Prior to beginning work on this assignment, be sure to have read all the required resources for the week.Locate a peer-reviewed qualitative research study in the Ashford University Library on the topi
RESEA RCHARTICL E Emotions surrounding friendshipsof adolescents withautism spectrum disorderin Japan: Aqualitative interviewstudy Motofumi Sumiya 1,2 , Kazue Igarashi 2 , Motohide Miyahara 1,3 1 Division ofCerebral Integration, NationalInstituteforPhysiolog icalSciences, Okazaki,Aichi,Japan, 2 Department ofChild Studies, Shirayuri College,Chofu,Tokyo,Japan, 3School ofPhysical Education, Sport andExercise Sciences, Universityof Otago, Dunedin, NewZealand motofum isumiya@gm ail.com Abstract Emotions areembedded inculture andplay apivotal roleinmaking friendsandinteracting with peers. Tosupport thesocial participation ofstudents withautism spectrum disorders (ASD) itis essential tounderstand theiremotional lifeinthe context ofethnic andschool cul- tures. Weareparticularly interestedinhow anxiety andloneliness areexperienced indevel- oping andmaintaining friendshipsinthe daily encounters ofadolescents withASD inthe specific contextofJapanese schools,because theseemotions couldserve either asfacilita- tors orbarriers tosocial interaction, dependingonhow individuals managethem.The present qualitative studyinvestigated perceptionsofemotions relatedtofriendship inthe everyday schoollifeof11 adolescents withASD inJapan. Datawere collected bymeans of semi-structured individualinterviews, whichrevealed awide range ofmotivations forsociali- zation, limitedfutureprospects todeepen friendships, robustself-awareness ofone's own social challenges, andconscious effortstocope withthese challenges. Aninductive approach todata analysis resultedinfour themes: socialmotivation, loneliness,anxiety, and distress. Toour knowledge thisisthe first study touncover therich emotional lifeofado- lescents withASD inthe context oftheir friendships inan Asian culture.
Introduction Friendship isimportant foreveryone throughout life.Ofalldevelopmental periods,adoles- cence marks aprimary periodofforming intimate friendships intypically developing youth [1,2]. Incontrast, youngpeople withautism spectrum disorder(ASD),whosedefining feature is social impairments (DSM-5)[3],seem tofollow different developmental trajectoriesbecause of their social communication challenges[See4for review]. Forinstance, childrenandadoles- cents withASD areknown tohave fewer friends thanage-matched peers[4,5].Below thesur- face level ofnumber offriends liepsychosocial processesinvolving individual perceptions of self and friends, andmotivation tomake friends anddeepen friendships. Howdoyoung peo- ple with ASD feelabout friends andfriendships? Dothey feelloneliness whenaloneoreven when theyaresurrounded byother people? Dothey want tohave more friends, orwould they PLOS ONE|https://doi.or g/10.1371/journal.po ne.0191538February 6,2018 1/14 a1111111111 a1111111111 a1111111111 a1111111111 a1111111111 2 3 ( 1 $ & & ( 6 6 Citation: SumiyaM,Igarashi K,Miyahara M(2018) Emotions surrounding friendshipsofadolescents with autism spectrum disorderinJapan: A qualitative interviewstudy.PLoSONE13(2):
e0191538. https://doi.org/10.1371/j ournal.
pone.019153 8 Editor: Rodrigo Huerta-Qui ntanilla,Cinvestav- Merida, MEXICO Received: November 6,2017 Accepted: January5,2018 Published: February6,2018 Copyright: 2018 Sumiya etal. This isan open access articledistributed undertheterms ofthe Creative Commons Attribution License,which permits unrestricte duse, distribu tion,and reproduction inany medium, providedtheoriginal author andsource arecredited.
Data Availabilit yStatement: Allrelevant dataare within thepaper anditsSupport ingInformation files.
