Iran Journal of Nursing

Introduction
According to the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders, autism spectrum disorder (ASD) is characterized by deficits in social communication and interactions and repetitive restricted behaviors. The theory of executive functioning is known as the most influential theory in explaining ASD. There are various methods to improve an ASD child’s understanding of his/her own emotions or the emotions of others, one of which is emotion labeling (EL), which has been applied with different approaches on ASD children. It is possible that the improvement in emotion regulation using the EL method can affect the behavioral problems of ASD children. In this study, we aim to assess this hypothesis by designing an educational intervention.

Methods
This is a quasi-experimental single-subject study with a pretest/posttest/follow-up design that was conducted in one of the exceptional elementary schools for boys, located in Ilam, Iran, in 2022. The criteria for entering the study were having high-functioning autism, the ability to respond to verbal commands, chronological age 8-12 years, IQ above 80 [19], not receiving emotion control training, willingness of mother and child to participate in the study, and no visual or hearing problems in the child. The criteria for withdrawing from the study were unwillingness to continue participating in the study and any problems related to the disease chronically in more than two sessions. In single-subject studies, due to the lack of a formula for determining the sample size, the sample size is considered between 2 and 10 [20, 21]. In this study, based on the entry criteria and the consent of parents and children, 5 samples were selected to participate in the research and were placed in one intervention group. 
The training program consisted of two consecutive stages, recognizing facial expressions and labeling emotions. In the first stage, the educational software for autism children called “Let’s Face It” (LFI) was used as a prerequisite for labeling emotions [17]. It should be mentioned that the recognition of facial expressions is needed for EL [16]. For EL training, the book “Emotion Management in Children with Autism (Home and School Education)” in Persian was used. This book consists of 4 chapters [26]. Chapters 2 and 3 were used to teach children after the LFI software use. The second chapter was used one time as an exercise to recognize facial expressions and the third chapter was used for each child individually in 4 weeks, two session per week. 
Questionnaires were completed five times by mothers of children which included a demographic form (surveying the child’s age, birth rank, number of siblings, siblings with autism, time of ASD diagnosis, co-morbidities, and medications) and the test of behavioral disorders of children with ASD designed by Bardideh et al. [28]. Descriptive statistics (frequency, percentage, mean, standard deviation) and Friedman’s test were used to analyze the data in SPSS software, version 16. P<0.050 was considered statistically significant.

Results
The mean age of children was 11.2±2.13 years and the mean time of ASD diagnosis in children was 2.74±7.0 years. According to the results of between-phase and within-phase comparisons, there was a significant difference in the behavioral disorder score between phases 2 and 4 (P=0.037) and between phases 4 and 5 (P=0.019). No significant difference was observed between or within other phases. The EL training program showed a significant effect on the participants (P=0.030).

Conclusion
In this research, the findings showed that EL training can have a positive effect in reducing the behavioral disorders of children with ASD, which was more evident in the final phases of training. The people responsible for planning for the education of ASD children are recommended to develop educational plans using novel interventions, such as online EL training, and integrate it to the educational curriculum of these children in different schools.

Ethical Considerations
Compliance with ethical guidelines
This study has ethical approval from the ethics committee of Zahedan University of Medical Sciences (Code: IR.ZAUMS.REC.1400.348,). All participant parents were assured of their child’s information confidentiality and mothers completed the satisfaction form. 

Funding
This study was extracted from a research project (Grand No.:10040) and funded by Zahedan University of Medical Sciences.

Authors' contributions
The authors contributed equally to preparing this article.

Conflict of interest
The authors declare no conflict of interest.

Acknowledgments
The authors would like to thank all participants as well as the officials of the Faculty of Nursing & Midwifery, Zahedan University of Medical Sciences, and the manager of the exceptional school in Ilam for their cooperation.

