outcomes are as “good”, “fair”, or “poor” (Levy & Perry, 2011). Individuals with intellectual and developmental disabilities (IDD) have consistently been classified as having “poor” social outcomes (Howlin et al., 2013), suggesting that despite progress in the social inclusion of individuals with IDD, such inclusion has not always led to their improved social experiences (Hughes et al., 2002; Rossetti et al., 2015). In fact, differences in the type of IDD condition may relate to varying social outcomes across diagnoses. Specifically, the different behavioral characteristics of different IDD conditions indicates that one diagnostic group may present different social strengths and weaknesses compared to another IDD group (Waite et al., 2014). Three examples of diagnostic groups with different behavioral phenotypes and potentially different social outcomes include autism spectrum disorder (ASD), Williams syndrome (WS), and Down syndrome (DS). Social Outcomes for ASD ASD is typically characterized by delays in the development of social and communication skills (American Psychiatric Association, 2013). Significant advances in interventions targeting the social and communication skills of individuals with ASD across the lifespan have improved certain outcomes such as independent living, education attainment, and employment (Byrd, 2002; Howlin, 2005; Matson & Horovitz, 2010; Shattuck et al., 2007; Shea & Mesibov, 2005), particularly for individuals who are less impacted by ASD symptoms (Cederland et al., 2008; Gilchrist et al., 2001; Howlin, 2005; Shea & Mesibov, 2005). Unfortunately, these interventions do not seem to have the same impact on improving social 21 relationships. For example, in a meta-analysis of 18 descriptive research studies with 1,768 participants, school-aged boys with ASD reported poorer quality friendships and lower feelings of companionship, help, security, and closeness compared to school-aged boys without disabilities (Mendelson et al., 2016). Past research also suggests poor social outcomes extend to adults with ASD, as they experience limited support networks compared to the typically developing population (Beadle-Brown et al., 2006; Keogh et al, 2004). Social Outcomes for WS WS, caused by a micro-deletion of genes on chromosome 7 (Hillier et al., 2003), is a rare genetic disorder that results in borderline to moderate levels of intellectual disability (Mervis & John, 2010). Individuals with WS are generally described as hypersocial, often displaying social inhibition and overfriendliness toward known and unknown individuals (Jawaid et al., 2012; Jones et al., 2000). Despite their reported sociable personality, individuals with WS also experience poor social outcomes. For example, individuals with WS experience interpersonal difficulties that can result in poor peer relationships and social isolation (Davies et al., 1998; Dykens & Rosner, 1999; Fisher et al., 2020; Jawaid et al., 2012). The difficulties individuals with WS experience with developing and maintaining friendships also relate to feelings of loneliness (Davies et al., 1998; Sullivan et al., 2003; Thurman & Fisher, 2015). Social Outcomes of DS DS is the most common chromosomal cause of intellectual disability, in most cases due to a third copy of chromosome 21 (i.e., Trisomy 21; Fidler & Nadel, 2007; Sherman et al., 2007). Individuals with DS are often described as charming, social, engaging, and friendly toward others (Dykens, 2000); however, they also experience difficulties in initiating and maintaining conversations (Porter et al., 2007), which may then impact social relationships across the 22 lifespan. While studies on the social outcomes of DS are sparse in the more current literature, there is some research using parental reports that indicates that adults with DS experience infrequent social communication and interactions with friends (Esbensen et al., 2010). The Role of Empathy in Social Outcomes Empathy has long been regarded as a critical factor toward successful social outcomes and interactions (Chow et al., 2013; Cramer & Jowett, 2010; Roberts et al., 2014). Empathy can generally be described as a multicomponent phenomenon consisting of a cognitive component (i.e., the ability to understand another person’s emotional state) and an affective component (i.e., the ability to share and respond to another person’s emotional state; de Wied et al., 2007). Generally, researchers demonstrate that decreased displays of empathy are correlated with more anti-social behavior such as aggression, whereas better empathy skills may result in more prosocial behaviors (Eisenberg et al., 2010). Overall, the ability to empathize is considered critical for social functioning and wellbeing (de Waal, 2008; Fink et al., 2014; Gaudion et al., 2014) and may ultimately impact social outcomes. Empathy as a Facilitator of Friendship Development Developmental theorists have long suggested that meaningful and intimate relationships develop along with empathy and perspective-taking skills (Selman, 1980). Empathy development across the lifespan may also factor into the development of long-term friendships, with some suggesting that empathy is crucial to the maintenance of well-adjusted friendships (Davis, 1996; Davis & Karus, 1991). In fact, studies on children and adolescents in the general population have consistently demonstrated that those who display high levels of empathy report better functioning friendships characterized by more caring, companionship, validation of the 23 friendship, and fewer conflicts (Clark & Ladd, 2000; Davis & Karus, 1991; Smith & Rose, 2011; Soenens et al., 2007). Despite theoretical and empirical evidence illustrating the relationship between empathy skills and social outcomes in the general population, it is unclear if empathy skills are similarly related to social outcomes for individuals with IDD. In particular, whether differences in empathy skills are related to differences in social outcomes across different IDD groups, such as ASD, WS, and DS, remains relatively unknown. Therefore, the primary purpose of the current literature review is to examine the relation between empathy skills and social outcomes for these three distinct IDD conditions (i.e., ASD, WS, and DS). Measurement and Assessment of Empathy To fully understand the relationship between empathy skills and social outcomes for individuals with different IDD conditions, it is also important to account for the different ways in which empathy is defined and measured. Due to its multidimensional nature, empathy is a challenging construct to measure and assess. The complexity of empathy and its components have resulted in a myriad of different definitions and approaches for measurement (Innamorati et al., 2019). Given that not all measurement approaches will be equal or similar in methods or procedures and may even use different theories at the construct level, this review will also examine how empathy is defined and measured within the IDD population (Davis, 1983; Gerdes & Segal, 2011; Jolliffe & Farrington, 2006). Purpose of Current Study Given the relationship between empathy and social outcomes in the general population, we hypothesize that empathy may also be a critical factor in facilitating positive social outcomes for individuals with IDD and that the relationship between empathy and social outcomes may 24 differ across different IDD conditions such as ASD, WS, and DS. Therefore, the aim of this literature review was to examine the current research on empathy skills and social outcomes for individuals with ASD, WS, and DS by specifically evaluating a) how empathy is measured for each group; b) the reported empathy skills of each group; c) the reported social outcomes of each group; and d) any reported correlations between empathy skills and social outcomes. To achieve the study aims, the following research questions were used to guide the literature review: (a) In what ways is empathy defined and measured for individuals with ASD, WS, and DS?; (b) What are the reported empathy skills of individuals with ASD, WS, and DS?; (c) What are the reported social outcomes for individuals with ASD, WS, and DS?; and (d) What correlations between empathy skills and social outcomes are reported for each diagnostic group? Method Information Sources and Search Strategy A literature search was conducted in five online databases: Education Full-text, PsycInfo (including PsycARTICLES), ERIC, PubMed, and Sociological Abstracts. The following search terms were entered separately into each database: (a) “empath* AND autis* OR Asperger syndrome”; (b) “empath* AND Williams syndrome”; and (c) “empath* AND Down syndrome.” A manual search was also conducted in the top three journals that most frequently appeared during the online database search (Journal of Autism and Developmental Disabilities, Research in Developmental Disabilities, and Research in Autism Spectrum Disorders). After the database and manual search, all articles were screened through a three-step process (described below). The last update of this literature search was conducted on October 13, 2020. 25 Study Selection Studies were included in the literature review if they met the following three inclusion criteria. First, participants had to have an ASD diagnosis (e.g., autism or autistic disorder, Asperger’s syndrome), WS diagnosis, or a DS diagnosis, as indicated through self-report or a diagnostic assessment. Second, one of the variables of interest in the study had to include empathy or one of its main components (i.e., cognitive empathy, affective empathy). Third, the study had to be published in English in a peer-reviewed journal in 2004 or later. This final inclusion criterion is because the Empathy Quotient (EQ; Baron-Cohen & Wheelwright, 2004), published in 2004, is widely recognized as one of the leading standardized measures of empathy (Fletcher-Watson & Bird, 2020). The EQ has been validated with normative samples of individuals with ASD (Lawrence et al., 2004) and is widely used with other disability conditions. Given the extensive use of the EQ with individuals with IDD and in anticipation that many studies may have frequently used the EQ to measure empathy in individuals with disabilities, only research articles published in or after 2004 were considered for review. Studies were excluded if they solely used neurology-related tasks (e.g., FMRI) to measure empathy. Systematic literature reviews, think pieces, and dissertations were also excluded. Studies that focused on the empathy of others (e.g., parents, siblings, care staff, peers) toward individuals with IDD were not included in the literature review. Finally, studies that did not explicitly state that they were measuring empathy but instead reported findings of related components of empathy (e.g., facial emotion recognition, theory of mind, perspective-taking) were excluded given that this systematic literature review is specifically focused on empathy and not general or related components. 26 Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement (Page et al., 2021), trained coders (the first author and three research assistants) determined inclusion of relevant studies through a three-step procedure involving the sequential examination of the titles, abstracts, and full texts. Specifically, a screening form was developed to determine which articles from the database and manual search met inclusion criteria based first on an examination of the titles and abstracts. Two trained reviewers screened all titles and abstracts for relevance. A random sample of 10% of titles and abstracts (n = 442) was then double reviewed by the first author; this is an accepted practice when a review is large and resources are limited (Popay et al., 2006). Interrater reliability was 92.98% and all discrepancies between reviewers were resolved by discussion. Data Extraction and Synthesis Information from each full-text article of studies meeting the inclusion criteria was collected using a data extraction form (see Appendix A) designed to address the research questions of this literature review. The following information was extracted from reviewed studies: (1) characteristics of the participants (e.g., diagnosis, gender, ethnicity, age, etc.); (2) study characteristics (e.g., setting, study design); (3) how empathy was defined and measured (e.g., type of empathy skill(s), instrument or method used to measure empathy); (4) reported empathy skills of the participants (if empathy was measured more than one time, only baseline measures of empathy scores were extracted); (5) any reported reliability and validity of measures used to assess empathy; (6) characteristics of the social outcome(s) of interest including type of social outcome(s) reported (e.g., peer interactions, social skills, friendships, etc.); and (7) reports of any relationship between variables of empathy and social outcomes (e.g., correlations between variables or in a regression model). Two research assistants completed data extraction, and the 27 first author double coded 20% (n = 65) of all full-text articles. Interrater reliability was 90.77% and discrepancies between coders were resolved by discussion. Results The database search yielded a total of 7,362 articles. After duplicates were removed (n = 2,946), 4,416 articles were screened for inclusion based on an examination of the title and abstract. After screening, a total of 326 studies were considered to have met inclusion criteria and were assessed for data extraction through an examination of the full-text articles. Additionally, the manual search of journals yielded 1,031 articles. After removing duplicates and screening for inclusion criteria, an additional 9 articles were identified and examined for full-text data extraction. Following data extraction of the full-text articles, a total final count of 169 articles were included in the systematic literature review (see Figure 1 for the PRISMA diagram). Findings from these manuscripts highlight several key patterns across studies that focused on empathy and social outcomes for individuals with ASD, WS, and DS within the past 15 years (see Appendix B for an overview of all studies included in the study). Figure 1 PRISMA Flow Diagram of Systematic Literature Review Identification Records identified from: Records removed before screening: Databases (n = 7362) Duplicate records removed Manual Search (n = 1031) (n = 3910) Records screened Records excluded (n = 4483) (n = 4157) Screening Reports sought for retrieval Reports not retrieved (n = 326) (n = 0) 28 Figure 1 (cont’d) Reports assessed for eligibility Reports excluded: (n = 326) Not a study (n = 59) Not about the empathy of individuals with IDD (n = 85) Studies included in review No official diagnosis (n = 11) Included (n = 169) Reports of included studies (n = 169) General Study Characteristics Of the 169 articles included in this review, 98.2% (n = 166) focused on individuals with ASD and only 3 (1.8%) included individuals with WS and/or DS. In total, there were 48,408 participants with ASD included across studies, whereas there were only 41 participants with WS and 34 participants with DS. These diagnoses were primarily determined through participant self-report to the research team. Overall, the sample sizes across most studies were generally small (e.g., 20s, 30s), with a few studies reporting sample sizes in the hundreds or above (e.g., Grove et al., 2014; Kästner et al., 2015; Sucksmith et al., 2013). Most studies (n = 126; 74.5%) included more males than females in their samples. Only 22 studies (13.0%) reported the race or ethnicity of their sample, with the majority of participants being White and non-Hispanic. The mean age for most samples was in the adolescent or adulthood range; a few studies recruited participants in younger age groups (e.g., toddlers) or in age groups above 50 years old. In terms of setting, a majority of the studies were conducted in Western countries (e.g., United States, Canada, United Kingdom) and data were most often collected in a university research lab or similar university setting (n = 112; 65.5% of studies). A majority of the studies (n 29 = 147; 84.6%) used a group quasi-experimental or experimental design; a smaller number of studies used a single-case experimental design study (n = 11; 6.5%), qualitative methods (n = 5; 2.9%), or a mixed-methods approach (n = 2; 1.2%). Research Question 1: Definition and Measurement of Empathy All studies included some form of description or definition of empathy either in the introduction or method section of the article. Some studies provided general definitions of empathy, such as feeling concern for another person’s distress and a desire to intervene (e.g., Campbell et al., 2015) and a contextually appropriate response to a person’s display of emotion (e.g., Schrandt et al., 2009). Other studies, however, distinguished between cognitive and affective empathy and used various definitions to define these constructs. Examples of definitions for cognitive empathy include the capacity for self-other distinction (e.g., Bird et al., 2010), reflection about other people’s mental states and explicit self-assessment of the individual’s own emotions (e.g., Schulte-Rüther et al., 2014), and the ability to understand another person’s emotional state (e.g., Dziobek et al., 2008). Affective empathy was defined in several ways, including the degree to which an individual experiences feelings of compassion toward another person’s emotional state (e.g., Davis, 1980), sharing in the feelings of others (e.g., Peterson, 2014), and the drive to respond appropriately to another person’s emotional state (e.g., Baron-Cohen, 2003). Overall, 64 unique measures (including author-created measures) were used to assess empathy across the studies and standardized or psychometrically-sound measures were most often used (see Table 1 for overview of primary measures used). The two most frequently used measures were the Empathy Quotient (EQ; Baron-Cohen et al., 2004) and the Interpersonal Reactivity Index (IRI; Davis, 1980). The EQ is a 60-item self-report questionnaire with a Likert 30 format consisting of a list of statements about real life situations or experiences where empathy may be required (Baron-Cohen & Wheelwright, 2004). Unlike other measures of empathy, the EQ does not distinguish between cognitive or affective empathy. Table 1 Overview of Top Measures Used to Assess Empathy Name of Type of Type of Empathy Definition Measure Measure Empathy Measured Empathy Self- Cognitive An individual’s drive to identify another person’s Quotient Report Empathy emotions and thoughts and to provide an appropriate (EQ; Baron- Parent Affective emotional response to his or her emotional state. Both Cohen & proxy- Empathy cognitive and affective co-occur and as such, the EQ Wheelwright, report provides a total empathy score. 2004) Interpersonal Self- Empathic The capacity to form an emotional response (e.g., Reactivity report Concern warmth, compassion, concern to the emotional state of Index (IRI; another person). The IRI consists of other subscales Davis, 1980) related to empathy including perspective taking, fantasy, and personal distress. Griffith Parent Cognitive Cognitive empathy is understanding another’s emotional Empathy proxy- Empathy state while affective empathy is experiencing and Measure report Affective emotionally responding to another’s emotional state. The (GEM; Empathy GEM does provide sub-scale scores for cognitive and Dadds et al., affective empathy. 2008) Basic Self- Cognitive Cognitive empathy is defined as the understanding of Empathy report Empathy another person’s affective state and affective empathy is Scale (BES; Affective defined as the ability to feel an appropriate response Jolliffe & Empathy when on is confronted with the mental state of another Farrington, person. The BES focuses on four basic emotions (i.e., 2006) anger, fear, happiness, sadness). Rather, the EQ provides a total score of empathy (max score = 80) with higher scores indicating higher displays of empathy. While Baron-Cohen and Wheelwright acknowledge that empathy consists of cognitive and affective components, they believe both components co-occur and cannot easily be distinguished from one another (Baron-Cohen & Wheelwright, 2004). 