Funding: Theauthors declarenocompeting financial interests. Thiswork wassupported bya KAKENHI grant(17H07336) toMS from theJapan Society forthe Promotion ofScience (JSPS).The funders hadnorole instudy design, datacollection and analysis, decisiontopublish, orpreparation of the manuscript. rather isolate themselves frompeople andbealone? Giventheirself-awareness oflimited social relationships [6,7]andtheir difficulties inemotional connection withfriends [8],doyoung people withASD havenegative feelingsofloneliness? Toanswer thesequestions inadolescents with ASD, thisqualitative interviewstudydelves intoemotions inthe context offriendship, as there hasbeen adearth ofresearch investigating thesetopics inAsian cultures todate.
Investigations intoemotional contributions tofriendship haveimplications forasuccessful school life[9], mental health,andwellbeing [10].Itisparticularly importanttoexplore feelings within friendships ofadolescents withASD whomayfaceanincreasingly complexsocial milieu andbecome moreaware oftheir interpersonal difficulties[11].Previous studiesin Western countries haveidentified feelingssuchasanxiety andloneliness withinfriendships in children andadolescents withASD inthe U.S.A. [12],Australia [13],andIsrael [14].Further- more, Calder etal. [15] explored thedesire forsocial relationships inchildren withASD inthe UK. Inastudy inthe Netherlands, itwas found thatduring adolescence, peoplewithASD experience anincrease insocial motivation andloneliness, whichispositively correlated with social anxiety [16].These findings inWestern countries yieldapicture ofyoung people with ASD whohave elevated motivation forsocial interaction asoften failing intheir social interac- tion with their peers andthus experiencing loneliness.
To date, thenature offriendship inyoung people withASD hasbeen explored byemploy- ing questionnaires [14,16,17],playground observation [5],and semi-structured interviews [1,18±22]. Amongothers,Carrington andhercolleagues [18±20]conducted aseries ofstudies that revealed howadolescents withASD played withtheir friends, whatsortsofdifficulties they faced, andhow theycoped withthese difficulties. Suchdescriptive datahave been obtained inthe U.S.A., UK,andAustralia. Toour knowledge, however,therehasbeen adearth of research thathasdocumented ininternational academicliteraturethefriendships ofyoung people withASD inthe context ofAsian cultures, usinganyofthe above descriptive methods.
Before investigating thefriendships ofyoung people withASD inan Asian culture, namely, Japan, inthe present study,itis useful toestablish thecomparability offriendships between Eastern andWestern culturesamongnon-ASD youngsters. Previousstudiesshowed bothsim- ilarities [23,24]anddifferences inyoung people's friendships betweenthetwo cultures [25].
Similarities includethetypes ofinteractions withtheir friends, features ofrelationships suchas reciprocity orprosocial behaviortothe partner, andtheimportance offriends [23,24]. Thedif- ferences involveparticular aspectsoffriendship, suchasthe expected emotions gainedfrom interactions withfriends. Forexample, Japaneseyoungpeople enjoycomfort andavoid uncer- tainty intheir friendships morethansurprise andexcitement, whichtheirAmerican counter- parts enjoy [25].Japanese peoplealsoprioritize socialharmony ininterpersonal relationships and value peeracceptance morethanpeople inWestern societiesdo[25±27]. Thus,thereare some unique cultural features offriendship inJapan, andculturally sensitiveandresponsive support andeducation havebeen proposed [28±31].Toformulate culturallyspecificstrategies to support youngpeople withASD inJapan, itis essential tofirst explore theirbehavioral and emotional experiences, understanding, andmotivation forfriendship qualitatively inaspecific cultural context.
Qualitative methodscanprovide adeeper understanding offriendship inASD from the perspective ofadolescents withASD themselves [32±33],andhighlight theroles thatanxiety and loneliness playindeveloping andmaintaining friendshipinthe daily encounters ofado- lescents withASD. Qualitative methodscanalso empower voicesofadolescents withASD, who often gounheard inautism research [34].Furthermore, qualitativeresearchgivesimpor- tant information toteachers andclinical serviceproviders [32].Therefore, qualitativemethods are highly beneficial forunderstanding howadolescents withASD themselves constructthe social world ofschool [35]inthe Japanese schoolsystem.