References

1. Glidden L, Abbeduto L, Lee McIntyre L, Tassé MJ. APA handbook of intellectual and developmental disabilities. Washington, D.C: American Psychological Association; 2020. [Link]
2. Ghanizadeh A. A preliminary study on screening prevalence of pervasive developmental disorder in schoolchildren in Iran.  J Autism Dev Disord. 2008; 38(4):759-63. [DOI:10.1007/s10803-007-0445-6] [PMID]
3. Samadi SA, Mahmoodizadeh A, McConkey R. A national study of the prevalence of autism among five-year-old children in Iran. Autism. 2012; 16(1):5-14. [DOI:10.1177/1362361311407091] [PMID]
4. Losh M, Capps L. Understanding of emotional experience in autism: Insights from the personal accounts of high-functioning children with autism. Dev Psychol. 2006; 42(5):809-18.  [DOI:10.1037/0012-1649.42.5.809] [PMID]
5. Lohmann H, Tomasello M. The role of language in the development of false belief understanding: A training study. Child Dev. 2003; 74(4):1130-44. [DOI:10.1111/1467-8624.00597] [PMID]
6. Hill EL, Frith U. Understanding autism: Insights from mind and brain. Philos Trans R Soc Lond B Biol Sci. 2003; 358(1430):281-9. [DOI:10.1098/rstb.2002.1209] [PMID]   
7. Howlin P. Interventions and outcome in autism. In: Singh NN, Ollendick TH, Singh AN, editors. International perspectives on child and adolescent mental health. Elsevier: Amsterdam; 2002. [DOI:10.1016/S1874-5911(02)80004-5]
8. Baker KF, Montgomery AA, Abramson R. Brief report: Perception and lateralization of spoken emotion by youths with high-functioning forms of autism. J Autism Dev Disord. 2010; 40(1):123-9. [DOI:10.1007/s10803-009-0841-1] [PMID]
9. Fitzpatrick SE, Srivorakiat L, Wink LK, Pedapati EV, Erickson CA.  Aggression in autism spectrum disorder: Presentation and treatment options. Neuropsychiatr Dis Treat. 2016; 12:1525-38. [DOI:10.2147/NDT.S84585] [PMID]   
10. Geurts HM, Begeer S, Stockmann L. Brief report: Inhibitory control of socially relevant stimuli in children with high functioning autism. J Autism Dev Disord. 2009; 39(11):1603-7. [DOI:10.1007/s10803-009-0786-4] [PMID]   
11. Hill EL. Evaluating the theory of executive dysfunction in autism. Dev Rev. 2004; 24(2):189-233. [DOI:10.1016/j.dr.2004.01.001]
12. Pellicano E. Individual differences in executive function and central coherence predict developmental changes in theory of mind in autism. Dev Psychol. 2010; 46(2):530-44. [DOI:10.1037/a0018287] [PMID]
13. Russell, J. Autism as an executive disorder. Oxford: Oxford University Press; 1998.  [DOI:10.1093/med:psych/9780198523499.001.0001]
14. Mashhadi A, Hamidi N, Soltanifar A,  Timoori S. [Response inhibition in Children with Autism Spectrum Disorders: Use of Computerized stroop test (Persian)]. Res Clin Psychol Couns. 2012; 1(2):87-104. [Link]
15. Mazefsky CA, Herrington J, Siegel M, Scarpa A, Maddox BB, Scahill L, et al. The role of emotion regulation in autism spectrum disorder. J Am Acad Child Adolesc Psychiatry. 2013; 52(7):679-88.  [DOI:10.1016/j.jaac.2013.05.006] [PMID]   
16. Centers for Disease Control and Prevention. Treatment and intervention services for autism spectrum disorder. Atlanta: Centers for Disease Control and Prevention ;2023. [Link]
17. Conallen K, Reed Ph. A teaching procedure to help children with autistic spectrum disorder to label emotions. Res Autism Spectr Disord. 2016; 23:63-72. [DOI:10.1016/j.rasd.2015.11.006]
18. Hasan Poor M, Moradi V, Fereydooni Sarije P, Haghani S, Yaghoobnezhad S. [From drawing cards to a better life by new method of label emotions in autistic children with high-function: Single-subject research (Persian)]. Stud Med Sci. 2019; 30(9):706-19. [Link]