31 On the other hand, the IRI consists of four seven-item subscales including perspective- taking, empathic concern, personal distress, and fantasy, with responses set to a 5-point Likert scale (Davis, 1980). The perspective-taking sub-scale assesses an individual’s ability to imagine the cognitive viewpoint of others. The fantasy sub-scale measures an individual’s tendency to emotionally relate to fictional characters depicted in different media such as books and movies. The empathic concern subscale assesses an individual’s capacity to form a response to another person’s emotional state. Finally, the personal distress subscale measures the extent to which an individual forms a self-centered emotional response to another person’s emotional state. Out of all the subscales, the perspective-taking and empathic concern subscales are considered the most appropriate approximations of cognitive and affective empathy, respectively (Davis, 1983). Research Question 2: Reported Empathy Skills Across studies, individuals with ASD performed lower on empathy-related measures compared to other groups (e.g., attention-deficit hyperactivity disorder, individuals without disabilities). On the EQ, individuals with ASD generally reported lower empathy scores compared to typically developing control groups. These lower EQ scores were often significantly correlated with higher scores on measures assessing for autism symptomatology such as the Autism Quotient (e.g., Paulus et al., 2013), indicating poorer empathy skills are related to more autistic symptoms. Sex differences were also reported in studies using the EQ, with some studies demonstrating that females with ASD reported significantly higher scores on the EQ (e.g., higher empathy skills) than males with ASD (e.g., Grove et al., 2015). On the IRI, individuals with ASD were rated significantly lower than control groups on various sub-scales of empathy, including perspective-taking and empathic concern (e.g., Bos & Stokes, 2019; Rogers et al., 2007). Interestingly, several studies demonstrated that individuals 32 with ASD scored higher on the personal distress subscale of the IRI (e.g., Brewer et al., 2017; Hagenmuller et al., 2014; Minio-Paluello et al., 2009). This particular sub-scale is defined as being distressed over problematic interactions with others, suggesting that individuals with ASD may experience higher personal distress with social interactions compared to other groups. Similar results were reported in age groups as young as adolescence with a few studies reporting that adolescents with ASD scored significantly lower on the perspective-taking subscale but scored higher on the personal distress subscale of the IRI. While many studies reported that individuals with ASD generally performed lower on empathy-related tasks, other studies reported more nuanced findings. A few studies highlighted that any differences in empathy observed between individuals with ASD and other groups may be related to challenges in cognitive empathy rather than affective empathy. For example, in their study of children with ASD, Deschamps et al. (2014) reported that both parents and teachers rated children with ASD lower on cognitive empathy compared to affective empathy and these differences remained when the children with ASD were also compared to a typically developing control group. Similar results were also reported for adults with ASD (e.g., Dziobek et al., 2008). Few studies reported on the empathy skills of individuals with WS and DS. Of the three studies that did include these groups (n = 1 study for WS; n = 1 study included both ASD and DS; n = 1 study included both WS and DS), the findings indicate that individuals with WS and DS performed well on empathy-related tasks. For example, Plesa Skwerer & Tager-Flusberg (2016) demonstrated that both children with WS and DS consistently scored higher on an empathy-related task of helpfulness compared to a typically developing control group, who scored average ratings of overall empathy. However, Plesa Skwerer & Tager-Flusberg (2106) noted that while children with WS and DS displayed higher ratings of empathy, they also scored 33 lower on overall helpfulness, suggesting that higher displays of empathy may not necessarily translate to other social skills or outcomes. Other studies reported interesting associations between empathy and various domains. In their study examining fetal testosterone, hypersociability, empathy skills, anxiety, and autistic symptoms of 25 individuals with WS, Osório et al. (2019) reported lower fetal testosterone was significantly associated with hypersociability and affective empathy while cognitive empathy was only marginally and negatively correlated with fetal testosterone. Finally, in their study examining how the familiarity of a person and emotional context may influence the empathic responding of children with ASD and DS, Hurdy & Slaughter (2009) reported that all participants (including a TD control group) were more likely to respond empathically to a familiar person; although, the nature of children’s responses varied depending on emotional context. Research Question 3: Reported Social Outcomes Only a handful of studies (n = 36, 21.3%) about empathy also examined the social outcomes of individuals with ASD, and no studies included an examination of social outcomes for individuals with WS or DS. Of the 36 studies that included social outcomes of individuals with ASD, 77.8% examined social skills (n = 28), 22.2% examined friendship outcomes (n = 8), and 27.8% examined peer interactions (n = 10). Overall, studies reported poorer social outcomes for individuals with ASD compared to other groups. For instance, Alvarez-Fernandez et al. (2017) examined the perceived social supports (e.g., friends, family, and significant others) of 49 adults with ASD and reported lower ratings on friendship outcomes compared to other groups, including individuals with attention deficit hyperactivity disorder and individuals without disabilities. A few qualitative and mixed method studies also highlighted some key concerns 34 regarding social outcomes for individuals with ASD. Using a mixed method design, Senland and Higgins-D’Alessandro (2016) explored sociomoral reasoning, empathy, and challenging and supporting factors during the transition to adulthood for 22 young adults with ASD and reported that some participants admitted to struggling with perspective-taking, specifically when it comes to conflict resolution between friends and family. Research Question 4: Relationship between Empathy and Social Outcomes Of the few studies that examined social outcomes for individuals with ASD, even fewer studies explored the relationship between social outcomes and empathy (n = 14; 8.28%). Generally, these studies reported that empathy was significantly related to social outcomes across different age groups. Some studies reported on the role of empathy in challenging sociomoral situations (e.g., concerns about justice, rights, and welfare) that involved helping others. For example, in the same mixed methods study described above, Senland & Higgins- D’Alessandro (2016)’s results suggested that the control group were more likely than the ASD group to use perspective-taking and empathic concern to describe, reason, and reflect on challenging sociomoral situations. Other studies noted the mediating role of empathy skills (e.g., perspective-taking and empathic concern) on the individual’s happiness and positive affect (e.g., Rueda et al., 2014). As with social outcomes, no studies included in this review reported on the relationship between empathy and social outcomes for individuals with WS or DS. Discussion Conducted to identify the extent of the research that has evaluated empathy skills and their relation to social outcomes for individuals with ASD, WS, and DS, this study reviewed the existing literature on empathy across the three diagnostic conditions. The results of this review demonstrate the advances made in our understanding of empathy and social outcomes for 35 individuals with ASD, WS, and DS while also highlighting areas for future research. Three main findings arose from this study. First, although a large body of research has examined empathy skills and social outcomes for individuals with ASD, there is a need for additional research evaluating the empathy and social outcomes of individuals with WS and DS. The lack of research between empathy and social outcomes for individuals with WS and DS may be due to the friendly and personable social behavioral phenotype of these groups (e.g., Dykens, 2006; Fidler et al., 2005; Järvinen- Pasley et al., 2010; Jones et al., 2000), as there may be an assumption that such a behavioral phenotype would then correspond to positive social outcomes. However, given that the social outcomes of these groups are often described as poor (e.g., Esbensen et al., 2010; Porter et al., 2007), additional research is warranted to identify whether and how empathy skills are related to social outcomes for individuals with WS and DS. Second, a majority of the studies in this systematic literature review reported that individuals with ASD experience challenges in empathy skills, whereas the relatively few studies to include individuals with WS and DS indicated they perform relatively well on empathy- related tasks and measures. Such differences in empathy skills between individuals with ASD and individuals with WS and DS may stem from differences in their social behavioral phenotypes. Given that individuals with ASD often experience impairments in various social domains, these deficits may extend to poorer empathy skills. In the general research literature, empathy skills are often described as interdependent with other important social skills such as social awareness, emotion regulation, and perspective-taking (Barr & Higgins-D’Alessandro, 2009; Decety & Jackson, 2004; Eisenberg, 2007). For individuals with ASD, impairments in 36 various social domains (e.g., perspective-taking) may negatively impact their empathy skills resulting in lower performance on different tasks and measures. Additionally, several studies which used the IRI to assess the empathy skills of individuals with ASD demonstrated that both adults and adolescents with ASD reported greater personal distress over problematic interactions with others compared to typically developing groups. Such findings suggest that across age groups, individuals with ASD may experience higher levels of discomfort or anxiety in tense social situations, which may then impact their ability to empathize with others. These reports of greater personal distress coincide with a more current focus on reporting empathy skills from the lived experiences of the individuals with ASD. For example, in published personal accounts, individuals with ASD describe experiencing ‘intense, uncontrollable empathy’ (Williams, 1998, p. 59) and a ‘hyperarousal of the empathic system…’ (Elcheson et al., 2018, p. 189). Therefore, lower performances on empathy related tasks and measures may stem from greater distress or overstimulation for individuals with ASD rather than any actual deficits. Further research is warranted to examine the empathy skills of individuals with ASD from the perspective of their lived experiences. The findings from the IRI also coincide with more recent research suggesting that rather than lacking empathy skills, individuals with ASD experience and express empathy differently than individuals without ASD (Mitchell et al., 2021). Referred to as the ‘double empathy problem’, more researchers are exploring differences, rather than deficits, in empathy skills between individuals with and without ASD (e.g., Crompton et al., 2019; Heasman & Gilliespie, 2019). This view differs from prominent theories which historically adopted a medical model and framed challenges in empathy for individuals with ASD as deficits (e.g., Baron-Cohen et al., 1985). As such, current measures of empathy may be inadequate as they aim to assess deficits 37 rather than differences in empathy skills between individuals with and without ASD. Thus, there is a need to develop measures that function to draw out and identify the empathy skills of individuals with ASD rather than solely focusing on potential challenges. In contrast to those with ASD, individuals with WS and DS are reported to perform well on empathy-related tasks. This performance is not surprising, given that their social behavioral phenotypes are generally described as friendly and amicable in nature. Still, given the small number of studies to examine empathy in WS and DS, these results should be interpreted with caution and additional research is needed to better understand the relation between the behavioral phenotypes of these conditions and the poor social outcomes they experience. Third, the use of self-report measures to assess empathy has important implications for interpretation and generalization of study findings. First, while self-report measures are quick and inexpensive, there are some limitations with their use. Self-report measures can be dependent on participants’ perceptions of themselves and their ability to understand the questions that are being asked (Borgers & Hox, 2004). Given the widely held notion that individuals with ASD present with challenges in empathy, individuals with ASD may be influenced to report such challenges even when they do express or feel empathic concern towards others (Fletcher-Watson & Bird, 2020). Such a possibility may confound the interpretation and generalization of empathy skills for individuals with ASD, including any perceived improvements from intervention or treatment. The use of other forms of measurement may assist in providing a more accurate picture of the empathy skills of individuals with IDD, including those with ASD. For example, given that younger age groups were underrepresented in this literature review and self-report measures from young children may be complicated by several confounding variables (Bryne, 1996), 38 researchers may rely on teacher- or parent-reported measures of empathy to better approximate the empathy skills of younger individuals with IDD. Teacher- and parent-reported measures can serve as proxies for younger age groups, particularly for identification of certain skills and abilities (Renk & Phares, 2004; Yoder & McDuffie, 2006) and are essential for intervention purposes to assess if certain skills or abilities are maintained and generalized within different settings and contexts (Yoder & McDuffie, 2006). Beyond proxy-reports from teachers and parents, experimental measures of empathy such as behavioral or observational tasks may also provide a broader picture of the empathy skills of individuals with IDD. For example, used as a proxy to assess cognitive empathy, Channell and colleagues (2014) developed an emotion knowledge task for children with DS that measured the ability to accurately identify the emotional state of others by different social cues using video clips. Given the potential limitations of self-report measures for young children, more experimental measures may provide a more accurate representation of the empathy skills of children with IDD. Limitations While this systematic literature review describes and provides an overview of empathy skills in relation to social outcomes for individuals with ASD, WS, and DS over the past 15 years, there are several limitations to consider. Most notably, the current literature review did not examine the quality of the studies included in the final count; therefore, the methodological rigor of the final included articles is currently unknown. Additionally, given the differences in measurement and that not all included studies were interventions, the certainty or confidence in the body of evidence (e.g., effect sizes) was not examined in this literature review. Given that the aim of this literature review was to generally examine the empathy skills of individuals with 39 ASD, WS, and DS, only empathy skills before intervention implementation were considered for this review as well. Certainty assessments as outlined in the PRISMA statement (Page et al., 2021) would further strengthen interpretation of the findings in this systematic literature review. Other limitations include the exclusion of studies not written in English and not published in peer reviewed journals, which may have resulted in potentially missed studies (e.g., some articles were dissertations that included individuals with WS and DS but were not published in a peer reviewed journal and were excluded in the current literature review). Future Directions The findings from this review point to critical areas for future research. First, there is a need to recruit more representative samples. The studies included in this systematic literature review lacked representation of female participants and other IDD conditions such as WS and DS. Few studies reported on the race and ethnicity of their sample, and among those that did, most samples were majority White. In addition, most studies focused on older age groups such as adolescents and adults. Very few examined the same phenomenon with younger age groups. More representative samples in studies will ensure that the results can be generalized to other individuals within the population and help improve our overall understanding of empathy and social outcomes. Additionally, the lack of examination of empathy skills in relation to social outcomes, as demonstrated in the current review, indicates that further research is warranted to examine whether interventions targeting empathy skills can improve social outcomes for individuals with IDD (i.e., measuring the effects of the intervention beyond the immediate treatment or behavioral goals). A meta-analysis of interventions targeting empathy skills would further strengthen our knowledge on the effectiveness of these interventions on improving social outcomes such as friendships and romantic relationships for individuals with IDD. 40 This systematic literature review demonstrates that empathy plays a critical role in the development of positive social outcomes and related social skills for individuals with ASD. However, knowledge of the role of empathy in promoting positive social outcomes for individuals with WS and DS is limited. Further examination of empathy in the IDD population is warranted to ensure that individuals of all abilities have the skills necessary to achieve more positive social outcomes, including meaningful friendships and relationships. Given that friendships and relationships are critical to an individual’s mental health and well-being (Hefner & Eisenberg, 2009; Wilkinson & Marmot, 2003), ensuring that individuals with IDD develop more positive social outcomes ultimately helps to promote a healthy quality of life. 41 APPENDICES 42 Appendix A Data Extraction Form for Reviewing Full-Text Articles 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 Appendix B Table 2: Overview of Studies Examining Empathy and Social Outcomes for Individuals with Intellectual and Developmental Disabilities Authors Sample Type(s) of Measure(s) Results Empathy Adler et al. ASD: 17 Empathic “Baum-circle” (Koch & Empathic concern predicted empathic (2015) TD: 24 embarrassment Harvey, 2012) embarrassment for the TD control Empathic traits Interpersonal Reactivity Index group while personal distress predicted (e.g., empathic (Davis, 1980) empathic embarrassment for the ASD concern, personal group. distress) Alkire et al. ASD: 49 Affective Empathy Abbreviated-version ASD children’s parents rated their (2021) TD: 50 Cambridge Behavior Scale children’s social anxiety higher and Empathy Quotient (Baron- Theory of Mind (ToM) subscales lower. Cohen et al., 2004) Social symptom severity and verbal- cognitive ToM is negatively related in individuals with low levels of social anxiety. Alvarez- ASD: 41 Affective Empathy Adapted empathy coding Lower empathy scores were found in Fernandez et al. TD: 69 system (Young et al., 1999) the ASD group than the TD and ADHD (2017) ADHD: 69 groups. On the Multidimensional Scale of Perceived Social Supports-friends subscale, the ASD group scored lower than the TD and ADHD groups. The three test groups did not differ significantly in their cognitive empathy. 