Friendsh ipsofadolescen tswith ASD inJapan: Aqualitat iveinterview study PLOS ONE|https://doi.or g/10.1371/journal.po ne.0191538February 6,2018 2/14 Competing interests:The authors havedeclared that nocompeting interests exist. To bridge thepreviously mentioned researchgaps,ourstudy aimsto1) describe friendships in adolescents withASD inJapan, and2)explore theexperience ofanxiety andloneliness in the context ofthe desire ofadolescents withASD tomake friends atschool.
Methods Participants A total of11 high-functioning adolescentswithASD (8males (73%) and3females (27%)) whose verbalIQonWISC-III wasover 85,aged 10to15 years wererecruited fromprivate remedial centers,college-based remedialteachingcenters,andspecial education classesin Tokyo andOkayama, Japan.Theywereallstudents fromdifferent elementary orjunior high schools. Twoofthe 11participants (18%)werediagnosed withAutistic disorder (AD),seven with Asperger's disorder(AS)(63%), andtwowith Pervasive Developmental Disorder(PDD) (18%). Because Shirayuri Collegehadneither aspecific institutional reviewboardnoranethics committee, thepresent studywasreviewed andapproved byaone-off committee, namedthe `Provisional EthicsCommittee', consistingofagroup ofdevelopmental psychologistsinthe college, andalso bythe heads ofthe centers andschools fromwhich students wererecruited.
Participation inthis study wasvoluntary, andprior tothe interview, allstudents withASD and their parents signedinformed consentformsaccording tothe principles inthe Declaration of Helsinki. Priortothe interview, theinterviewer orallyexplained tothe participants thatthe interview concerned theirfriendships, thatthey didnot have toanswer anyquestions ifthey did not want to,and that there werenoright orwrong answers tothe interview questions.
To confirm theparticipants' clinicalmanifestation andcognitive profileofASD, theJapa- nese version ofthe Autism Spectrum Quotient(AQ)[36]wasadministered totheir parents.
The AQscore anddemographic dataofeach participant aresummarized inTable 1;further- more, wehave provided supplemental tablesgiving additional cognitiveevidenceconsisting of the definitions offriendship (S1Table) andloneliness (S2Table) byeach participant andthose of same-age neurotypical adolescentswhosedatawere collected inthis study asan additional information source.
To protect theidentities ofthe participants andofpeople discussed inthe interviews, we used pseudonyms andslightly alteredtheages ofthe participants toan extent thatwould not affect theinterpretation ofthe interview data.
Data collection andanalysis We employed individual semi-structured interviewstodiscover thefeelings ofloneliness and anxiety relatedtofriendship. Allparticipants wereJapanese students, asnoted, andtheinter- views wereconducted bythe first author inthe Japanese language atthe participants' schools, clinical institutions, orthe participants' homes.Atthe time ofthe interviews, theinterviewer (MS) wasamaster's studentmajoring inclinical psychology withthree yearsoffieldwork experience withstudents withneurodevelopmental disorders.Ifthe participating students, their parents, ortheir teachers requested orrecommended thepresence ofparents orteachers during theinterview, theywere allowed tobe present atthe interview, withthestudent's con- sent. Sixofthe 11students askedforthe presence ofeither aparent orateacher inthe inter- view. When theresponse ofthe interviewee wasunclear, theinterviewer askedtheparent or the teacher toclarify theresponse duringtheinterview. Theremaining fivestudents didnot ask foradults toaccompany them,andtheinterviewer securedtheseinterviewees' permission to ask their parents orteachers forclarification andconfirmation aftertheinterviews.
Before theinterviews, weprepared questions concerning friendship(seesupplemental information). Weused thequestions developed byCarrington, Templeton,andPapinczak Friendsh ipsofadolescen tswith ASD inJapan: Aqualitat iveinterview study PLOS ONE|https://doi.or g/10.1371/journal.po ne.0191538February 6,2018 3/ 14 [20], andadded someofour original questions aboutloneliness (e.g.,ªWhen doyou feel lonely?º) andanxiety (e.g.,ªWhen youarewith your friends, howanxious areyou?º). Further- more, wedecided toask theparticipants whotheir friends werebecause aprevious studyby Bauminger andKasari [17]showed thatchildren withASD hadmentioned theirteacher aids and parents asfriends. Allquestions weremade available inadvance uponrequest. Atthe beginning ofeach interview, theinterviewer establishedrapportwiththeinterviewee bytalk- ing about theparticipant's hobbiesandwhat theyenjoyed recently. Thentheinterviewer explained thepurpose ofthe interview: ªSomechildren aregood atmaking friends,andother children arenot sogood atmaking friends.Iam interested inhow youinteract withyour friends.º Whentheinterviewer actuallyaskedthepreplanned questions,thewords weremodi- fied inaccordance witheach participant's languageability.Ifparticipants didnot seem to understand thequestions, theinterviewer rephrasedthem,trying todo soinaccordance with the participant's languageability,andprovided prompts, whiletrying nottoask leading ques- tions. When interviewees haddifficulty communicating abouttheiremotions, theinterviewer focused onbehavioral aspectsoffriendship. Whentheinterview topiccovered sensitive issues, such asfeelings ofloneliness oranxiety, theinterviewer expressedtothe students howmuch he appreciated theirdisclosure offeelings andexperiences. Aftereachinterview, theinter- viewer ensured witheach interviewee's parentorteacher thattheinterviewee wasnotdis- tressed bythe interview.
Table 1.Demographi cinformation andclinical character isticsofthe participants.
Name Jiro Ken Anna Akira Sex Male Male Female Male Grade 5th 5th 9th9th Age (years) 12 11 1515 Diagnosi s AD AD ASAS Verbal IQ 110 87 9290 AQ 23 36 2444 Features manyfightsinschool havingdifficulties thinkingandfocusing knowsherown difficulties OCD,afraidofbe scolded byteachers Name Michio Haruo EigoShiho Sex Male Male MaleFemale Grade 7th 6th 6th5th Age (years) 13 12 1211 Diagnosi s AS AS ASAS Verbal IQ 96 100 142 94 AQ 35 36 3232 Features depression experienceofbullying ADHD,Learning Disorder, liesathome Name Rie Toshi Hiro Sex Female Male Male Grade 7th 9th 5th Age (years) 13 15 12 Diagnosi s AS PDD PDD Verbal IQ 85 110 100 AQ 31 32 24 Features depression,self-harm schoolrefusal LearningDisorder,difficulty coping withhisirritability AD, autistic disorder; AS,Asperger's disorder;PDD,Pervasiv eDevelopmen talDisorder ;OCD, Obsessive-Co mpulsiveDisorder;AQ, autism spectrum quotient https://do i.org/10.1371/j ournal.pone.0191538.t001 Friendsh ipsofadolescen tswith ASD inJapan: Aqualitat iveinterview study PLOS ONE|https://doi.or g/10.1371/journal.po ne.0191538February 6,2018 4/ 14 A total of20 to30 questions wereasked ineach interview; interviews lastedfrom20to40 minutes. Allinterviews wererecorded withadigital audio-recorder andwere transcribed ver- batim. Thematic analysis[37]wasused toexamine andidentify themeswithintheinterviews, following thesesixsteps: familiarizing data,generating codes,searching forthemes, reviewing themes, defining andreviewing themes,andproducing thereport. Thetranscribed interview data were coded bythe first author (MS)andtwocoders whowere students pursuing their masters inclinical anddevelopmental psychology(SMandYS), andtheunderlying themes were agreed uponfollowing discussions acrossmultiple meetings. Thesecond (KI)andthe third author (MM)served asmethodological auditorstoexamine thecredibility ofthe concep- tual interpretation ofthe original data[38]. Weused QDA software (WeftQDA, www.
pressure.to/qda/) toanalyze andorganize thedata.
Results Nine ofthe 11students responded tothe interview questions indetail, withspecific examples.
One participant tookrelatively longpauses beforeanswering questions,andtheremaining participant providedonlybrief answers. Theinterview datayielded fourmajor themes: social motivation, loneliness,anxiety,anddistress.