64 Table 2 (cont’d) Anderson & ASD: 15 Affective Empathy Empathy Quotient (Baron- Means scores on the EQ was 14.86 Meints (2016) Cognitive Empathy Cohen & Wheelwright, 2004) indicating lower empathy skills pre- intervention. There was a clear reduction of ASD traits following equine assisted activities; caregiver identity was not statistically significant. Andrews et al. ASD: 40 Communicating Affection for Others The communicating empathy subscale (2013) HFA: 9 PDD- Empathy Questionnaire (Sofronoff et treatment (Tx) group had pre scores of NOS: 9 al., 2013) 14.07 and post scores of 15.76. On the general affection questionnaire, the Tx group had pre scores of 41.86 and the control group had pre scores of 41.30. On the social competence portion of the questionnaire, the Tx group had pre scores of 5.67 and the control group had pre scores of 5. Argott et al. ASD: 4 Affective Empathy Affection for Others Three of the four participants did not (2017) Questionnaire (Sofronoff et display empathic responses that were al., 2013) complex. The fourth participant displayed an inconsistent response to joy, but not to pain or frustration. Argott et al. ASD: 3 Affective Empathy Affective Situation Test All three participants showed no (2008) (Asakawa & Matsuoka, 1087) unscripted empathic responding prior to intervention. Auyeung et al. TD: 1030 Affective Empathy Author-created Children with ASD scored lower than (2012) ASD: 213 TD girls and boys, on average, but did not show any variance between girls with ASD and boys with ASD. 65 Table 2 (cont’d) Auyeung et al. TD: 1256 Affective Empathy Author-created There was a significant difference in (2009) ASD: 265 test scores between typical boys and girls and the ASD group. Typical girls scored the highest, followed by typical boys, and then the ASD group. Avirame et al. ASD: 2 Empathic Concern Interpersonal Reactivity Index Self-report questionnaires showed slight (2017) (Davis, 1980) improvement in autistic symptoms and empathy IRI. Baez et al. TD: 15; ASD: Affective Empathy Author-created TD adults scored lower than adults with (2012) 15 Cognitive Empathy Interpersonal Reactivity Index ASD on Personal Distress and (1983) Perspective Taking subscales. No difference was found between the two groups on the Empathic concern and Fantasy subscales. Balch & Ray 5 ASD Affective Empathy Author-created Three of the five participants did not (2015) have change in their empathy throughout intervention, while the other two showed an increase. Barnes et al. ASD: 28 Affective Empathy Empathy Quotient (Baron- A significant correlation was found (2009) TD: 28 Cognitive Empathy Cohen & Wheelwright, 2004) between verbal IQ and the level of mentalizing in film narratives for the ASD group, but not the control group, while the reverse pattern was found with a measure of self-reported cognitive and affective empathy. 66 Table 2 (cont’d) Baron-Cohen et ASD: 395 Affective Empathy Empathy Quotient (Baron- Eyes test-Empathy Quotient and Eyes al. (2015) TD: 320 Cognitive Empathy Cohen & Wheelwright, 2004) test-Autism Quotient (AQ) correlations were significant only in females with ASD. Baron-Cohen & ASD: 90 Affective Empathy Empathy Quotient (Author- Females scored significantly higher Wheelwright TD: 90 Cognitive Empathy created) than males on the EQ. (2004) Baron-Cohen et Asperger’s Affective Empathy Empathy Quotient The ASD group scored much lower on al. (2005) syndrome: 31 Cognitive Empathy (Author-created) the EQ and much lower on the AQ than HFA: 3 the TD group. The ASD group’s scores No Dx: 8 on the EQ were lower than the cut-off of 30. Begeer et al. Treatment: Not explicitly Index of Empathy for Children Self-reported and parent-reported (2011) 19 ASD stated and Adolescents (Bryant, empathy and social skills did not show Waitlist: 1982) an effect of training. 17 ASD Bellebaum et ASD: 10 Affective Empathy Author-created Trait affective empathy, congruent state al. (2014) TD: 12 affective empathy, and incongruent state affective empathy did not vary significantly between the TD and ASD groups. Trait cognitive empathy was significantly lower in the ASD group than the TD group. Bellini (2004) ASD: 35 Affective Empathy Author-created A curvilinear relationship was found PDD-NOS: 6 between the Social Anxiety Scale for Adolescents and Social Skills Rating System Empathy subscales. 67 Table 2 (cont’d) Bernhardt et al. ASD: 16 Empathic Concern Interpersonal Reactivity Index Analysis of IRI subscales showed that (2014) TD: 16 (Davis, 1980) the ASD group did not differ from controls on the IRI subscales fantasy, empathic concern, and personal distress after correction for multiple comparisons. The ASD group did score significantly lower on the perspective taking subscale relative to controls. Bethroz et al. ASD: 16 Affective Sharing Author-created EQ and IRI scores were equivalent to (2008) TD: 410 and Cognitive The Interpersonal Reactivity those of other studies. The EQ scores Attribution Index-empathic concern were similar to the scores in the report General Empathy (French version) by Baron-Cohen et al. Empathy Quotient (Baron- Cohen et al., 2004) Bird et al. ASD: 18 Affective Empathy Author-created There was a negative correlation (2010) TD: 18 Cognitive Empathy Interpersonal Reactivity Index between the alexithymia questionnaire General Empathy (Davis, 1980) and IRI scores. This suggested the severity of the relationship between alexithymia and empathy. Bos & Stokes ASD: 24 Affective Empathy Author-created The ASD group scored lower than the (2019) TD: 24 Cognitive Empathy Interpersonal Reactivity Index control group on the IRI subscales (Davis, 1980) empathic concern and perspective taking. There was no relationship found between gender and IRI scores. 68 Table 2 (cont’d) Brewer et al. ASD: 163 Affective Empathy Author-created On the IRI, the ASD group scored (2017) TD: 80 Cognitive Empathy Interpersonal Reactivity Index lower than the control group on the (Davis, 1980) Perspective taking, Empathic concern, and Personal distress subscales. Butean et al. ASD: 26 Affective Empathy Author-created 76% of children with ASD scored lower (2014) TD: 37 Cognitive Empathy than TD children on affective responses. No significant differences were found between the two groups in verbal empathic initiations and prosocial behaviors. Campbell et al. ASD: 38 Affective Empathy Author-created High-risk toddlers and toddlers with (2015) TD: 31 Cognitive Empathy ASD had lower empathic concern than low-risk toddlers. Campbell et al. HR: 59 Affective Empathy Author-created Low-risk toddlers had higher empathic (2017) LR: 90 Cognitive Empathy concern than ASD and high-risk ASD: 20 toddlers. Cascia & Barr ASD: 20 Affective Empathy Author-created Parents rated their children’s empathy (2017) Cognitive Empathy Children's Empathy Quotient and function skills higher than the (Auyeung et al., 2009) children’s teachers. Cassidy et al. ASD: 2871 Affective Empathy Author-created Participants with ASD had self-reported (2016) TD: 10,706 Cognitive Empathy empathy that was lower than TD participants. 69 Table 2 (cont’d) Cheng et al. ASD: 3 Empathic behaviors Empathy Rating Scale (Lin, Based on visual analysis results, the (2010) 2008) scores for the three participants varied during the baseline stage indicating slight differences in their initial behavior. Courty et al. TD: 15 Affective Empathy Author-created Participants with ASD scored higher on (2013) ASD: 15 Cognitive Empathy Empathy Quotient (Baron- the IRI Personal Distress subscale than Cohen et al., 2004) the TD group, but lower on the EQ and Interpersonal Reactivity Index IRI Empathic Concern subscale. (Davis, 1980) De Coster et al. ASD: 20 Trait Empathy Author-created Adults with ASD showed increased (2018) TD: 20 Empathic Concern Interpersonal Reactivity Index empathic responses over time after (Davis, 1980) being imitated. Demurie et al. ASD: 13 Affective Empathy Author-created There was a significant difference (2011) TD: 18 Cognitive Empathy between parent and self-reported empathy, with self-reported empathy much lower than parent-reported empathy. DeNigris et al. ASD: 22 Affective Empathy Author-created Eleven of the fifteen ASD participants (2018) TD: 15 Cognitive Empathy who had been bullied displayed cognitive empathy compared to seven of eleven mentors. 70 Table 2 (cont’d) Deschamps ASD: 22 Affective Empathy Author-created Teachers and parents rated the children (2014) TD: 29 Cognitive Empathy Griffith Empathy Measure with ASD lower on cognitive empathy (Dadds et al., 2008) than TD children, but the same on affective empathy. There was a negative relationship between cognitive empathy rated by parents and total SRS scores. Dudas et al. Full sample: Affective Empathy Empathy Quotient (Baron- There was a significant difference (2017) ASD: 640 Cognitive Empathy Cohen & Wheelwright, 2004) between scores of the TD and ASD TD: 2081 groups on the EQ. Dziobek et al. ASD: 50 Affective Empathy Interpersonal Reactivity Index The TD individuals scored much higher (2008) TD: 68 Cognitive Empathy (Davis, 1980) on cognitive empathy than ASD participants. On the IRI, ASD participants did not score significantly differently than TD participants. Evers et al. ASD: 50 Victim Empathy Victim Empathy Scale- Participants with higher empathy scores (2015) TD: 68 Adapted (Beckett & Fisher, also scored higher on the Emotion 1994) Recognition Task. Frolli et al. ASD Affective Empathy Basic Empathy Scale (Jolliffe There was no difference in the scores (2020) (experimental): Cognitive Empathy & Farrington, 2006) between the two groups when baseline 25 data was taken. ASD (control): 25 71 Table 2 (cont’d) Gantman et al. ASD: 17 Affective Empathy Empathy Quotient (Baron- During baseline data collection, the (2021) Cognitive Empathy Cohen & Wheelwright, 2004) treatment group had an average score on the EQ that was higher than the delayed treatment group. A positive correlation was found between loneliness and depression and anxiety. Garfinkel et al. ASD: 20 Affective Empathy Empathy Quotient (Baron- AQ scores were significantly higher for (2016) TD: 20 Cognitive Empathy Cohen & Wheelwright, 2004) the ASD participants than the TD participants, while their EQ scores were significantly lower. Gleichgerrcht ASD: 36 Affective Empathy Child Empathy Questionnaire- Empathy did not vary between the et al. (2013) TD: 36 Cognitive Empathy Systemizing Questionnaire deontological and utilitarian responders. (Wakabayashi et al., 2006) Golan et al. ASD: 50 Primarily victim The Impulsivity Deficit in the auditory domain, together (2007) TD: 26 empathy; some Venturesomeness Empathy–7 with similar deficits in recognition of cognitive and Questionnaire (French mental states from visual stimuli and affective aspects of version)- derived from context, support the existence of empathy from Mehrabian and Epstein’s an underlying mechanism for 27 Empathic Tendency empathizing which is impaired in Questionnaire individuals with ASD. Goldingay et al. ASD: 7 Affective Empathy Social Skills Improvement The average score for empathy on the (2015) Cognitive Empathy System (Gresham & Elliot, Social Skills Improvement System for 2008) participants was 11.8. The study found that an early pretend play intervention may help with participants' flexible thinking, self-regulation, and empathy. 72 Table 2 (cont’d) Gonzalez-Gada ADHD: 22 Affective Empathy Children's Empathy Quotient The participants with ASD scored an et al. (2013) ASD: 23 Cognitive Empathy (Auyeung et al., 2009) average of 19.72 (SD = 8.74) on the TD: 21 Empathy Quotient. Greenberg et al. Discovery: Affective Empathy Children's Empathy Quotient TD males and females scored higher on (2018) 671,606 with Cognitive Empathy (Auyeung et al., 2009) the EQ and Sensory Perception 36,648 ASD Quotient than males and females with Validation: ASD. 14,354 with 226 ASD Greimel et al. ASD: 15 Affective Empathy Chinese version of Griffith The male participants with ASD (2010) TD: 15 Cognitive Empathy Empathy Measure (Wei & Su, showed the lowest empathy out of all 2019) participants. Groen et al. ASD: 42 Affective Empathy Empathy Quotient (Baron- Females scored higher on the EQ than (2015) TD: 685 Cognitive Empathy Cohen & Wheelwright, 2004) males. Participants with ASD were found to score lower on the EQ than TD participants. Grove et al. ASD: 363 Affective Empathy Coding system based on The participants with ASD scored lower (2013) Parents of ASD Cognitive Empathy previous work (Young et al., on empathy than the control group. A participants: 1999; McDonald & Messinger, negative correlation was found between 439 2012) empathizing and systemizing, with a TD: 232 larger negative difference found in those with ASD. Grove et al. ASD: 363 Affective Empathy Empathy Quotient (Baron- Muncer et al.’s model of the EQ was (2014) TD: 232 Cognitive Empathy Cohen & Wheelwright, 2004) the best fit for the data found. 73 Table 2 (cont’d) Grove et al. ASD: 363 Affective Empathy Empathy Quotient (Baron- Individuals with ASD scored lower on (2015) TD: 232 Cognitive Empathy Cohen & Wheelwright, 2004) the EQ and higher on the Systemizing Quotient than TD individuals. TD males scored the highest on the EQ while males with ASD scored the lowest. Gu et. al (2015) ASD: 17 Affective Empathy Dutch version of Empathy Lower EQ scores and higher TD: 17 Cognitive Empathy Quotient (Baron-Cohen & alexithymia were found in the ASD Wheelwright, 2004) group than the TD group. Guivarch et al. ASD: 6 Affective Empathy Dutch-version of Empathizing- The baseline EQ scores ranged from 2 (2017) Cognitive Empathy Systemizing questionnaire to 13. (Auyeung et al., 2008) Hadjikhani et ASD: 36 Affective Empathy Emotion Attribution to Self ASD participants scored lower on both al. (2014) TD: 31 Cognitive Empathy (Burnett et al., 2009) affective and cognitive empathy than TD participants. There was a positive correlation between brain activation and affective empathy in participants with ASD. Hagenmuller et ASD: 29 Affective Empathy Empathic Accuracy Task Empathic concern and perspective- al. (2014) TD: 28 Cognitive Empathy (Ickes et al., 1990) taking scores were lower for participants with ASD. 74 Table 2 (cont’d) Hall et al. ASD: 12 Affective Empathy Empathy Quotient (Baron- Males and females showed a different (2012) TD: 12 Cognitive Empathy Cohen & Wheelwright, 2004) relationship between social brain activation and empathy, with males showing a positive whole brain correlation between left IFC activation and empathy scores during approachability judgements which was not seen in females. Hardstaff ASD: 1 Affective Empathy Empathy Continuum (Strayer, Empathy may be a way to show critical (2014) Cognitive Empathy 1993) thinking skills through taking an evaluative approach to characters’ behavior. Hillier et al. ASD: 13 Affective Empathy Empathy for Pain Paradigm There were no significant differences in (2007) Cognitive Empathy (Singer et al, 2004) score for those who participated in the Aspirations program and those who did not. On 17 of 25 questions, responses were higher after Aspirations. Those with ASD have lower social skills, resulting in lower cognitive empathy. Hirvelä & ASD: 41 Affective Empathy Interpersonal Reactivity Index ASD participants scored lower on both Helkama TD: 139 Cognitive Empathy (Davis, 1980) the affective and cognitive empathy (2011) subscales than the TD participants, as well as the perspective taking and fantasy subscales. Hobson et al. ASD: 20 Affective Empathy Empathy Questionnaire Only 2 of 20 ASD participants (2009) TD: 14 Cognitive Empathy (Baron-Cohen et al., 2005) responded to the drawing compared to 11 of 14 TD participants. 75 Table 2 (cont’d) Holopainen et ASD Treatment: Trait Empathy The Me Scale II (Chang, 2011) No difference was found between al. (2019) 72 parent-reported empathy and empathic ASD Waitlist: responsiveness. 63 Horwitz et al. ASD: 249 Reduced Empathy Adult Social Behavior Adults with ASD scored higher on the (2016) ADHD: 34 Questionnaire (ASBQ; ASBQ than other groups - TD, ADHD, Depressive Author-created) schizophrenia, and adults with Disorder: 59 depressive disorder. Schizophrenia: 21 Hudry & ASD: 26 Affective Empathy Empathy Questionnaire Participants with ASD showed the most Slaughter DS: 15 Cognitive Empathy (Overgaauw et al., in comfort to their caregiver compared to (2009) TD: 54 preparation) other children and unknown adults. TD participants also comforted their caregiver and the other child, but the unknown adult less so. Jermakow & Anorexia Affective Empathy Empathy Quotient (Baron- The Anorexia Nervosa group differed Brzezicka Nervosa: 11 Cognitive Empathy Cohen & Wheelwright, 2004) significantly from the ASD group in (2016) ASD: 10 Interpersonal Reactivity Index empathy level and ToM, exhibiting TD: 60 (Davis, 1980) results similar to the comparison group. Johnson et al. ASD: 20 Affective Empathy Empathy Quotient (Baron- The TD group was found to have higher (2009) TD: 22 Cognitive Empathy Cohen & Wheelwright, 2004) EQ scores than the ASD group. There was a correlation found between parent and children’s ratings for empathy: the lower the parent score, the lower the child score. 76 Table 2 (cont’d) Jones et al. ASD: 21 Affective Empathy Empathy Quotient (Baron- Participants with ASD rated their fear (2010) TD: 31 Cognitive Empathy Cohen & Wheelwright, 2004) significantly higher than the TD group. Kästner et al. ASD: 148 Affective Empathy Empathy Quotient (Baron- AQ and EQ were not found to vary (2015) ASD Cognitive Empathy Cohen & Wheelwright, 2004) dependent on ADOS diagnosis. AQ and schizophrenia: EQ performed at chance level in the 137 prediction of ASD. Non-ASD schizophrenia: 168 TD: 97 Kember & ASD: 41 Affective Empathy Empathy Quotient (Baron- EQ scores were significantly correlated Williams TD: 343 Cognitive Empathy Cohen & Wheelwright, 2004) with autism symptomatology with (2021) lower sores on the EQ relating to higher scores on autism traits. Kirchner, et al. ASD: 20 Affective Empathy Empathy Quotient (Baron- In the face identity task, participants (2011) TD: 21 Cognitive Empathy Cohen & Wheelwright, 2004) with ASD had a more difficult time correctly identifying the emotions than the TD participants. Koch et al. ASD: 31 Affective Empathy Empathy Quotient (Baron- Scores on the EES did not vary between (2016) Cognitive Empathy Cohen & Wheelwright, 2004) the control group and the treatment General Empathy The Emotional Empathy Scale group. Social skills, however, did show (EES; Caruso and Mayer, a significant difference between the two 1998) groups, with the treatment group having a greater increase in their social skills. 77 Table 2 (cont’d) Koegel et al. ASD: 3 Affective Empathy Empathy Quotient (Baron- In the baseline data collection, the (2016) Cognitive Empathy Cohen & Wheelwright, 2004) participants showed appropriate empathy 0%, 5.6%, and 37%, respectively. Koehne et al. ASD: 51 Affective Empathy Interpersonal Reactivity Index Participants scored an average of 14 on (2016) Cognitive Empathy (Davis, 1980) the empathic concern portion of the IRI. Koehne et al. ASD: 20 Affective Empathy Empathy Quotient (Baron- On both cognitive and affective (2016) TD: 22 Cognitive Empathy Cohen & Wheelwright, 2004) empathy, ASD participants rated themselves lower than the TD participants. Komeda et al. ASD: 22 Affective Empathy Empathy Quotient (Baron- In stories with TD characters, both the (2019) TD: 20 Cognitive Empathy Cohen & Wheelwright, 2004) ASD and TD participants had higher empathic responses than in stories with ASD characters. ASD participants showed higher empathic responses in stories with ASD characters than the TD participants. Decreased empathy was linked with social skills and attention to detail. Krajmer et al. ASD: 50 Affective Empathy Empathy Quotient (Baron- Older individuals with ASD scored the (2011) TD: 79 Cognitive Empathy Cohen & Wheelwright, 2004) lowest on the EQ than other participants. Younger TD and participants with ASD scored the same on the EQ. Kubota et al. ASD: 18 Affective Empathy Interpersonal Reactivity Index The ASD group had lower scores than (2020) TD: 20 Cognitive Empathy (Davis, 1980) control group on perspective taking and empathic concern subscales. 78 Table 2 (cont’d) Kuo et al. ASD: 55 Affective Empathy Empathy Quotient (Baron- There was a significant difference (2014) TD: 29 Cognitive Empathy Cohen & Wheelwright, 2004) between the ASD and TD groups’ empathic scores. On the social awareness subscale, the ASD group scored higher than the other participants. As expression towards others becomes more appropriate for the situation, social ability increases, as well. Lai et al. (2011) ASD: 62 Affective Empathy Empathy Quotient (Baron- Females had higher self-reported AQ Cognitive Empathy Cohen et al., 2004) scores while the EQ scores for both males and females with ASD were similar. Larson et al. ASD (no Affective Empathy Empathy Quotient (Baron- The ASD-Psychosis group scored (2015) psychosis): 71 Cognitive Empathy Cohen et al., 2004) significantly lower on full scale IQ ASD scores and higher empathizing bias (psychosis): 64 scores than the ASD-No Psychosis group. Lawson et al. ASD: 18 Affective Empathy Empathy Quotient (Baron- The TD females scored the highest on (2004) TD: 89 Cognitive Empathy Cohen et al., 2004) the EQ, followed by the TD males, then by the males with ASD. 79 Table 2 (cont’d) Lawson & ASD: 2 Affective Empathy N/A Data were collected on participant's Walsh (2007) Cognitive Empathy responses to empathy questions to 20 pictures and 20 real life situations in the classroom. Participant A emitted 15 correct responses to, “what happened?” 14 correct responses to, “How does the person feel?” and 5 correct responses to “What could you do to help?” during the pre-probe session of pictures. Participant B emitted 11 correct responses to, “What happened?” 14 correct responses to, “How does the person feel?” and 9 correct responses to, “What could you do to help?” during the pre-probe session of picture Lepage et al. TD: 100 Affective Empathy Empathy Quotient (Baron- The group of participants with ASD (2009) ASD: 23 Cognitive Empathy Cohen et al., 2004) scored lower on the EQ-F than the TD group, with women scoring the highest. AQ scores were also lower for the group of participants with ASD than the TD group, with men scoring higher than women. Lever & Geurts ASD: 237 Affective Empathy Interpersonal Reactivity Index Participants with ASD had lower scores (2018) TD: 198 Cognitive Empathy (Davis, 1980) on the perspective taking and fantasy subscales than the TD group and similar scores on the empathic concern subscale. 80 Table 2 (cont’d) Levin et al. ASD: 15 Affective Empathy Empathy Quotient (Baron- The scores of the participants with ASD (2015) Cognitive Empathy Cohen et al., 2004) on the EQ were much lower than the scores of the TD participants. Libero et al. ASD: 27 Affective Empathy Empathy Quotient (Baron- There was a significant correlation (2014) TD: 23 Cognitive Empathy Cohen et al., 2004) between the emotion condition and EQ for participants with ASD, while there was not a significant difference between the two for TD participants. Lombardo et al. ASD: 30 Affective Empathy Empathy Quotient (Baron- On the EQ, IRI, and ECS, participants (2007) TD: 30 Cognitive Empathy Cohen et al., 2004) with ASD scored lower than the TD Interpersonal Reactivity Index participants. Participants with ASD had (Davis, 1980) more difficulty remembering words Emotional Contagion Scale used to describe themselves. (ECS; Doherty, 1997) Lombardo et al. 1 case study Affective Empathy Empathy Quotient (Baron- The case study individual had lower EQ (2012) compared to Cognitive Empathy Cohen et al., 2004) and IRI scores compared to both the TD previous data of Interpersonal Reactivity Index group and the ASD group. Their score study with 30 (Davis, 1980) on the Self Reference Effect paradigm ASD and 30 TD Emotional Contagion Scale was also worse than the other two (Doherty, 1997) groups, with social-cognition having the biggest difference between the groups. Malhotra ASD: 1 Affective Empathy Empathy Quotient (Baron- Following intervention, the participant (2019) Cognitive Empathy Cohen et al., 2004) had an increase in their EQ score. 81 Table 2 (cont’d) Mastrominico 73 Affective Empathy Empathy Quotient (Baron- The treatment group had increased et al. (2018) Cognitive Empathy Cohen et al., 2004) scores in all components of the tests Empathic concern Empathic concern subscale of while the control group had increased Interpersonal Reactivity Index scores in the empathy and affective (Davis, 1983) empathy. Mathersul et al. ASD: 28 Affective Empathy Empathy Quotient (Baron- Participants with ASD had significantly (2013) TD: 31 Cognitive Empathy Cohen et al., 2004) lower cognitive and affective empathy scores than the control group. There was a significant negative correlation between skin conductance levels and cognitive and affective empathy for participants with ASD. Mathersul et al. ASD: 40 Affective Empathy Empathy Quotient (Baron- The individuals with ASD had lower (2013) TD: 33 Cognitive Empathy Cohen et al., 2004) empathy scores than the TD participants. Cognitive empathy was influenced by the “think,” “do,” and “say” probes. Mazza et al. ASD: 15 Affective Empathy Empathy Quotient (Baron- There was a statistically significant (2014) TD: 15 Cognitive Empathy Cohen et al., 2004) correlation between the participants Multifaceted Empathy Test with ASD and positive and negative (Dziobek et al., 2008) cognitive empathy. There was also a statistically significant correlation between the participants with ASD and negative affective empathy, but no correlation with positive affective empathy. 82 Table 2 (cont’d) Mazza et al. ASD: 10 Affective Empathy Empathy Quotient (Baron- Participants with ASD had lower (2020) TD: 10 Cognitive Empathy Cohen et al., 2004) overall scores on the EQ than the TD group. There was not a significant correlation found between the conditions in the Golden Beauty task and empathy tests. McDonald & ASD: 13 Affective Empathy Empathy Quotient (Baron- Children who were later diagnosed with Messenger TD: 25 Cognitive Empathy Cohen et al., 2004) ASD had lower empathic responses (2012) than children who were not diagnosed with ASD. They were, however, found to progress with their empathy skills at the same speed as the TD children. McDonald et Low risk/no Affective Empathy Empathy Quotient (Baron- Higher IQ was found to be associated al. (2017) ASD: 30 Cognitive Empathy Cohen et al., 2004) with higher empathy in participants. No High risk/no Empathy & Prosocial significant correlation was found ASD: 36 Response Subscale of the between empathy and gender. A ASD: 12 Conscience Questionnaire significant positive correlation was (Kochanska et al., 1994) found between visible distress and empathic concern. McVey et al. Experimental Affective Empathy Empathy Quotient (Baron- Participants showed improvement in (2016) ASD: 24 Cognitive Empathy Cohen et al., 2004) their social responses, empathy, and Waitlist Control social anxiety over the course of the ASD: 23 experiment. 83 Table 2 (cont’d) Melvin et al. ASD: 10 Affective Empathy Empathy Quotient (Baron- The participants were found to (2020) Cognitive Empathy Cohen et al., 2004) understand cognitive empathy, but the offenders lacked affective empathy and empathy for their victims. One participant improved in victim empathy, but not significantly. Mensi et al. ASD: 58 Affective Empathy Empathy Quotient (Baron- The majority of ASD patients have low (2018) Cognitive Empathy Cohen et al., 2004) levels of empathy according to both parents' points of view; noteworthy, mothers and fathers are highly concordant in this respect. Children's levels of empathy negatively correlate with many behavioral problems, both internalizing and externalizing. Metcalfe et al. ASD: 27 Cognitive Empathy Questionnaire of Cognitive A diagnosis of ASD was correlated (2019) TD: 27 Emotional and Affective Empathy with the AQ and QCAE, but beyond Reactivity (QCAE; Reniers et al., 2011) diagnosis, they do not provide much information. Minio-Paluello ASD: 16 Cognitive Empathy Empathy Quotient (Baron- On the IRI Personal Distress subscale, et al. (2009) TD: 20 Affective Empathy Cohen et al., 2004) no difference was found between the Interpersonal Reactivity Index group with ASD and the TD group. The (IRI; Davis, 1996) participants with ASD scored lower on the EQ and IRI than the TD group. Montgomery et HF-ASD: 43 Cognitive Empathy Empathy Quotient (Baron- The two groups of participants did not al. (2016) Asperger’s: 43 Affective Empathy Cohen et al., 2004) have any difference in their empathy, and empathy did not differ between males and females among either group. 84 Table 2 (cont’d) Moriwaki et al. ASD: 24 Parallel Empathy Affective Situation Test (AST; Parallel empathy scores were not (2011) TD: 24 Reactive Empathy Asakawa& Matsuoka, 1987) significantly different between the TD group and group with ASD. Reactive empathy was lower in participants with ASD than TD participants. Mul et al. ASD: 26 Communicating Empathy Quotient (Baron- Participants with ASD scored lower on (2018) TD: 26 Empathy Cohen et al., 2004) cognitive empathy than TD participants, Affective Empathy Multifaceted Empathy Test but their affective empathy was similar. (Dziobek et al., 2008) Participants with ASD who had alexithymia scored lower on empathy than those who did not have alexithymia. Murphy et al. Group One: 7 Victim Empathy Victim Empathy Scale- Participants’ attitudes, sexual (2007) Group Two: 8 Adapted (VES-A; Beckett & knowledge, and victim empathy Fisher 1994) improved from the beginning to the end of the experiment. Murray et al. ASD: 20 Empathic Concern Interpersonal Reactivity Index The participants rated themselves on (2017) TD: 20 (Davis, 1980) empathic concern and fantasizing, with the two groups rating themselves similarly in the two categories. The participants with ASD rated themselves significantly higher on the personal distress subscale. 85 Table 2 (cont’d) Myles et al. ASD: 156 Empathic Abilities Empathy Quotient (Lawrence No differences were found between (2007) et al., 2004) males and females, with both groups scoring lower than average in empathy. The only delay found between the participants with ASD and TD individuals was in social interaction. Oberman ASD: 13 Empathic Empathy Quotient (Rogers et The group with ASD had lower (2009) TD: 13 abilities/behavior al., 2007) empathy and ToM scores than the TD Basic Emotional Empathy group. Scale (Mehrabian, 1996) Osório et al. WS: 25 Cognitive Empathy Griffith Empathy Measure Both cognitive and affective empathy (2019) TD: 25 Affective Empathy (Dadds et al., 2008) scores were correlated with 2D:4D in the group with WS. Park et al. ASD: 111 Cognitive Empathy Empathy Quotient for Females had higher overall EQ-C (2012) Siblings: 98 Affective Empathy Adolescents (Baron-Cohen et. scores than males for the TD group, but TD: 51 al, 2012) no difference was found between genders in participants with ASD. Patil et al. ASD: 17 Empathic Accuracy Empathy Quotient for adults Alexithymia was associated with (2016) TD: 17 State Empathy (Lawrence et al., 2004) increased harmful actions and lower Multifaceted Empathy Test empathic concern in participants with (Dziobek et al., 2008) ASD. Paulus et al. ASD: 32 Trait Empathy German version of the E-Scale Trait empathy was significantly (2013) TD: 32 (Leibetseder et al., 2007) correlated with autistic symptoms, with participants with ASD having lower trait empathy. 86 Table 2 (cont’d) Pepper et al. ASD: 60 Cognitive Empathy Empathy Quotient for The participants with ASD had lower (2019) TD: 26 Affective Empathy Children (Baron-Cohen et. al, scores on all subscales of the EQ than 2009) the TD participants. On the social skills subscale, participants with ASD showed more impairment than the TD participants. Pepper et al. ASD: 53 Cognitive Empathy Empathy Quotient- Children's There was a significant difference in (2018) EP: 51 Affective Empathy Version (Auyeung et al., 2004) EQ scores between the participants with SAD: 64 ASD and the TD group. TD: 31 Peterson (2014) ASD: 37 Empathic Concern Empathy subscale from Teacher-reported empathy suggested TD preschool: Children's Behavior that children with ASD had lower 20 Questionnaire (Rothbart et al., empathy than TD children, but these TD primary 2001) differences were not linked to ToM school: 19 development. Peterson et al. Study 1 - ASD: Empathic Concern Empathy subscale of the Participants with ASD were found to (2015) 34 Multisource Assessment of have lower empathy than TD TD: 41 Social Competence Scale participants. Older children with ASD Study 2 - (Junttila et al., 2006) were less empathetic, likely because of ASD 33 a lack of motivation to assist other TD: 31 people and not understanding how to help them out. Petrides et al. ASD: 30 Empathic Concern Empathy task (Zahn-Waxler et TD participants had higher social (2011) TD: 43 al., 1992) awareness than participants with ASD. Participants with better sociomoral outcomes were more likely to use perspective taking. 87 Table 2 (cont’d) Plesa Skwerer WS: 16 Empathic Concern Interpersonal Reactivity Index On empathic concern, participants with & Tager- DS: 15 (Davis, 1983) WS had the highest ranking, followed Flusberg (2016) TD: 18 by participants DS and then TD participants. Participants with WS and DS had higher empathy scores than helpfulness. Ponnet et al. ASD: 19 Empathic Accuracy Empathic Accuracy Task Video 1 targets had more thoughts and (2004) TD: 19 (Ickes, 1997; feelings than video 2 and no significant Ickes et al., 1990a; Marangoni differences in scores were found et al., 1995) between the two groups. Ponnet et al. ASD: 22 Empathic Accuracy Empathic Accuracy Task There was a positive correlation (2008) TD: 22 (Ickes, 1990) between IQ score and accuracy on video 1 for participants. Empathy was correlated with IQ score; the higher the IQ, the higher the empathy. Ponnet et al. PDD-NOS: 11 Empathic Accuracy Empathic Accuracy Task There was no significant difference (2005) TD: 11 (Ickes, 1990) between the empathic accuracy for PDD-NOS and TD participants. Pouw et al. ASD: 67 Empathic German version of the E-Scale Self-reported aggression and anger did (2013) TD: 66 Responsiveness (Leibetseder et al., 2007) not vary between the two groups. Participants with ASD self-rated themselves lower on empathic responsiveness than TD participants. 88 Table 2 (cont’d) Rabin et al. Immediate Empathic social Empathy Quotient (Baron- Pre-intervention, participants had an (2018) intervention: 20 initiation Cohen & Wheelwright, 2004) average EQ score of 32.44. Delayed General Empathy Social Skills Improvement intervention System (Gresham & Elliott, control: 21 2008) Radtke et al. Chronic Cognitive Empathy Empathy Quotient (Baron- Participants with ASD had the lowest (2019) Depression: 31 Affective Empathy Cohen & Wheelwright, 2004) empathy scores of the three groups, ASD: 27 followed by the Chronic Depression TD: 31 group and the TD group had the highest scores. On the AQ, the participants with ASD scored the highest. Riedel et al. ASD: 57 Cognitive Empathy Empathy Quotient (Baron- A strong correlation was found between (2014) TD: 56 Affective Empathy Cohen & Wheelwright, 2004) the AQ and EQ; the higher the score on Other the AQ, the lower the EQ score. psychiatric disorders: 66 Rieffe et al. ASD: 69 Cognitive Empathy Griffith Empathy Measure Young participants with ASD showed (2021) TD: 124 Affective Empathy (Dadds et al., 2008) the least empathy. No gender differences were found. Rigby et al. ASD: 16 Cognitive Empathy Empathy Quotient (Baron- Participants with ASD had lower EQ (2016) TD: 16 Affective Empathy Cohen & Wheelwright, 2004) scores. The participants with lower EQ looked at faces for less time. Rigby et al. ASD: 16 General Empathy Index of Empathy for Children The participants with ASD scored lower (2018) TD: 16 and Adolescents (Bryant, on empathy than the other participants. 1982) 89 Table 2 (cont’d) Robinson & Adult ASD General Empathy Interpersonal Reactivity Index Emotion regulation, empathy, self- Elliott (2016) group: 3 (Davis, 1983) reflection, and mental representation Adolescent were strongly correlated. ASD group: 3 Rogers et al. ASD: 21 Empathic Concern Interpersonal Reactivity Index On the cognitive empathy scales, there (2007) TD: 21 (Davis 1983) was a statistically significant difference between the participants with ASD and TD group. On the affective empathy scales, there was no difference. Roy et al. Only ADHD: Cognitive Empathy Empathy Quotient (Baron- The eight participants diagnosed with (2013) 45 Affective Empathy Cohen & Wheelwright, 2004) both ADHD and ASD had lower EQ ADHD & later scores than the participants who were ASD: 8 diagnosed with only ADHD. Rudra et al. ASD: 25 Cognitive Empathy Empathy Quotient (Baron- A statistically significant negative (2016) TD: 26 Affective Empathy Cohen & Wheelwright, 2004) correlation was found between scores on the AQ and EQ. Rueda et al. ASD: 38 Empathic Concern Interpersonal Reactivity Index A positive correlation was found (2015) TD: 38 (Davis, 1980; Davis, 1983) between Perspective Taking and Empathic Concern. Self-reported cognitive empathy in participants showed that participants with ASD have lower cognitive empathy than TD. 90 Table 2 (cont’d) Rueda et al. ASD: 42 Empathic Concern Interpersonal Reactivity Index Participants with ASD scored lower on (2014) TD: 44 (Davis, 1980) the Perspective Taking and Empathic Concern subscales of the IRI than the TD participants. There was a positive correlation between happiness, positive affect, affective balance, and the empathic variables. Russ et al. ASD: 134 Cognitive Empathy Empathy Quotient (Baron- The group with ASD reported fewer (2020) TD: 39 Affective Empathy Cohen & Wheelwright, 2004) traits of empathy than the TD group. Empathy was positively correlated with emotion regulation. The two groups did not differ in emotion evaluation. Samson & ASD: 19 Cognitive Empathy Empathy Quotient (Baron- TD participants had higher empathizing Hegenloh TD: 109 Affective Empathy Cohen & Wheelwright, 2004) and lower systemizing scores than the (2010) participants with ASD. There was a difference in humor processing found between the two groups, thought to be affected by cognitive flexibility, central coherence, and local bias. Santiesteban et ASD: 21 Empathic Response Continuous Affective Rating Participants with ASD showed affective al. (2021) TD: 45 Empathic Concern and Empathic Response empathy when taking their alexithymia (CARER) Task (extension of into account and they can share the the Empathic Accuracy Task; same emotional state as others even if e.g. Ickes et al. 1990; Zaki et they struggle to infer their affective al. 2008) state. Interpersonal Reactivity Index (Davis, 1980) 91 Table 2 (cont’d) Schaller & ASD: 23 Cognitive Empathy Empathy Quotient (Baron- Participants with ASD did not differ in Rauth (2017) TD: 22 Affective Empathy Cohen & Wheelwright, 2004) systemizing from the TD participants, but they had lower empathy. Scheeren et al. High ADOS General Empathy Interpersonal Reactivity Index Sadness had the most empathic (2013) group: 56 Empathic (Davis, 1980) responses, followed by happiness and Low ADOS Responsiveness Author-created pain. The older participants showed group: 95 more empathy than the younger TD: 50 participants. Schneider et al. ASD: 18 Cognitive Empathy Empathy Quotient (Baron- The participants with ASD scored lower (2013) TD: 16 Affective Empathy Cohen & Wheelwright, 2004) on the EQ, on average, by 17 points than TD participants. Schneider et al. ASD: 28 Cognitive Empathy Empathy Quotient (Baron- Control groups gave empathic (2013) TD: 28 Affective Empathy Cohen & Wheelwright, 2004) responses 20% more often than participants with ASD. Schrandt et al. ASD: 4 General Empathy Interpersonal Reactivity Index During baseline, there was very little (2009) Empathic Concern (Davis, 1980) response from participants to empathy Author-created situations. Schulte-Rüther ASD: 18 Cognitive Empathy Empathy Quotient (Baron- EQ scores were correlated with et al. (2011) TD: 18 Affective Empathy Cohen & Wheelwright, 2004) responses during the self-task. Schulte-Rüther ASD: 27 Affective Empathy Author-created Participants with ASD were able to et al. (2014) TD: 27 Cognitive Empathy Bryant Index of Empathy for identify the emotions of others, but they Empathic Abilities children/adolescents (Bryant, struggled with having a reaction to 1982) these emotions. 