Social motivation Seven outof11 students hadatleast onefriend whoweconsidered tobe inareciprocal friend- ship with them; twostudents wereinaone-way friendship, whosereciprocity couldnotbe confirmed; andthetwo remaining studentshadnofriendships atall, according tothe informa- tion firstprovided bythe students andlater confirmed bytheir parents andschoolteachers.
Some ofthe students whoclaimed tobe inreciprocal friendships seemedtohave alow level of motivation tointeract withtheir friends. Around thetime ofthe interview, Haruoonlyhad one friend, whosenamewasMakoto. Haruoexplained howhewould spendtimewithhis friend:
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He told theinterviewer thathedid not hang outwith anyone atschool, andthat herarely played withMakoto evenathome. Theonly game heplayed withMakoto was on Nintendo DS.The range ofactivities throughwhichHaruo interacted withhisfriend, Makoto, seemed tobe rather limited. Theinterviewer askedHaruo whatkindofhelp heneeded from teachers tomake friends ordevelop friendship, hopingtogain information forthe teacher's possible intervention. Haruo'sanswerwasªnothing.º Inresponse tothe interviewer's question regarding themotivation tofurther develop friendship, Haruoanswered ªratherlowºfollowed by ªno prospects offuture friendship.º Eventhough itwas very rareforHaruo tohang out with Makoto, hismotivation forfurther friendship wasnothigh.
Similarly, Jiroalso reported thathismotivation todeepen friendship withhisfew friends was ªrather low.º Friendsh ipsofadolescen tswith ASD inJapan: Aqualitat iveinterview study PLOS ONE|https://doi.or g/10.1371/journal.po ne.0191538February 6,2018 5/ 14 : ! : " , . # $ , $ % . & % % .
Jiro needed friendswhowould occupy histime andcare about him.Heseemed towant a friend ªinneed,º andnotareciprocal friendship. Suchaone-sided relationship wouldnot develop intoadeeper friendship, whichJiromight bewell aware of:
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Jiro was well aware ofthe standard waysofmaking friends.Inhis case, heanticipated chal- lenges todeepening friendships. Theinterview withJirouncovered thathisway ofªinteracting with friendsº waslimited torough-and-tumble play,suchaswrestling andsumo. Infact, Jiro mentioned thathehad inflicted injuriesonhis friends afew times. Asaresult, Jirousually played byhimself because hisinvitations towrestle declined. Jiro'slowmotivation todevelop friendship mightbedue tohis learned helplessness fromhisnarrow andrather dangerous rep- ertoire ofskills related tointeraction withother students.
In contrast, someother participants werehighly motivated tosocialize, butfordifferent rea- sons. Forexample, Michiowanted tomake asmany newfriends aspossible inhis new class, whereas EigoandRieonly wanted compatible friends,andthenumber offriends didnot mat- ter. Thus, someemphasized thequantity, andsome thequality offriendships. Yetothers, such as Shiho, valued bothquantity andquality offriends; however, shehad difficulty approaching her classmates.
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Extracurricular activitiescanserve asvehicles forsocialization. Ofthe 11participants, three students tookpartinextracurricular activities(namely,basketball club,school choir,history club, andrailway club).Michio expressed howheliked playing ballgames:
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In sum, theparticipants' levelsandtypes ofsocial motivation tomake friends varied, although mostofthem valued friendship highly.Thestudents whohadnofriends generally wished tomake friends. Thus,withafew exceptions, theadolescents withASD were notsatis- fied with their ownworld, butappreciated anddesired friendship.
Loneliness The theme ofloneliness emerged,reflecting thefeelings ofadolescents withASD whohaddif- ficulty casually socializing withtheir peers atschool andinother group situations. Therewere a variety ofsituations inwhich participants experienced loneliness,suchassituations where they were ingroups butnot surrounded byfriends, andsituations wherebidirectional interac- tions werenotoccurring. Bycontrast, someparticipants reportedthatthey hadnoexperience of loneliness.
Rie goes toaspecial support schoolforstudents whoareunable tocope withmainstream schools forvarious reasons. Rieconsiders Lisa,Tomoko, andherhomeroom teacher,Mr.
Shirai, tobe her friends because shecan easily converse withthem. Intheir absence, Riehas no one totalk toor spend timewith.
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Rie also mentioned thatshefeltlonelier whenherfriends talkedwithother students than when herfriends werenotaround. Itseems thatRie's desire tomonopolize herlimited num- ber offriends, coupled withherlack ofoptions tointeract withother students, exacerbated her loneliness.
Adolescents withASD canfeelloneliness evenwhen theyareinteracting withtheir class- mates inagroup situation. Jiroexplained howthishappened.
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It seems thatJirowasbeing selectively excludedasatarget of`ijime' whichisthe Japanese term forbullying withaless physically violentconnotation andgreater emphasis onsocial manipulation [39],probably becausehehad physically harmedothersbefore. Giventhatchil- dren withASD arethrice morelikely tobe victims ofbullying thannon-autistic children [40,41], Jiromight havebeen atarisk forbullying. Hisexperience indicatesthatphysical pres- ence inagroup isnot enough; meaningful interactions arenecessary forstudents withASD to feel included inand connected withthegroup.
Friendsh ipsofadolescen tswith ASD inJapan: Aqualitat iveinterview study PLOS ONE|https://doi.or g/10.1371/journal.po ne.0191538February 6,2018 7/ 14 Although someparticipants couldelaborate onboth their understanding andexperiences of loneliness, othersunderstood lonelinessonlyonthe conceptual levelwithout anyexperience of the feeling. Forexample, Shihoseemed toknow whatloneliness was;sheexplained her understanding asªsad forbeing alone, andnobody isaround totalk with.º However, shesaid that shehad notfeltloneliness evenwhen shehad nofriends.
Anxiety Adolescence isaremarkable periodwhenthedevelopment ofsocial cognition, whichyoung people totune intosocial differences [42,43].Thistendency ofadolescents increasestherisk of anxiety symptoms particularly inpersons withASD [44].Whether itis specific toaparticu- lar topic ofconversation orgeneral toany kind ofsocial situation, anxietyaffectssocial interactions. Conversation topicswereanimportant themeforadolescents withASD. Shiho confided that shewas constantly worriedwhether shecould keepupwith conversations. Inthe case of Rie, herconcern waswhether theperson sheconversed withknew thetopic shewanted totalk about.
Eigo andToshi alsohadmore general anxietyregarding friendship.
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In another case,Hiro wasdeeply worried ifhe could makenewfriends, because hewanted to have friends verymuch without knowing howtoaccomplish this.Itseems thathishigh level ofsocial motivation madehimworried andanxious, aphenomenon identifiedbyWhite, Bray, andOllendick [44].Such anxiety apparently impededhischance ofsuccessfully making new friends.
Distress Distress insocial situations interfereswiththesuccessful development ofsocial relationships [45]. Carrington andGraham [18]referred toªmasking,º whichchildren withASD useasa device tohide their negative feelingstowards anddifficulty insocial interactions. Rieexplained how sheuses masking:
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Rie said shewould oftenpretend tounderstand conversations thatshehad trouble follow- ing. Inaddition toputting onanact, Riesaid shelether friends winincard games topreserve friendship. Masking,ormasquerading [18],mayhelp with adaption tosocial situations, but excessive usemay cause othertypesofdistress. InRie's case,shegrows wearyaftermaking so much socialeffort.
Masa wasannoyed byhis friends' unpredictable behaviors,suchassuddenly leavinga group orjumping intoagroup. Thisannoyance mightreflect thedifficulty youngpeople with ASD experience predictingothers'behaviors [46].Whatever thecauses ofdistress, adolescents with ASD need tomake extraordinary effortstoengage insocial relationships andendure unavoidable socialstressdoing so.