92 Table 2 (cont’d) Schulte-Rüther ASD: 18 General Empathy Interpersonal Reactivity Index Parents of children with ASD rated et al. (2017) TD: 18 Empathic Ability (Davis, 1980) their children as less empathetic than Griffith Empathy Measure those with TD children. (Dadds et al., 2008) Schwarz et al. ASD: 45 Empathic Concern Interpersonal Reactivity Index Lower empathy scores were associated (2011) TD: 50 (Davis, 1983) with higher AQ scores, indicating that individuals with ASD have lower empathy. Schwenck et al. Conduct Cognitive Empathy Video Sequence Task in style Older children scored higher on (2012) Disorder (CD) + Affective Empathy of empathy response task emotion recognition than younger Callous (ERT; Ricard & Kamberk- children. Post-hoc tests indicated that Unemotional Kilicci,1995) participants of the ASD group had more Traits (CU): 36 problems taking the perspective of the CD-CU (w/o protagonist of the films than all other Callous groups. Unemotional Traits: 34 ASD: 55 TD: 67 Senland & HF-ASD: 16 General Empathy Interpersonal Reactivity Index Empathic concern did not vary between Higgins- TD: 16 Empathic Concern (Davis, 1983) the two groups, but participants with D’Alessandro Author-created ASD had higher personal distress. (2013) Moral reasoning was lower for participants with ASD than TD. 93 Table 2 (cont’d) Senland & ASD: 22 General Empathy Interpersonal Reactivity Index The two groups scored similarly on Higgins- TD: 22 Empathic Concern (Davis, 1983) Empathic Concern. TD participants D’Alessandro scored higher on Perspective Taking (2016) participants with ASD scored higher on the Personal Distress subscale. “Sex Offender ASD: 4 Victim Empathy Victim Empathy Scale Victim empathy did not change as Treatment” (Beckett & Fisher 1994) – expected, likely due to lack of (2010) Adapted participants at follow-up. Shi et al. (2020) ASD: 11 Early- Cognitive Empathy Griffith Empathy Measure GEM scores were significantly lower onset Affective Empathy (GEM; Dadds et al., 2008) for participants with ASD and EOS schizophrenia than TD participants. Cognitive (EOS): 20 empathy varied between the groups, but TD: 26 affective empathy did not. Silani et al. ASD: 15 Cognitive Empathy Empathy Quotient (Baron- There was a significant correlation (2008) TD: 15 Affective Empathy Cohen & Wheelwright, 2004) between EQ and Perspective-Taking Empathic Concern Interpersonal Reactivity Index subscale of the IRI. (Davis, 1983) Sivaraman ASD: 2 General Empathy Interpersonal Reactivity Index During baseline, both participants had (2017) (Davis, 1983) low empathy. Soorya et al. Tx group: 35 Empathic Concern Interpersonal Reactivity Index There were significant improvements (2015) Control: 34 (Davis, 1983) for participants on empathic responding, but not for social cognitive outcomes. 94 Table 2 (cont’d) Stauder et al. ASD: 25 Cognitive Empathy Empathy Quotient (Baron- The TD participants scored higher on (2011) TD: 25 Affective Empathy Cohen & Wheelwright, 2004) the EQ than the participants with ASD. There was no difference between genders. Strunz et al. Online ASD: Emotional Empathy Multidimensional Social The participants did not vary in their (2017) 198 Outpatient Cognitive Empathy Competence Scale (author- cognitive empathy. Social support did ASD: 31 created) not affect relationship status. Mental State Perception sub- scale of the Cognitive and Emotional Empathy Questionnaire (Savage et al. 2010) Sucksmith et al. ASD: 329 Cognitive Empathy Empathy Quotient (Baron- Mother-reported empathy was lower (2013) ASD parent: Affective Empathy Cohen & Wheelwright, 2004) than father-reported empathy. 310 Participants with ASD were less likely TD: 187 to correctly identify emotions than TD participants. Tavassoli et al. ASD: 68 Cognitive Empathy Empathy Quotient (Baron- The participants with ASD had lower (2018) Sensory Affective Empathy Cohen & Wheelwright, 2004) EQ and Systemizing Quotient scores Processing than the TD participants. On the EQ, Conditions girls scored higher than boys. (SPC): 79 TD: 63 Thaler et al. ASD: 16 Empathic Concern Interpersonal Reactivity Index Participants with ASD had lower (2018) TD: 16 (Davis, 1983) Empathic Concern and higher Personal Distress than TD participants. 95 Table 2 (cont’d) Trimmer et al. ASD: 25 Empathic Concern Parent-adapted Interpersonal Participants with ASD scored lower on (2017) TD: 25 Reactivity Index (Davis, 1980) the Empathic Concern and Perspective Taking subscales. Verschuur et al. Study 1= ASD: Victim Empathy Victim Empathy Scale-- The study 1 participants had baseline (2019) 13 parent/child Adapted (Beckett & Fisher, empathy from 0 to 0.75, while study 2 pairs 1994) participants had baseline from0 to 0.15. Study 2= 13 parent/child pairs Vuori et al. Treatment Cognitive Empathy Parent-adapted Questionnaire Participants in the intervention group (2017) group= Child: Affective Empathy of Cognitive & Affective had more disruptive and impulsive 121 Mothers: Empathy (Reniers et al., 2011) behavior. Parents of the participants 117 Fathers: 86 reported increased antisocial behavior Teachers: 97 among their children in the intervention TD group= group. Child: 318 Parent: 299 Teachers:14 Wagels et al. ASD: 32 Empathic Concern Interpersonal Reactivity Index On the IRI, males with ASD scored the (2020) TD: 40 (Davis, 1980) lowest, while TD females scored the highest. On the empathy scale, the same two groups scored the highest and lowest. Wakabayashi et ASD adults: 48 Cognitive Empathy Empathy Quotient (Baron- The participants with ASD scored al. (2007) Company Affective Empathy Cohen & Wheelwright, 2004) significantly lower on the EQ than the employees: 137 TD participants. Males scored lower University than females on the tests. students: 1250 96 Table 2 (cont’d) Wang et al. ASD: 30 Cognitive Empathy Empathy Quotient (Baron- There was a significant difference in (2019) TD: 39 Affective Empathy Cohen & Wheelwright, 2004) scores on the EQ and Systemizing Quotient (SQ), with TD participants scoring higher on the EQ and lower on the Systemizing Quotient. Wheelwright et ASD: 125 Cognitive Empathy Empathy Quotient (Baron- The participants’ sex affected the scores al. (2006) TD: 1761 Affective Empathy Cohen & Wheelwright, 2004) on the EQ, with females scoring higher than males. Williams & Overall sample: Cognitive Empathy Empathy Quotient (Baron- The EQ correlated with the actions and Cameron 1391 Affective Empathy Cohen & Wheelwright, 2004) feelings questionnaire (2017) ASD sub- sample: 326 Yager & ASD: 135 Empathic Concern Multidimensional Social Higher scores on the MSCS were Iarocci (2013) TD: 48 Competence Scale (MSCS; correlated with more friends amongst Author-Created) participants. Seven relatively distinct domains of social competence were identified including social motivation, social inferencing, demonstrating empathic concern, social knowledge, verbal conversation skills, nonverbal sending skills, and emotion regulation. Yoshimura et ASD: 10 Cognitive Empathy Empathy Quotient (Baron- The mismatch field (MMF) has been al. (2018) Affective Empathy Cohen & Wheelwright, 2004) used as a neurophysiological marker for the automatic detection of changes in auditory stimuli. The change in MMF and change in the EQ were significantly correlated. 97 Table 2 (cont’d) Ziemans et al. ASD: 53 Parallel empathy & TEIQue v. 1.50 (Petrides, The TD group had significantly higher (2019) TD: 29 Reactive empathy 2009) cognitive empathy scores than the group with ASD, and this stayed true as cognitive alexithymia was added as a covariate. The participants with ASD had higher cognitive alexithymia scores. Note. 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Others, however, have highlighted the critical importance of considering the etiology of different disorders and its role in the strengths and challenges observed across and within IDD conditions. The relationship between etiology and behavior is often referred to as “behavioral phenotypes” (Dykens et al., 2000). One important principle regarding behavioral phenotypes is the observance of probabilistic rather than deterministic outcomes (when a genetic disorder determines the outcome for every individual diagnosed with the syndrome; Dykens, 1995). Probabilistic outcomes mean that a group of individuals with a specific genetic condition are more likely to exhibit a “characteristic” or “typical” behavioral feature relative to those without the condition (Dykens, 1995, p. 523). Identifying and understanding these probabilistic outcomes and how they impact other aspects of the individuals’ lives could help to inform the development of interventions to address unique challenges experienced by individuals with specific IDD conditions. Understanding the pathways between genes and behavior can inform our understanding of the social difficulties individuals with different forms of IDD experience, including for example social exploitation, poor friendship qualities, and social skills deficits (Waite et al., 2014). Specifically, although individuals with several forms of IDD experience poor social outcomes, the pathways, or reasons that lead to these outcomes may differ across disability conditions. These inter-group differences may give rise to intervention considerations and 124 recommendations that may be unique for a specific IDD group. Acknowledgement of the variation of pathways to similar outcomes within the IDD population allows practitioners and researchers to develop appropriate interventions for different IDD groups while accounting for individual and group-specific characteristics. Empathy (i.e., the ability to understand and respond to the emotional state of others) is one general area of concern for individuals with IDD (de Wied et al., 2007). Overall, individuals with IDD have been reported to have impairments in empathy skills. Generally, empathy can be described as two sub-components: cognitive empathy and affective empathy. Cognitive empathy refers to a person’s understanding of another person’s emotions while affective empathy refers to how that person shares in or experiences the other person’s emotional state (Hoffman, 2001). Although neurological research suggests that these two sub-constructs of empathy may be governed by separate brain systems (Nummenmaa et al., 2008; Shamay-Tsoory et al., 2009), cognitive and affective empathy are considered interdependent in that a person cannot express the same emotional state of another person without the ability to first identify the emotion accurately (Behrends et al., 2012). While lower levels of empathy are consistently reported for individuals with IDD, these skills may vary across specific IDD groups such as autism spectrum disorder (ASD), Williams syndrome (WS), and Down syndrome (DS). For instance, individuals with ASD seemingly have more difficulties with understanding and identifying the emotions of others (i.e., cognitive empathy) compared to the expression of empathy (i.e., affective empathy; Blair, 2008; Frith, 2012; Smith, 2009). In contrast, individuals with DS display strong cognitive empathy skills, as they are more attentive to facial expressions and engage in positive affect (Kasari et al., 2003). Individuals with WS also seem to display strong empathy skills and are described as having 125 higher cognitive empathy, particularly due to their heightened sensitivity to the emotional needs of others (Jones et al., 2000). Specific social skills may also be crucial to understanding and expressing empathy toward others (Nugent & Halvorson, 1995; Koegel et al., 2016; Hill, 2009). In fact, empathy itself can also be defined and understood as a specific social and communication skill (Riggio et al., 1989). An individual who can successfully understand and express empathy toward others demonstrates competency in verbal communication and social role playing (Riggio, 1986). Specifically, empathy is particularly important during childhood and adolescence due to its role in the development and maintenance of friendships (Allemand et al., 2015; Eisenberg et al., 2006). While childhood friendships are mainly centered around concrete and quantitative constructs (e.g., sharing of toys), adolescent friendships emphasize more abstract constructs such as empathy (Eisenberg et al., 2006; Hoffman, 2000). Given the relationship between empathy and social skills in the general population, it is critical to examine the same relationship for various IDD groups. If empathy skills and social skills are similar or different across different IDD conditions, it is critical to identify any observed differences to account for those differences in future interventions. That is, identifying what differences may lead to one outcome or the other will provide a deeper understanding of what to address in interventions for each diagnostic group. Current examination of the research literature (Josol, [Chapter 2]) suggests that few studies have examined the relationship between empathy and social skills for individuals with WS and DS; however, some studies report that empathy skills are significantly related to various social domains including helpfulness, perspective-taking, displaying concern for others, and positive affect for individuals with ASD (e.g., Rueda et al., 2014; Senland & Higgins-D’Alesandro). 126 Purpose of Current Study Given the relationship between empathy and social skills in the general population, there is a serious need to examine the same phenomenon with the IDD population. To achieve this aim, etiology must be considered, as specific characteristics or traits of certain IDD group may also affect the relation of empathy to various social skills. The examination of group differences accounts for such etiological factors and will aid in designing interventions that are unique and prevalent to a specific IDD group. The current study was conducted to examine the specific relationship of empathy and social skills for individuals with ASD, WS, and DS as well as to assess for any differences across groups (including a typically developing [TD] control group). The research questions for the current study were (a) Do parent ratings of empathy and social skills differ between individuals with ADS, WS, DS, and TD?; (b) Are empathy skills and social skills related to each other for individuals with ASD, WS, DS, and TD ?; and (c) Are there differences in the relationship between empathy skills and social skills between groups? Method Sample Participants with IDD were recruited through various programs and organizations throughout the United States that support individuals and families with ASD, WS, and DS. Specifically, participants and their families with ASD were recruited from organizations such as Autism Speaks, the Simons Foundation Powering Autism Research (SPARK), and the Autism Alliance of Michigan (AAOM). Participants and their families with WS were recruited through local chapters of the Williams Syndrome Association, one of the largest organizations for Williams syndrome in the United States, as well as through the Williams Syndrome Associations Research Registry. Participants and their families with DS were recruited through local chapters 127 of the Down Syndrome Association, such as the Capital Area Down Syndrome Association, and through DS-Connect, a national Down syndrome registry. Finally, to serve as a control group, participants without IDD and their families were recruited from elementary and middle schools primarily in the Midwest region of the United States and through various parent listservs. Specifically, after obtaining approval from the institutional review board, a recruitment email describing the study and containing a link to a sign-up form was sent to the listservs of most of these programs and organizations. For large national organizations such as SPARK and DS-Connect, the research team applied for access to their recruitment services. Upon approval of both applications, the research team worked closely with the administrative team for SPARK and DS-Connect to recruit potential participants from their large database systems consisting of hundreds of individuals with their respective disabilities and their families interested in learning about research opportunities throughout the United States. Initial recruitment focused on recruiting adolescent participants with IDD (i.e., 10-15 years old) given that empathy plays an increasingly important role in social relationships (e.g., friendships) in adolescence (Eisenberg et al., 2006; Hoffman, 2000). However, due to difficulties recruiting participants in this narrow age range, the age requirement was reduced to include individuals as young as eight years old. For individuals with ASD, WS, or DS to be included in the present study, potential participants and families were asked to complete an initial screening form to confirm (a) the age of the child participant (i.e., 8-15 years old); (b) willingness to provide educational or medical records (e.g., an individualized education program [IEP], Section 504 plan, or genetic testing report) confirming diagnosis of ASD, WS, or DS; (c) ability to verbally communicate and hear due to the online nature of the study; and (d) the ability to attend to several computer tasks with 128 accommodations, if necessary. Due to the nature of the computer tasks, individuals with severe to profound intellectual disability were excluded. Parents of individuals without IDD (i.e., the TD group) were also asked to complete an initial screening form to assess for the following inclusion criteria: (a) child participant must be between 8-15 years of age; (b) caregivers report that the child does not have an educational or medical record indicating IDD (e.g., no IEP, Section 504 plan, or genetic testing report); (c) child is able to verbally communicate and hear due to the online nature of the study; and (d) the ability to attend to several computer tasks with accommodations if necessary. All TD participants were expected to have average intellectual functioning. The final sample (N = 120) included 30 individuals diagnosed with ASD (mean age = 10.73 years) and their caregivers, 30 individuals diagnosed with WS (mean age = 12.07 years) and their caregivers, 30 individuals with DS (mean age = 11.53 years) and their caregivers, and 30 TD individuals (mean age = 10.90 years) and their caregivers (see Table 3 for more demographic characteristics of the participants). Caregivers were 111 females and 9 males with educational levels ranging from some high school to a professional/graduate degree and annual incomes ranging from $15,000 to over $100,000. Table 3 Participant Characteristics Total ASD WS DS TD X2/ F Mean age (years) 11.30 10.73 12.07 11.53 10.90 2.54 Sexa 10.56* % male 58.3 83.3 53.3 50.0 46.7 % female 41.7 16.7 46.7 50.0 53.3 Race 1.59 % White 70.0 63.3 73.3 66.7 76.7 % Other 30.0 36.7 26.7 33.3 23.3 129 Table 3 (cont’d) Services (%) Occupational Therapy 56.7 56.7 76.7 93.3 0.00 60.54* Physical Therapy 28.3 16.7 50.0 46.7 0.00 25.78* Speech Language Pathology 67.5 70.0 90.0 100.0 10.0 66.67* Behavioral Services 19.2 50.0 16.7 10.0 0.00 27.27* Psychiatry 19.2 33.3 20.0 6.7 16.7 7.05* Social Skills Training 30.0 43.4 43.4 30.0 3.30 15.24* None 21.7 10.0 0.00 0.00 76.7 72.47* Special Education Services (%) 73.3 86.7 100.0 100.0 6.7 92.73* NIHTB-Cognitive Battery Picture Vocabulary Test 38.26 44.77 29.97 25.77 48.68 12.49** Picture Sequence Memory Test 38.41 43.69 32.97 31.52 45.67 20.77** Note. ASD = Autism Spectrum Disorder; WS = Williams syndrome; DS = Down syndrome; TD = Typically developing; NIHTB = NIH Toolbox. *p < .05 **p < .01. aASD group had more males than WS, DS, or TD Measures To measure empathy skills, caregivers were asked to complete the children's version of the Empathy Quotient (EQ-C; Auyeung et al., 2009). The EQ-C consists of 27 items with response options from definitely agree to definitely disagree and provides an overall total score (max score = 54) with lower scores indicating poorer empathy skills. Within the EQ, empathy is defined as “the drive to identify another person’s emotions and thoughts and respond to these with an appropriate emotion” (Baron-Cohen & Wheelwright, 2004; p. 361). While the EQ was originally intended for individuals with ASD (Baron-Cohen & Wheelwright, 2004; Hillier et al., 2007), it has been effectively used with individuals with intellectual disability in previous research (Hockley & Langdon, 2015; Woodard, 2009). For the EQ-C in the current study, Cronbach’s α was .45 for the total sample, .37 for the ASD group, .55 for the WS group, .64 for the DS group, and .51 for the TD group. 130 To measure social skills parents were asked to complete the Social Responsiveness Scale- Second Edition (SRS-2; Constantino & Gruber, 2005), a parent-report measure that assesses the presence and severity of social impairment. The SRS-2 consists of five subscales including social awareness (i.e., aware of what others are thinking and feeling), social cognition (e.g., ability to identify when something is unfair), social communication (i.e., ability to communicate feelings to others), social motivation (e.g., confidence when socializing with others), and autistic mannerisms (e.g., demonstrates an unusual narrow range of interests). For the purposes of this study, only the social awareness, social cognition, social motivation, and social communication subscales were used for data analysis. The SRS-2 has been used with various IDD populations both in research and clinical practice (e.g., Constantino et al., 2004; Fisher et al., 2020; Sturm et al., 2017) with good to excellent psychometrics properties demonstrated in United States samples (Bölte et al., 2008). For the current study, Cronbach’s α for the social awareness subscale was .72 for the total sample, .58 for the ASD group, .47 for the WS group, .12 for the DS group, and .47 for the TD group. On the social cognition subscale, Cronbach’s α was .86 for the total sample, .80 for the ASD group, .70 for the WS group, .21 for the DS group, and .55 for the TD group. For the social communication subscale, Cronbach’s α was .93 for the total sample, .91 for the ASD group, .80 for the WS group, .65 for the DS group, and .75 for the TD group. On the social motivation subscale, Cronbach’s α was .83 for the total sample, .67 for the ASD group, .54 for the WS group, .70 for the DS group, and .84 for the TD group. Higher scores on the SRS-2 indicate more challenges in social and communication skills. Due to the variation in cognitive ability likely to be observed across the ASD, WS, DS, and TD groups, child participants completed the iPad-based National Institutes of Health Toolbox Cognitive Battery (NIHTB-CB) recommended for ages 7 and over consisting of tests to 131 measure various cognitive domains such as executive functioning, attention, episodic memory, language processing speed, and working memory (Gershon et al., 2013; Weintraub et al., 2013). For the purposes of this study, only two of the tests that can be remotely administered were used, including the Picture Vocabulary Test and Picture Sequence Memory Test. The NIHTB-CB has been demonstrated to be a reliable and valid test battery for both children and young adults with IDD (Hessl et al., 2016; Shields et al., 2020). Procedures After administration of the initial screening form, informed consent was obtained by all child participants and their caregivers who met the inclusion criteria. Due to the COVID-19 pandemic, data were exclusively collected through online data collection methods. All caregiver- reported measures were sent as a survey via REDCap, a secure web-based software platform designed to support data collection for research studies (Harris et al., 2009). REDCap was also used to store all other data for the present study including participant demographics and scores on child measures. The NIHTB-CB is housed under the NIH Toolbox®, a comprehensive set of neuro-behavioral measurements that can assess for cognitive, emotional, sensory, and motor functions from an iPad (Hodes et al., 2013) which allows for remote administration via screen sharing using Zoom (Zoom Video Communications Inc., 2016). Another feature of the NIH Toolbox® is the ability to collect participant data through the application on the iPad and export to other data management programs such as REDCap. As such, the NIHTB-CB was administered live with the child participant over Zoom with a HIPAA Business Associate Agreement via screen sharing with responses safely exported to and stored in REDCap. As compensation for their time and effort, participants and their caregivers received an Amazon gift card upon completion of the study. 132 Data Analysis Preliminary data analysis procedures included checking the distribution of the variables (e.g., assessing skewness and kurtosis), multicollinearity of the variables, homogeneity of variance between groups, and calculating Cronbach alphas to verify the reliability of all scales and subscales within the sample study. First, a one-way ANOVA was conducted to determine if mean scores on the EQ-C and SRS-2 subscales differed across groups. A multiple-group path analysis (Muthén & Muthén, 2012) was then conducted to assess the relationship between empathy and social skills as well as whether differences in empathy and social skills were statistically significant across the four groups. The Picture Vocabulary Test and Picture Sequence Memory Test from the NIHTB-CB and child age served as covariates in the models. Criteria for acceptable model fit included the comparative fit index (CFI) and the Tucker-Lewis fit index (TLI), which was greater than (or equal to) .90; chi-square (𝜒2)/ degrees of freedom (df), which was lower than 2; and root mean square error of approximation (RMSEA) of .08 or less (Bryne, 2016; Hu & Bentler, 1999). The chi-square test for variance or difference was used to compare the mediation models in the multi- group path analysis (Tabachnick & Fidell, 2007). Results Preliminary Analyses First, univariate analyses were conducted to check the score distributions of the study variables. A visual inspection of histograms for each variable demonstrated fairly normal distributions for some variables and non-normal distributions for others. An additional inspection of normal Q-Q plots demonstrated a normal distribution for most variables. The skewness and kurtosis of all variables were within the range of -1 to 1; however, the Picture Sequence Memory 133 Test had a skewness value of 1.437 and a kurtosis value of 2.384. Tests of normality including the Kolmogorov-Smirnov Test and the Shapiro-Wilk test indicated that only the EQ-C met assumptions of a normal distribution. Group Differences in Empathy and Social Skills First, examining empathy skills across groups, the one-way ANOVA was statistically significant (F (3, 116) = 22.87, p < .001) with a large effect size (ɲ2 = .372), suggesting that about 37% of the variance of mean scores on the EQ-C was due to differences in group condition (see Table 4 for the means and standard deviations of mean scores on the EQ-C for each group). Table 4 Mean Scores and Standard Deviations for Each Group Variable ASD WS DS TD F EQ-C 18.53 (8.50) 25.20 (8.31) 27.00 (7.00) 35.60 (8.32) 22.87** SRS-2 Total Score 70.67 (10.31) 60.63 (6.99) 56.13 (4.57) 44.23 (4.64) 72.95** Social 67.33 (9.53) 61.17 (8.23) 56.13 (5.39) 46.50 (6.40) 40.71** Awareness Social Cognition 69.37 (10.73) 66.50 (8.31) 58.03 (5.14) 43.70 (4.42) 69.18** Social 69.20 (11.67) 58.97 (7.85) 55.83 (5.32) 43.70 (4.50) 53.73** Communication Social 62.20 (8.33) 47.70 (5.72) 48.70 (7.56) 46.10 (7.56) 33.07** Motivation Note. ASD = Autism spectrum disorder; WS = Williams syndrome; DS = Down syndrome; TD = Typically developing; EQ-C = Children’s version of the Empathy Quotient; SRS-2 = Social Responsiveness Scale-2nd edition. **p < .01. Additional post-hoc analyses were conducted using Bonferroni adjusted alpha levels of .0125 to specifically determine which groups differed from each other. Results of the post-hoc 134 analyses indicated that mean scores on the EQ-C for the ASD group were significantly lower compared to the WS (M = -6.67, SE = 2.08), DS (M = -8.47, SE = 2.08), and TD (M = -17.07, SE = 2.08) groups. The WS group (M = -10.04, SE = 2.08) and the DS group (M = -8.60, SE = 2.08) also reported lower scores on the EQ-C compared to the TD group. Next, examining social skills across groups, the one-way ANOVA was statistically significant (F (3, 116) = 72.95, p < .001) with a large effect size (ɲ2 = .654) suggesting that about 65% of the variance of mean scores on the SRS-2 was due to differences in group condition (see Table 4 for the means and standard deviations of total t-scores on the SRS-2 for each group). Additional post-hoc analyses were conducted using Bonferroni adjusted alpha levels of .0125 to specifically determine which groups differed from each other. Results of the post-hoc analyses indicated that mean scores on the SRS-2 for the ASD group were significantly higher compared to the WS (M = 10.03, SE = 1.81), DS (M = 14.53, SE = 1.81), and TD (M = 26.43, SE = 1.81) groups. The WS group (M = 16.40, SD = 1.81) and the DS group (M = 11.90, SD = 1.81) also reported higher scores on the SRS-2 compared to the TD group. There were similar patterns of responding for the social awareness and social communication subscales of the SRS-2 (see Table 4 for scores). In terms of social cognition, the one-way ANOVA was statistically significant (F (3, 116) = 69.18, p < .001) with a large effect size (ɲ2 = .641) suggesting that about 64% of the variance of mean scores on the SRS-2 social cognition subscale was due to differences in group condition. Results of the post-hoc analyses indicated that mean scores on the social cognition subscale of the SRS-2 for the ASD group were significantly higher compared to the DS (M = 11.33, SE = 1.96), and TD (M = 25.67, SE = 1.96) groups. Scores for the WS group were also significantly higher than the DS (M = 8.57, SE = 1.96) and the TD group (M = 22.80, SE = 1.96), but the ASD and WS groups did not differ from 135 each other. Finally, the DS group scored significantly higher than the TD group (M = 14.33, SE = 1.96). In terms of social motivation, the one-way ANOVA was statistically significant (F (3, 116) = 33.07, p < .001) with a large effect size (ɲ2 = .461) suggesting that about 46% of the variance of mean scores on the SRS-2 social motivation subscale was due to differences in group condition. Results of the post-hoc analyses indicated that mean scores on the social motivation subscale of the SRS-2 for the ASD group were significantly higher compared to the WS (M = 14.50, SE = 1.83), the DS (M = 13.50, SE = 1.83), and TD (M = 16.10, SE = 1.83) groups. There were no differences in scores between the WS, DS, and TD group (see Table 4 for scores). Relationship between Empathy and Social Skills Across Groups Two models for the four groups were compared to test cross-group variance: (a) an unconditional model with no equality constraints (no constraints across the groups) and (b) a constrained model where all parameters were constrained to be equal between the four groups. Then the fits of the two models were compared using the chi-square difference test. If the chi- square test for difference is significant, then structural paths for the four groups are non- invariant. The unconditional model provided an acceptable fit to the data (𝜒2(88) = 383.33, CFI = .980, RMSEA = .071), whereas the constrained model did not provide an adequate fit with the data (𝜒2(48) = 89.51, CFI = .859, RMSEA = 0.175) indicating that restricting the parameters to be equal resulted in a decrease in model fit. As such, coefficients in the path model were freed separately for certain groups one at a time (see Figures 2, 3, 4, and 5 for significant pathways in the model for each group) based on an examination of larger modification indexes until acceptable fit was reached (see Table 5). 136 Figure 2 Results from the multiple group path analysis for ASD group Note: Red arrows indicate statistically significant relationships (p < .001). ASD = Autism Spectrum Disorder; EQ-C = Children’s version of Empathy Quotient; PVT_T = T-scores of Picture Vocabulary Test; PSMT_T = T-scores of Picture Sequence Memory Test; TSRSAWR = T-scores of social awareness subscale of Social Responsiveness Scale-Second Edition (SRS-2); TSRSCOG = T-scores of social cognition subscale of SRS-2; TSRSCOM = T-scores of social communication subscale of SRS-2; TSRSMOT = T-scores of social motivation subscale of SRS-2. 137 Figure 3 Results from the multiple group path analysis for WS group Note: Red arrows indicate statistically significant relationships (p < .001). WS = Williams syndrome; EQ-C = Children’s version of Empathy Quotient; PVT_T = T-scores of Picture Vocabulary Test; PSMT_T = T-scores of Picture Sequence Memory Test; TSRSAWR = T-scores of social awareness subscale of Social Responsiveness Scale-Second Edition (SRS-2); TSRSCOG = T-scores of social cognition subscale of SRS-2; TSRSCOM = T-scores of social communication subscale of SRS-2; TSRSMOT = T-scores of social motivation subscale of SRS-2. 138 Figure 4 Results from the multiple group path analysis for DS group Note: Red arrows indicate statistically significant relationships (p < .001). DS = Down syndrome; EQ-C = Children’s version of Empathy Quotient; PVT_T = T-scores of Picture Vocabulary Test; PSMT_T = T-scores of Picture Sequence Memory Test; TSRSAWR = T-scores of social awareness subscale of Social Responsiveness Scale-Second Edition (SRS-2); TSRSCOG = T-scores of social cognition subscale of SRS-2; TSRSCOM = T-scores of social communication subscale of SRS-2; TSRSMOT = T-scores of social motivation subscale of SRS-2. 139 Figure 5 Results from the multiple group path analysis for TD group Note: Red arrows indicate statistically significant relationships (p < .001). TD = Typically developing; EQ-C = Children’s version of Empathy Quotient; PVT_T = T-scores of Picture Vocabulary Test; PSMT_T = T-scores of Picture Sequence Memory Test; TSRSAWR = T-scores of social awareness subscale of Social Responsiveness Scale-Second Edition (SRS-2); TSRSCOG = T-scores of social cognition subscale of SRS-2; TSRSCOM = T-scores of social communication subscale of SRS-2; TSRSMOT = T-scores of social motivation subscale of SRS-2. 140 Table 5 Estimates and Confidence Intervals of Pathway Models Across Groups Pathways constrained Modification Path coefficients for separately Indexes Unconstrained Model (𝑋 2 ) ASD WS DS TD Estimate 95% CI Estimate 95% CI Estimate 95% CI Estimate 95% CI Child age → SRS-2 3.801 0.719a (-0.008, -0.636 (-1.306, -0.636 (-1.306, -0.636 (-1.306, Social Motivation 1.445) 0.035) 0.035) 0.035) Empathy Quotient → 5.929 -0.409 (-0.569, -0.741a (-0.907, -0.409 (-0.569, -0.409 (-0.569, SRS-2 Social Awareness -0.248) -0.575) -0.248) -0.248) Child age → 4.202 0.099 (-0.315, -0.768a (-1.612, 0.099 (-0.315, 0.099 (-0.315, SRS-2 Social 0.513) -0.076) 0.513) 0.513) Communication Empathy Quotient → 2.279 -0.360 (-0.519, -0.153a (-0.376, -0.360 (-0.519, -0.360 (-0.519, SRS-2 Social Motivation -0.200) 0.069) -0.200) -0.200) Picture Sequence 8.365 0.116 (-0.028, 0.116 (-0.028, 0.116 (-0.028, -0.250 (-0.411, Memory Test → SRS-2 0.261) 0.261) 0.261) 0.460) Social Awareness Picture Vocabulary Test 5.302 -0.082 (-0.197, -0.082 (-0.197, -0.082 (-0.197, 0.096 (-0.025, →SRS-2 Social 0.032) 0.032) 0.032) 0.217) Cognition Picture Sequence 6.066 -0.168 (-0.351, -0.168 (-0.351, -0.168 (-0.351, 0.078 (-0.063, Memory Test → SRS-2 0.015) 0.015) 0.015) 0.219) Social Cognition 141 Table 5 (cont’d) Note. SRS-2 = Second Edition of Social Responsiveness Scale; ASD = Autism spectrum disorder; WS = Williams syndrome; DS = Down syndrome; TD = Typically developing. a Covariates allowed to be freed or to vary for a group. 142 The multi-group path analyses indicated significant correlations between empathy skills and some social skills across groups (see Table 6). For the ASD group, the EQ-C was moderately and negatively correlated with all of the subscales of the SRS-2, indicating that poorer empathy skills related to poorer social skills. For the WS group, the EQ-C was moderately to strongly correlated in a statistically significant negative direction for all the SRS-2 subscales except for social motivation (r = -0.15, p = 0.18), indicating that social motivation may have no substantial relationship with empathy skills for individuals with WS. For the DS group, the EQ-C was moderately correlated in the negative direction with all the subscales of the SRS-2, indicating lower ratings of empathy related to poorer ratings on social skills. Finally, for the TD group, the EQ-C was moderately and negatively correlated with all the subscales of the SRS-2, demonstrating that poorer empathy skills also relate to lower ratings on social skills for individuals without IDD. 143 Table 6 Descriptive Statistics and Correlations for Empathy and Social Skills Group Variable M SD 1 2 3 4 5 ASD 1. Children’s EQ 18.62 8.50 -- -0.41** -0.431** -0.36** -0.34** 2. SRS-2 Social Awareness 67.07 9.53 -0.41** -- 44.59** 25.39** 37.96** 3. SRS-2 Social Communication 68.93 11.67 -0.43** 44.59** -- 34.64** 62.20** 4. SRS-2 Social Motivation 62.03 8.33 -0.36** 25.39** 34.64** -- 18.45 5. SRS-2 Social Cognition 69.03 10.73 -0.34** 37.96** 62.20** 18.45 -- WS 1. Children’s EQ 25.20 8.31 -- -0.74** -0.43** -0.15 -0.34** 2. SRS-2 Social Awareness 61.17 8.23 -0.74** -- 17.54** 4.15 19.50** 3. SRS-2 Social Communication 58.97 7.85 -0.43** 17.54** -- 16.71** 28.93** 4. SRS-2 Social Motivation 47.70 5.72 -0.15 4.15 16.71** -- 7.80 5. SRS-2 Social Cognition 66.50 8.31 -0.34** 19.50** 28.93** 7.80 -- DS 1. Children’s EQ 27.41 7.00 -- -0.41** -0.43** -0.36** -0.34** 2. SRS-2 Social Awareness 55.52 5.40 -0.41** -- 2.38 4.68 3.98 3. SRS-2 Social Communication 55.56 5.32 -0.43** 2.38 -- 8.89 7.14** 4. SRS-2 Social Motivation 48.63 6.40 -0.36** 4.68 8.89 -- 2.66 5. SRS-2 Social Cognition 57.89 5.14 -0.34** 3.98 7.14** 2.66 -- TD 1. Children’s EQ 36.11 8.32 -- -0.41** -0.43** -0.36** -0.34** 2. SRS-2 Social Awareness 46.07 6.40 -0.41** -- 1.86 1.57 3.56 3. SRS-2 Social Communication 43.26 4.50 -0.43** 1.86 -- 9.53** 7.64** 4. SRS-2 Social Motivation 46.15 7.56 -0.36** 1.57 9.53** -- 15.49** 5. SRS-2 Social Cognition 43.42 4.49 -0.34** 3.56 7.64** 15.49** -- Note. ASD = Autism spectrum disorder; WS = Williams syndrome; DS = Down syndrome; TD = Typically developing; EQ = Empathy Quotient; SRS-2 = Social Responsiveness Scale-2nd edition. ** p < .01 144 Results of the multi-group path analysis also indicated significant differences in the relationship between empathy skills and social skills across groups. Most notably, the WS group differed significantly from the other groups on performance on the EQ-C in relation to the social awareness subscale (M = -0.33, p < .001) but did not differ with the social motivation subscale (M = 0.21, p = 0.13) of the SRS-2. Correlations between the different subscales of the SRS-2 also differed across groups. More specifically, the TD group differed significantly with the IDD groups regarding correlations between social awareness and social motivation (M = -0.37, p < .001) and social motivation and social cognition (M = 0.25, p = 0.047) of the SRS-2. Discussion Given the relation of empathy and social skills to positive social outcomes and differences in behavioral phenotypes across different IDD conditions, the current study examined the relationship between empathy skills and social skills for individuals with ASD, WS, DS, and individuals without disabilities. The results of this study indicate that empathy and social skills differ between individuals with ASD, WS, and DS. These findings have important implications for future research and practice. Differences in Empathy Skills First, compared to those with WS and DS, as well as to those without disabilities, individuals with ASD exhibit poor empathy skills. This finding supports the general consensus among ASD researchers that challenges in empathy are a key aspect of the ASD behavioral phenotype (Baron-Cohen and Wheelwright, 2004), as often measured with the Empathy Quotient (Fletcher-Watson & Bird, 2020; Josol, [Chapter 2]). This finding also highlights that empathy might be a critical intervention target for individuals with ASD but might not be as important for individuals with WS or DS. 145 Additionally, cognitive ability was not related to empathy in the path models for each group, despite statistically significant differences in intellectual disability between groups. This finding suggests that cognitive ability may not play a significant role in the empathy skills of individuals with IDD and mirrors past research that have demonstrated that IQ may not add significantly to differences in empathic responsiveness for individuals with IDD such as children and adolescents with ASD (e.g., Scheeren et al., 2018). Still, because individuals with WS and DS were reported to have lower empathy skills than the TD controls, future research should continue to explore whether empathy deficits exist among these populations and whether specific empathy-focused interventions are warranted. Relationship between Empathy and Social Skills Exploring the relationship between empathy and social skills across the different groups, the primary findings were among those in the WS group. Specifically, individuals with WS differed from other groups regarding the relationship between their empathy skills and social skills. Unlike for the ASD, DS, and TD groups, lower ratings on empathy skills were not significantly correlated with social motivation for individuals with WS. In other words, empathic abilities are not related to the motivation to interact with others. This finding supports past research indicating that individuals with WS are highly motivated in social situations (Jawaid et al., 2012; Jones et al., 2000) and do not experience deficits in the social motivation domain of social skills (Fisher et al., 2020; Fisher & Morin, 2017). The lack of empathy’s relation to social motivation for individuals with WS is different from the general research literature, which suggests that social motivation and empathy skills are interdependent (Ickes, 2011; Smith et al., 2011; Zaki, 2014). This difference will be important to further examine. 