Discussion Our interview datarevealed different degreesofdesire inthese adolescents withASD tosocial- ize with peers, limited futureprospects todeepen friendships, solidawareness oftheir own social limitations, andimpressive effortstocope withthese limitations. Wealso uncovered the complex rolesthatfeelings ofanxiety andloneliness playedintheir process ofmaintaining friendships. Someparticipants wereanxious tobehave properly andafraid tolose friends. Oth- ers felt lonely whentheyfeltrejected orexcluded. Yetothers claimed thatthey hadlimited feel- ings assuch. Inthe following discussion, wedescribe friendships inadolescents withASD in Japan andcontrast themwiththose inother cultures, andexplore theexperience ofanxiety and loneliness inthe context ofthe desire ofadolescents withASD tomake friends atschool.
Possible uniqueness ofcoping strategies inJapanese adolescents withASD There seemtobe similarities anddifferences betweentheJapanese participants inthe current study andindividuals withASD inWestern culturesreported oninprevious studiesonmask- ing coping strategies tomaintain friendships [19±20,22]. AmongtheJapanese participants who feltrejected andexcluded wereadolescents whomasked theirfeelings, asalso seen inthe case ofAustralian adolescents withASD [19,20]. Inthe study ofCarrington etal. [19], Austra- lian participants withASD confided thatthey concealed theirsocial awkwardness bybehaving in the same waysasothers andpretending toshare thesame interests. Likewise, Riewould often pretend tounderstand conversations thatshehad trouble following. Eventhough acting in this way wasstressful toher, sheused thisstrategy toavoid peerrejection. Thiscommon masking strategymaybebased onthe knowledge thatsharing interests andparticipating in common activitiesareimportant forfriendship [21].
A possible culturaldifference betweenJapanandAustralia inmasking copingstrategies may beseen incoping strategies. Rieused aninternal copingtechnique andsacrificed herself by masking herdesire towin and intentionally losinginthe card game. Thiscoping technique may beunique toJapanese culture,whichemphasizes socialharmony overself-interest [25± 27]. Incontrast, anAustralian adolescent withASD employed anexternal copingtechnique by pretending tohave awide social network, suchasafictional accountofan extensive listof Friendsh ipsofadolescen tswith ASD inJapan: Aqualitat iveinterview study PLOS ONE|https://doi.or g/10.1371/journal.po ne.0191538February 6,2018 9/ 14 friends andfabricated storiesaboutinteractions withthem [20].Theopposite directions of these coping strategies mayreflect differences betweenEasternandWestern culturesinthat 1) people inEastern cultures tendtoset coping goalsthatfocus onthe needs ofothers, related- ness, andinterdependence, whichmayrequire self-sacrifice, whereaspeopleinWestern cul- tures tendtofocus ontheir ownneeds, asserting independence andcontrol ofthe external environment [47].These cultural differences inthe direction ofcoping strategies mightneces- sitate different directions inthe masking strategies usedbyadolescents withASD toadapt to social situations. Ifinternalizing copingisunique toJapanese individuals amongpeoplewith ASD, parents andteachers shouldbeaware ofthis tendency andteach culturally appropriate social skills[31].However, furtherstudyisneeded toconfirm ifthis unique copingtendency apparent inthis study actually holdstrue.
Emotions surrounding adolescentswithASD The levels andtypes offriendship-related socialmotives andemotional experiences varied among thestudents withASD whoparticipated inthis study. Consistent withaprevious study by Chen etal. [48], ahigh level ofsocial motivation madesomeindividuals withASD, suchas Hiro, worried andanxious aboutfriendship withoutknowing howtomake friends. Suchanxi- ety could either keepthem motivated, or,worse, impede theirchance ofsuccessfully making new friends. Morestudies areneeded toexplore howsocial anxiety relatestomaintaining and developing friendships intheir daily school life.
In another case,Jiro,whose onlywayofhanging outwith hisfriends wasrough-and-tumble play, suchaswrestling andsumo, seemed tobe ostracized inhis classroom. Jiroreported that he had inflicted injuriesonhis friends afew times during suchplay. Thus, hemight besocially excluded byhis classmates (e.g.,when nobody triedtocatch himduring playtag). Thesocial demands aroundhimmight haveexceeded thecapacity ofhis social skillstocope [49].