146 Furthermore, the results of this study also demonstrate that individuals with WS differed significantly in their relationship between empathy skills and social awareness (i.e., one’s ability to recognize social cues) compared to other groups. More specifically, the relationship between empathy skills and social awareness was significantly poorer for those with WS compared to ASD, DS, and those without disabilities, indicating that individuals with WS with poor social awareness also had poorer empathy skills. This finding highlights a potential area for intervention for individuals with WS. The social-emotional learning literature defines social awareness as “the ability to take the perspective of and empathize with others from diverse backgrounds and cultures [and] to understand social and ethical norms for behavior” (Collaborative for Academic, Social and Emotional Learning, 2012, p. 11). Much of this definition aligns with affective empathy (i.e., how one responds to the emotional state of others; Björkqvist et al., 2000). Thus, to address the relation between poor empathy skills and social awareness skills for individuals with WS, interventions that address affective empathy may be important for this population. Many school- based social-emotional learning programs currently include some form of empathy intervention (Malti et al., 2016) and may provide a helpful framework to specifically address the unique empathy and social awareness challenges of individuals with WS. Limitations The primary aim of this study was to examine the role of empathy skills in relation to social skills for different IDD groups and compared to those without disabilities. While the results of this study demonstrate key differences and significant relationships regarding empathy and social skills among individuals with various IDD conditions, there are limitations. First, given the small sample size used for the multiple group path analysis, the results should be 147 interpreted with caution. While simple models can be meaningfully tested in small sample sizes (Hoyle & Kenny, 1999; Marsh & Hau, 1999), a typical sample size in studies for path analysis is around 200 participants (Kline, 2011). Given that the current study included individuals with relatively rare genetic conditions (e.g., WS), recruitment of 30 individuals within each group was considered sufficient. Second, only caregiver reports were used to measure and compare the empathy and social skills of participants in this study. While caregivers are uniquely positioned to report on their child’s empathy and social skills, the inclusion of other proxy reports, such as teachers, can provide more insight into the presentation of certain skills and abilities in different social contexts and settings (Yoder & McDuffie, 2006). Third, this study was conducted during the COVID-19 pandemic. As a result of social distancing requirements, all data collection was conducted online, and most data were collected when participants were attending school virtually. Thus, ratings of empathy and social skills may have been impacted by the change in social circumstances during the pandemic. Fourth, the reliability of many scales and subscales within the sample was poor or unacceptable, particularly for the DS group on the social awareness and social cognition subscales of the SRS-2. Further research is warranted to examine and ensure the reliability of social measures for different IDD groups. Future Directions The findings of this study indicate that empathy in relation to social skills can differ between individuals with different IDD conditions and highlights the importance of considering etiology and its role in the strengths and challenges observed within and across IDD conditions. While differences in empathy and social skills were observed between children and adolescents with ASD, WS, and DS, future research should examine whether such differences would be present in adults with these same IDD conditions. Given that developing empathy skills is a 148 gradual process beginning with reflexive crying in newborns to more stability of empathy as a trait in adulthood (McDonald and Messinger, 2012), further examination across age groups between and within different diagnostic groups may strengthen current and future interventions by accounting for developmental level as well. Finally, regarding future intervention research, use of the social-emotional learning framework may provide a useful means of targeting specific empathy and social skills for individuals with IDD as many social-emotional learning programs are already school-based. In a meta-analysis of 213 school-based social-emotional learning programs on behavior problems, academic performance, and positive social behavior, Durlak et al. (2011) reported that the largest effect sizes were found in programs targeting empathy development and emotion recognition, suggesting that empathy-related constructs were crucial to the success of the program. Future research should examine whether the social-emotional learning framework could be adapted for individuals with ASD, WS, and DS. For example, given that empathy and social awareness skills were related among individuals with WS in the present study, a social-emotional learning program could be developed to explicitly target affective empathy skills while capitalizing on their strengths in social motivational skills. Alternatively, the overall empathy and social skills deficits displayed by individuals with ASD may warrant a broader social-emotional learning approach to teaching empathy skills for that population. As demonstrated in the current study, different IDD conditions can elicit differences in empathy and social skills. Therefore, consideration of etiology and its impact on observed social phenotypes is critical for research and clinical application. Clearly, different IDD groups present with different strengths and weaknesses in certain social domains. Carefully addressing weaknesses while also acknowledging and using their strengths, as determined by IDD 149 condition, may assist in ensuring that current and future interventions are effective for specific IDD groups. The development of more adapted interventions for different IDD groups will not only help improve the relationship between empathy and social skills but ultimately improve the social outcomes of individuals with IDD. 150 REFERENCES 151 REFERENCES Allemand, M., Steiger, A. E., & Fend, H. A. (2015). Empathy development in adolescence predicts social competencies in adulthood. 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Yet empathy remains elusive in many school settings, as students continue to experience bullying victimization and to struggle with developing positive peer relationships. These negative experiences are particularly true for students with autism spectrum disorder (ASD). Thus, this conceptual piece reviews the relation of empathy to positive social outcomes, outlines important considerations for empathy assessment and intervention, and provides guidelines for improving the empathy skills of students with ASD. The Importance of Empathy Empathy is a multicomponent phenomenon encompassing a wide range of processes which can generally be divided into a cognitive component and an affective component. Cognitive empathy is the ability to understand another person’s feelings, while affective empathy refers to the ability to share in or respond to the other person’s emotional state (de Weid et al., 2007). Empathy skills are consistently linked to promoting prosocial behaviors (e.g., helping others) and inhibiting aggressive behaviors (Eisenberg et al., 2010), resulting in better quality friendships and relationships (Chow et al., 2013; Cramer & Jowett, 2010). Empathy is more than just being kind to one another, placing yourself in another person’s shoes, or treating others how you want to be treated; empathy is crucial for social functioning and well-being (Damon et al., 2006; De Waal, 2008). 158 Empathy Skills of Students with ASD Individuals with ASD exhibit challenges in various social domains including struggles with social interactions, unconventional communication skills, and restricted and repetitive behaviors (American Psychiatric Association, 2013). A lack of empathy has also been observed across the autism spectrum for individuals of all ages. In fact, according to teacher reports, compared to their typically developing peers, students with ASD between the ages of 3 and 12 are significantly less empathic (Peterson, 2014). Adolescent self-reports also indicate that individuals with ASD perceive themselves as struggling to display empathy toward others (Senland & Higgins-D’Alesandro, 2013). The behavioral characteristics of any disability condition can impact individuals to a certain and oftentimes significant degree (Waite et al., 2014). Further complicating the situation is the multi-dimensional nature of empathy, which can make it difficult to identify specific factors that may need to be uniquely addressed. Individuals with ASD seemingly demonstrate more challenges with cognitive empathy (i.e., understanding and identifying the emotions of others) compared to affective empathy (i.e., the expression of empathy; Firth 2012; Smith, 2009). Thus, it is important for professionals such as special and general education teachers, applied behavioral analysts, and school psychologists to account for the specific skill deficits of students with ASD when assessing and developing empathy interventions for this population. Researchers have developed several theories to explain the observed empathy challenges in individuals with ASD. One prominent theory suggests that ASD should be defined as a single- minded attentional system (i.e., monotropism) that prefers to take in one information source at a time (Murry et al., 2005). This preference may lead some individuals with ASD to miss certain social cues which then impacts their cognitive and affective empathy skills. In fact, according to 159 some research, this theory of monotropism may explain why young children with ASD are less likely to identify the emotional cues of another person (i.e., cognitive empathy) as it requires orienting toward other people (Mundy, 2018). Overall, it is critical for educators to understand that empathy might be an important social skill to address for students with ASD and that specific aspects of empathy should be assessed when developing an intervention plan. In the next section, we describe two different cases of students with ASD who are struggling with their empathy skills. Guidelines and suggestions for how to develop and address the unique needs of students with ASD for intervention are provided for each scenario (see Figure 6 for overview). Figure 6 Empathy Assessment and Intervention Considerations for Students with ASD •Consideration 1: Carefully select measures based on overall target or goal •Consideration 2: Obtain multiple sources of informants if possible •Consideration 3: Review old records such as diagnostic reports and past IEPs Assessment •Consideration 4: Ensure that assessments are feasible and accessible for all involved for ASD •Consideration 1: Consider and address impact of IDD status (i.e., other challenges in social skills that may impact empathy outcomes) •Consideration 2: Collaborate with other professionals (e.g., behavioral specialistis) when appropriate •Consideration 3: Consider that type of empathy may affect the type and Intervention delivery of intervention •Consideration 4: Ensure that the intervention can be implemented with for ASD relaitive ease and accessibility 160 The final section then discusses general recommendations that should be considered when defining and targeting empathy for interventions. Specific Guidelines and Suggestions We now present our first case. At the beginning of the school year, Ms. Shultz, a special education teacher, began working with Kara, an eleven-year-old student diagnosed with ASD. Kara’s IEP states that for the new school year she will transition from less than 40% of the day in general education to 80% of the day or more in general education. Kara’s parents expressed concern about how their child would get along with her classmates, fearing that their daughter may be left alone or even bullied in a general education setting due to her ASD symptomatology. Her parents state that Kara struggles with “connecting with others” and has difficulty recognizing the emotions of other people. They worry that because of this Kara may struggle to make friends in the general education classroom. Fortunately, Ms. Shultz also helps run a social skills training program for students with disabilities at Kara’s school. Ms. Shultz suggests that Kara enroll in the program in order to address some of her parent’s concerns. Once enrolled in the social skills training program, Ms. Shultz reviews Kara’s diagnostic reports and past IEPs and determines that Kara may benefit further from empathy training to better connect with fellow students and gain the skills to correctly identify the emotional state of others. Ms. Shultz realizes she will need to develop an empathy intervention that is not only appropriate but incorporates any special considerations for students with ASD such as Kara. To capture a general picture of Kara’s empathic skills, it is critical to obtain reports from multiple informants including self-report, parent-report, and teacher-report. In particular, teacher- and parent-reports are useful for the identification of certain skills and abilities of 161 younger individuals across different contexts, such as school and home settings (Renk & Phares, 2004; Yoder & McDuffie, 2006). There are several empathy measures available to identify areas for intervention (see summary of different empathy measures in Table 7). Table 7 Summary of Different Measures Used to Assess Empathy Measure Type of Number of Scale/Score Target Age Empathy Items Group(s) Self Empathy Cognitive 60 Likert scale Young-Late Report Quotient (Baron- Empathy providing Adulthood Cohen & Affective overall Wheelwright, Empathy empathy score 2004) Interpersonal Empathic 28 Four subscales Reactivity Index Concern providing sub- Young-Late (Davis, 1980) scores for each Adulthood scale and an overall empathy score Parent Children’s Empathizing 27 Likert scale Ages 4-11 Proxy version of providing Report Empathy overall Quotient empathy score (Auyeung et al., 2009) Griffith Empathy Cognitive 23 Likert scale Children/ Measure (Dadds Empathy providing a Adolescents et al., 2008) Affective cognitive and Empathy affective empathy sub- score and overall total score Teacher Teacher-adapted Cognitive 23 Likert scale Children Proxy Griffith Empathy Empathy providing a Report Measure (e.g., Affective cognitive and Deschamps et al., Empathy affective 2014) empathy sub- score and overall total score First, to confirm general empathy deficits, Ms. Schultz asks Kara’s parents to complete the parent-report version of the Empathy Quotient (EQ-C; Auyeung et al., 2009) which is widely 162 used to assess the empathy skills of individuals with ASD. The EQ-C provides one overall empathy score (max score = 54) with lower scores indicative of poorer empathy performance. More information regarding the scoring and items are detailed by Auyeung and colleagues (2009). Kara’s mother completed the EQ-C and reported an overall score of 22 indicating that Kara demonstrates poor empathy skills in general. To confirm which specific areas of empathy Kara seems to struggle with the most, Ms. Schultz then asks her teacher from the previous year to complete the 23-item Griffith Empathy Measure (GEM; Dadds et al., 2008), which can be adapted for teachers and has been used in the research literature to assess the empathy skills of students with ASD (e.g., Deschamps et al., 2014). The GEM provides separate scores for cognitive empathy (6 items; max score = 24) and affective empathy (9 items; max score = 36) as well as a total overall score (max score = 92) with lower scores indicative of poorer empathy skills. More information about the items and scoring can be found by Dadds et al. (2008). Kara’s previous teacher reported scores of 12 for cognitive empathy, 20 for affective empathy, and 66 for the total overall score indicating that Kara exhibits poor performance in both cognitive and affective empathy. Ms. Schultz determines that Kara should first focus on improving her cognitive empathy skills given that in order to respond appropriately to another person’s emotional state she will need to first identify their emotions or feelings accurately (Behrends et al., 2012). Given that Kara is enrolled in the social skills training program, Ms. Schultz recommends they develop an intervention program focused on improving her ability to accurately label the emotions or feelings of others. There are two types of social skills training programs depending on whether implicit or explicit learning is required. Explicit social skills groups are often quite structured, may follow a manual with different modules, and consist of practice with repeated 163 exercises to practice social norms in group or at home (Cotugno, 2009). While explicit social skills training has its benefits, some children with ASD who participate in such training demonstrate challenges with generalizing learned skills in different situations (Baker & Myles, 2003; Cotugno, 2009). Instead, Ms. Schutz opts for an implicit social skills training approach in which individuals learn social skills on their own first and then they are exposed to different social situations often in the form of games in a group setting meant to elicit those social skills (Jonsson et al., 2016). Past research indicates that implicit social skills training can improve the cognitive empathy skills of adolescents with ASD. For instance, to improve cognitive empathy skills, Goldingay and colleagues (2013) conducted a pilot of an implicit social skills training program for seven adolescents with ASD incorporating a number of group activities such as creating a movie together that considered understanding the emotional state of each character (i.e., understanding what it would feel like to be that character). This way, Kara’s peers can be involved in the intervention so Kara may practice accurately identifying the emotional state of others. Here is our second case. Mr. Sanchez is a special education teacher who is working with Max, a fourteen-year-old student diagnosed with ASD. While discussing behavioral goals with Max and his parents, Mr. Sanchez learns that Max struggles with appropriately responding to the emotional states of other people, particularly regarding tense social situations and will often elope in most cases. His parents report that parents of other peers tell them that their children think Max “doesn’t seem to care” about their problems; however, Max reports that he simply feels overwhelmed and does not know how to respond in tense social situations. This is of great concern to his parents who worry this may make it more difficult for Max to make friends with his peers, especially as he gets older. 