According toan experimental study[50],adolescents withASD aresensitive toostracism and experience increasedanxietyandneed threat following it.Therefore, Jiro'sloneliness andlow motivation todevelop friendships mighthavefollowed fromthesituations heexperienced dur- ing play.
There werestudents withASD whoreported theyhadlimited feelings. Therearetwo possi- bilities: oneisthat they actually feelnothing, whiletheother isthat they have feelings buthave difficulties recognizing andexplaining theirownfeelings andthose ofothers [51,52]. Indeed, some researchers [53,54]pointed outthat individuals withASD haveemotional interoception difficulties similartothose inindividuals withalexithymia. Recently,BirdandCook [55]pro- posed thatdeficits inrecognition ofemotions orthe internal stateofthe body areassociated with co-occurring alexithymiaforsome individuals withASD, although alexithymia isnot commonly considered characteristic ofASD [56].Alternatively, assuggested, theremaybea genuine lackofcertain emotions forsome participants; whicheveristhe case, thisstudy has extended thegrowing knowledge onthe friendships ofadolescents withASD byfocusing on their emotional life,particularly theirfeelings ofloneliness andanxiety.
Limitations Our study hasshed lightonthe emotional lifeofstudents withASD inthe context oftheir friendships, butthelimitations ofthis study needtobe considered forthe interpretation ofthe findings andforfuture research. Theparticipants werefewinnumber, andallofthem were clinically diagnosed withautism disorder, Asperger's syndrome, orpervasive developmental disorder according toDSM-IV-TR [57]bymedical doctorsspecialized inchild psychiatry or developmental pediatrics.Futurestudies needtouse contemporary diagnosticcriteriaofASD Friendsh ipsofadolescen tswith ASD inJapan: Aqualitat iveinterview study PLOS ONE|https://doi.or g/10.1371/journal.po ne.0191538February 6,2018 10/ 14 and itscomorbid conditions definedinDSM-5 [3]and gold-standard measuressuchasthe Autism Diagnostic Interview-Revised (ADI-R)[58]orthe Social Communication Question- naire [59],which werenotavailable inJapanese atthe time ofthis research (2011),forthe veri- fication ofthe ASD diagnosis.
A recent studybyDean etal. [60] found thatchildren withASD preferred tosocialize with same-gender friends,asdid their typically developing counterparts. Futureresearch could yield different dimensions ofinsight intothese friendships. Forexample, thisline ofstudies needs totap into theemotional lifeofindividuals withASD indifferent agegroups, suchas young children andadults, because thenature offriendship islikely tochange throughout life.
Conclusion This study isprobably thefirst touncover therich emotional lifeofadolescents withASD in the context oftheir friendships inan Asian culture. Inaddition toemotions suchasanxiety, loneliness, anddesires forsocial relationships thathave already beenidentified byprevious studies conducted inWestern cultures, wediscovered apossibly uniquecopingstrategy char- acterized byinternalization andself-sacrifice inour study.
Supporting information S1 File. Questions afterCarrington etal., 2003 andoriginal questions.
(DOCX) S1 Table. Definitions offriendship.
(DOCX) S2 Table. Definitions ofloneliness.
(DOCX) Acknowledgmen ts We thank theparticipants andtheir parents, teachers, andcounselors, whokindly contributed to this study. Wealso gratefully appreciate ShihoMochizuki andYuki Shinoda forsupporting this research ascoders.
Author Contributions Conceptualization: KazueIgarashi.
Data curation: Motofumi Sumiya.
Formal analysis: Motofumi Sumiya,KazueIgarashi, Motohide Miyahara.
Funding acquisition: MotofumiSumiya.
Methodology: MotofumiSumiya,Motohide Miyahara.
Supervision: KazueIgarashi, Motohide Miyahara.
Writing ±original draft:Motofumi Sumiya,KazueIgarashi, Motohide Miyahara.
Writing ±review &editing: Motofumi Sumiya,Motohide Miyahara.
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