164 Given the parents’ concerns, Mr. Sanchez determines that he will need to collaborate with a behavior specialist and develop a targeted behavior intervention plan for Max to learn a few ways to appropriately respond to a peer during tense social interactions. Max will need to be taught how to state an empathic listening statement and an empathic follow-up question as a way to appropriately respond to a peer. There are several approaches and methods that Mr. Sanchez may use to achieve this aim, but the approach will depend on the results of the assessments he first chooses to conduct. Given that the main area of concern for Max is related to affective empathy (i.e., how one responds to the emotional state of others), Mr. Sanchez, in collaboration with a behavior specialist, determines that multiple reports of Max’s current empathy skills should be obtained. First, Mr. Sanchez asks that one of Max’s parents complete the EQ-C to determine general challenges in empathy. Max’s father completed the EQ-C resulting in a total score of 26 indicating that Max exhibits poor empathy skills in general. Next, being Max’s current teacher, Mr. Sanchez completes the teacher-adapted version of the GEM. Mr. Sanchez reported scores of 20 for cognitive empathy, 16 for affective empathy, and 68 for the total overall score indicating that Max demonstrates more weakness in affective empathy compared to cognitive empathy. Mr. Sanchez and the behavior specialist determine that Max can accurately understand the feelings of others but may struggle to respond in an appropriate manner. The behavior specialist suggests using a video feedback intervention package to specifically teach Max how to respond to a peer using an empathic listening statement and a follow-up question to improve his affective empathy skills. Video feedback is a relatively accessible and affordable intervention (Schreibman et al., 2000) that involves recording an individual performing specific behaviors and then reviewing the recording for self-evaluation 165 (Maione & Mirenda, 2006). Past research indicates that video feedback interventions can be effective at improving the affective empathy of individuals with ASD (Josol et al., 2022; Koegel et al., 2016). For example, Josol and colleagues (2022) used a video feedback intervention package to teach four adolescents with ASD to respond to peers with an empathic listening statement (e.g., “That seems like a lot of pressure!”) and an empathic follow-up question (e.g., “Have you talked to anyone else on the team?”) in response to a statement of emotion (e.g., “I’m worried about the basketball try-outs”). Mr. Sanchez and the behavior specialist agree that if the video feedback intervention proves effective for Max, the next step should be to assess if Max can generalize his learned affective empathy skills to different peers across different settings (e.g., classroom, lunchroom, library). General Considerations While differences should be accounted for when developing empathy interventions for individuals with ASD, there are general guidelines that working professionals should also consider for intervention. First, how empathy is defined will be of critical importance for assessment or intervention. There is no general consensus on an exact definition or measurement of empathy (Innamorati et al., 2019). This lack of consensus can make defining and measuring empathy particularly challenging for those who assess empathy and develop interventions for individuals with ASD. Figure 7 provides general suggestions for elements that should be considered to define empathy. Second, the developmental age or level of the individual with ASD should be a general consideration when designing and implementing an intervention. Throughout the developmental lifespan, empathic responses grow in complexity, particularly during childhood and adolescence (Dadds et al., 2008). In the first 12 months of life, infants display empathic responses that are 166 involuntary and automatic by appearing stressed and seeking comfort for themselves (Dondi et al., 1999). As humans grow older, so does the cognitive capacity to understand and respond to a variety of subtle and diverse emotions (Hart, 1999; Hoffman, 1990; Schulte-Rüther et al., 2014). Figure 7 provides general suggestions to assist professionals in considering developmental age or level when designing and implementing empathy interventions. Figure 7 General Considerations for Empathy Assessment and Intervention • Consideration 1: Cognitive and affective empathy, while distinct in definition, are interrelated (Behrends et al., 2012) Defining • Incorporating elements of both components may provide a more accurate descprition of empathy. • Consideration 2: Not all measurement approaches will be equal or similar in methods or procedures Empathy (Gerdes & Segal, 2011; Jolliffe & Farrington, 2006) • If choosing to use a standardized measure to assess for empathy, review how the measure defines empathy to ensure it will fit with overall aims and goals • Consideration 1: Long-term follow-up of an intervention should be considered with a developmental framework (Hill et al., 2016) • Conssider age of student(s) as empathy varies in Developmental development across age groups (McDonald and Messinger, 2010) • Consideration 2: Identify other social skills that may Level be rquired to understand and express empathy (Josol et al., 2022) • Certain IDD conditions may result in developmental delays with certain social bnechmarks which may impact empahty skills Third, other social skills may need to be addressed before specifically focusing on cognitive and affective empathy for intervention. That is, other social skills may be required in order to appropriately communicate empathy towards others (Hills, 2009; Josol et al., 2022; Koegel et al., 2016). In fact, lower performance in empathic responses may be due to challenges in communication during a conversation (Baron-Cohen & Wheelwright, 2004) rather than any actual deficits in empathy skills. Other social skills that may impact empathic performance 167 include conversation skills such as the speaker and listener adopting each other’s point of view, turn-taking during conversation, and conversing on topics relevant to all parties (Chin & Bernard-Opitz, 2000). Given that individuals with ASD may struggle with such social skills, assessment of social strengths and weaknesses may be needed prior to implementation of interventions targeting empathy skills. Final Thoughts The ability to connect with and build meaningful social relationships with each other is rooted in empathy. That is, the ability to understand and respond to the emotional state of others is prevalent in all aspects of our day-to-day social lives. Given that deficits in empathy skills are associated with poorer social outcomes and that individuals with ASD already face barriers to developing and maintaining meaningful relationships, there is an urgent need to develop and implement effective and appropriate interventions for this population. These suggestions and guidelines can be used to design interventions that address the unique considerations and needs of individuals with ASD. There are also general considerations that should be accounted for, such as being mindful of how empathy is defined and measured as well as ensuring that any empathy measure or intervention is developmentally appropriate for the individual with ASD. By considering such factors in assessment and intervention development, we can more effectively address and improve the empathy skills of individuals with ASD. 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The importance of understanding the behavioural phenotypes of genetic syndromes 172 associated with intellectual disability. Paediatrics and Child Health, 24(10), 468-472. https://doi.org/10.1016/j.paed.2014.05.002 Yoder, P. J., & McDuffie, A. (2006). Treatment of joint attention in children with disabilities. In T. Charman, & W. Stone (Eds.), Social & communication in autism spectrum disorders: Early identification, diagnosis, & intervention (pp. 117–142). Guilford. 173 CHAPTER 5 The Importance of Empathy for Individuals with Intellectual and Developmental Disabilities The understanding between empathy, social skills, and their impact on individuals with intellectual and developmental disabilities (IDD) continues to improve. Described as a multidimensional construct, empathy consists of a cognitive component and affective component. Cognitive empathy refers to an individual’s ability to recognize the emotional state of others, while affective empathy refers to an individual’s ability to share in another person’s emotional state (van Noorden et al., 2015). Both components of empathy are interdependent in nature (Behrends et al., 2012). Generally, individuals with IDD exhibit challenges with the understanding and expression of empathy compared to individuals without IDD (e.g., Cebula & Wishart, 2008; Johnson et al., 2017). However, different etiologies can elucidate different strengths as well as weaknesses in relation to empathy skills (Waite et al., 2014). For example, challenges in empathy skills can be observed for individuals with autism spectrum disorder (ASD) across age groups (e.g., Peterson, 2014; Senland & Higgins-D’Alesandro, 2013; Trimmer et al., 2017). On the other hand, individuals with Williams syndrome (WS) and Down syndrome (DS) appear to display stronger empathy skills, especially cognitive empathy, compared to their ASD counterparts (e.g., Jones et al., 2000; Kasari et al., 1995). Empathy is closely linked to other social domains including various social skills and social outcomes. More specifically, empathy itself can be considered a specific social and communication skill (Riggio et al., 1989) and has been linked to other social skills such as social motivation (Smith et al., 2011; Zaki, 2014) and social awareness (Collaborative for Academic, 174 Social, and Emotional Learning, 2012). Researchers also demonstrate that better empathy skills are associated with more positive social interactions and higher quality meaningful relationships and friendships (Chow et al., 2013; Cramer & Jowett, 2010). Additionally, higher empathy skills are related to the inhibition of aggressive or anti-social behaviors (Roberts et al., 2014). Given the importance of empathy to social skills and outcomes as well as potential differences across IDD conditions, the current dissertation was conducted to examine the empathy and social skills as well as social outcomes of individuals with ASD, WS, and DS. Chapter 2 of this dissertation was a systematic literature review of 169 studies conducted to identify the current research on empathy skills and social outcomes for individuals with ASD, WS, and DS. Although the majority of studies focused on the empathy skills of individuals with ASD, the findings of this literature review highlight several key patterns across articles that focused on empathy and social outcomes within the past 15 years. Regarding general study characteristics, a majority of the studies focused on individuals with ASD, had more male than female participants for their samples, and used a group quasi-experimental or experimental design. The top empathy measures used across studies were the Empathy Quotient (EQ; Baron- Cohen et al., 2004) and the Interpersonal Reactivity Index (IRI; Davis, 1980). On the EQ, individuals with ASD generally reported lower scores compared to typically developing control groups. Lower empathy scores also often correlated with higher scores on measures for autism symptomatology such as the Autism Quotient (e.g., Paulus et al., 2013). On the IRI, individuals with ASD rated significantly lower than control groups on various sub-scales including perspective-taking and empathic concern (e.g., Bos & Stokes, 2019; Rogers et al., 2007). Of the 175 few studies to include individuals with WS and DS, findings indicate that these groups perform well on empathy-related tasks (e.g., Plesa Skwerer et al., 2016). Only a few studies examined empathy in relation to social outcomes; however, these studies generally reported that empathy played a significant role in social outcomes across different age groups for individuals with ASD (e.g., Rueda et al., 2014; Senland & Higgins- D'Alessandro, 2016). Overall, the results of the systematic literature review indicate that individuals with ASD experience poorer empathy skills and these deficits relate to poor social skills. Further, there is a lack of research on empathy for other IDD conditions (e.g., WS and DS) and in relation to other social domains (e.g., social skills). As such, Chapter 3 of this dissertation examined the specific relationship of empathy and social skills for individuals with ASD, WS, and DS and examined differences across groups and compared to a typically developing (TD) control group. The final sample (N = 120) included 30 students diagnosed with ASD (mean age = 10.73 years) and their caregivers, 30 students diagnosed with WS (mean age = 12.07 years) and their caregivers, 30 students with DS (mean age = 11.53 years) and their caregivers, and 30 TD students (mean age = 10.90 years) and their caregivers. Caregivers were asked to complete the children's version of the Empathy Quotient (EQ-C; Auyeung et al., 2009) and the Social Responsiveness Scale-Second Edition (SRS-2; Constantino & Gruber, 2005). Results demonstrate that, according to parent reports, students with ASD present with lower empathy skills compared to students with WS and DS and to students without disabilities. Students with WS and DS also were reported to have poorer empathy skills compared to students without disabilities. Differences between groups were also demonstrated regarding the relationship between empathy skills and social skills. More specifically, for students with WS, 176 lower empathy skills were not significantly correlated with social motivation. Rather, compared to other groups, students with WS differed significantly in their relationship between empathy skills and social awareness (i.e., the ability to recognize social cues). The results of Chapter 3 highlight that differences in empathy and social skills should be accounted for in empathy- related interventions and underscore the importance of developing etiology-specific interventions. In response to the importance of developing interventions that account for the student’s disability, Chapter 4 was written to the development of intervention to address empathy skills deficits for students with ASD. When assessing empathy skills, it is crucial to obtain the perspective of multiple informants including parent- and teacher-reports. The use of multiple sources will provide both a general picture of a student’s empathy skills along with information for specific areas of concern. Other general considerations for empathy assessment and intervention include incorporating elements of cognitive and affective empathy during assessment, adopting a developmental framework to guide both short term and long-term goals, and identifying additional social skills deficits to target prior to or during the empathy intervention, if applicable. This dissertation highlights key differences in empathy and social skills among individuals with ASD, WS, and DS. First, some of the current research, as demonstrated in Chapter 2, suggests that rather than lacking empathy, individuals with ASD may experience greater distress or overstimulation in social situations which may impact the ability to empathize with others (e.g., Bos & Stokes, 2019; Elcheson et al., 2018). Additionally, other research demonstrates that individuals without ASD may have difficulties with identifying the emotional states of individuals with ASD (Edey et al., 2016; Sheppard et al., 2016). Such findings align 177 with more current research focused on the ‘double empathy problem’, the notion that challenges in empathy may be due to individuals without ASD misunderstanding the empathy skills of individuals with ASD and vice versa (Mitchell et al., 2021). Future research is warranted to explore the ‘double empathy problem’ including a closer examination of current empathy measures as some of these (e.g., the EQ and IRI) have been used to assess for deficits rather than differences in empathy skills between individuals with and without ASD. Clearly, the results of this dissertation and other research indicate that the mechanisms underlying empathy challenges for individuals with ASD are complex, requiring further research and examination into factors that may be impeding or facilitating better empathy skills for individuals with ASD. Second, the findings of this dissertation demonstrate that the relationship between empathy skills and different social domains is complex and can vary across IDD groups. While the results of Chapter 2 demonstrate a lack of research examining the relationship between empathy skills and various social domains for specific IDD groups such as WS and DS, the findings of Chapter 3 indicate that diagnosis can elicit differences in empathy skills and social skills. For example, students with WS differed significantly in their relationship between empathy skills and social awareness (i.e., an individual’s ability to recognize and understand social cues) compared to students with ASD, DS, and without disabilities. More specifically, the relationship between empathy and social awareness was significantly poorer for students with WS compared to the other groups. Additionally, compared to other IDD groups, the relationship between empathy and social motivation was not significant for students with WS, suggesting that other factors may be impacting their empathy skills. These differences in empathy and social skills highlight the importance of the relationship between etiology and behavior (often referred to as “behavioral phenotypes”; Dykens et al., 2000). The different behavioral phenotypes of 178 various IDD conditions may be a contributing factor to any observed differences in outcomes and may have important implications for intervention. Consequently, the lack of research on empathy skills and different social domains for different IDD groups may impact the effects of current and future interventions. That is, while interventions may be effective at achieving specific short-term behavioral goals (e.g., more turn- taking in a conversation, prolonged eye contact), it remains unclear whether such results relate to long-term social outcomes (e.g., improved friendships, better relationships) for individuals with different forms of IDD. Examination of long-term intervention effects is generally quite rare in the research literature (Farrington, 2006) given some of its limitations including selection bias and differential attrition (Hill et al., 2017). However, a focus on long-term intervention outcomes would improve the current understanding of whether short-term behavioral goals in socially related interventions correlate with long-term social outcomes such as more meaningful friendships and relationships. Doing so will ensure that interventions for individuals with IDD will produce both positive and lasting improvements in their social outcomes. There is no question that the concept of empathy is complex, particularly in relation to social domains. Empathy is so connected to other social domains that researchers from different fields have pursued its origins, processes, and outcomes (Hall & Schwartz, 2019). The overall aim of this dissertation was to examine the relationship between empathy and social outcomes for individuals with different IDD conditions. Clearly, empathy and social outcomes have an important relationship for individuals with IDD; however, this relationship can vary across and within different IDD conditions. 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