19. Lartseva A, Dijkstra T, Buitelaar JK. Emotional language processing in autism spectrum disorders: A systematic review. Front Hum Neurosci. 2015; 8:991. [DOI:10.3389/fnhum.2014.00991] [PMID]   
20. Hendrix NM, Pickard KE, Binion GE, Kushner E. A systematic review of emotion regulation in parent-mediated interventions for autism spectrum disorder.Front Psychiatry. 2022; 13:846286. [DOI:10.3389/fpsyt.2022.846286] [PMID]   
21. Odom SL, Hall LJ, Morin KL, Kraemer BR, Hume KA, McIntyre NS, et al. Educational interventions for children and youth with autism: A 40-year perspective. J Autism Dev Disord. 2021; 51(12):4354-69.  [DOI:10.1007/s10803-021-04990-1] [PMID]   
22. Mirzaei F, Cheraghi F, Khazaei S, Rezaei M, Mohammadi F. Effect of intervention training on the mother-child relationship in children with autism: A control trial. Shiraz E-Med J. 2022; 23(3):e113583. [Link]
23. Mahoney WJ, Villacrusis M, Sompolski M, Iwanski B, Charman A, Hammond C, et al. Nursing care for pediatric patients with autism spectrum disorders: A cross-sectional survey of perceptions and strategies. J Spec Pediatr Nurs. 2021; 26(4):e12332.[DOI:10.1111/jspn.12332] [PMID]
24. Araghi NM, Zahedi Barough A, Alizadeh Zareie M, Akbarzadeh Baghban A, Pashazadeh Azari Z, Rezaee M, et al.[ Deficit of neutral facial expression recognition between children with high-functioning autism and typical peers aged 7-11 (Persian)]. J Rehab Med. 2014; 3(3):43-53. [Link]
25. Cakiroglu O. Single subject research: Applications to special education. Br J Spec Educ. 2012; 39(1):21-9. [DOI:10.1111/j.1467-8578.2012.00530.x]
26. Davis CA, Brady MP, Hamilton R, McEvoy MA, Williams RE.  Effects of high-probability requests on the social interactions of young children with severe disabilities. J Appl Behav Anal. 1994; 27(4):619-37.  [DOI:10.1901/jaba.1994.27-619] [PMID]   
27. Price PC, Jhangiani R. Research methods in psychology. Victoria: BCcampus; 2015.
28. Bardideh M, Mansor M, Karimpoor M. [Preparation and validation of behavioral disorders in autistic spectrum children (parent form) (Persian)]. Psychol Models Methods. 2010; 1(1):15-26. [Link]
29. Heydarpour F,  Siahkamari R, Heidarisharaf P, Ziapour A, Dehghan F. Relationship between attachment styles and parenting styles with self-esteem in dyslexic children of Kermanshah City, Iran. Int J Pediatr. 2018; 6(12):8745-55. [Link]
30. Ramdoss S, Machalicek W, Rispoli M, Mulloy A, Lang R, O'Reilly M. Computer-based interventions to improve social and emotional skills in individuals with autism spectrum disorders: A systematic review. . Dev Neurorehabil. 2012; 15(2):119-35.  [DOI:10.3109/17518423.2011.651655] [PMID]
31. Gross TF. The perception of four basic emotions in human and nonhuman faces by children with autism and other developmental disabilities. J Abnorm Child Psychol. 2004; 32(5):469-80. [DOI:10.1023/B:JACP.0000037777.17698.01] [PMID]
32. Mahaki M, Najafi M, Jafari Z. [Effect of “Let's Face It” computer game on improving face recognition skills in patients with autism spectrum disorders (Persian)]. J Isfahan Med Sch. 2016; 33(365):2279-87. [Link]
33. Tanaka JW, Wolf JM, Klaiman C, Koenig K, Cockburn J, Herlihy L, et al. Using computerized games to teach face recognition skills to children with autism spectrum disorder: The Let's Face It! program. J Child Psychol Psychiatry. 2010; 51(8):944-52. [DOI:10.1111/j.1469-7610.2010.02258.x] [PMID]
34. Moradi V, Namnabati M, Yaghobnezhad S, Haghani Sh.  [Emotion management in autistic children (home and school education) (Persian)]. Esfahan: Esfahan University of Medical Sciences; 2021. [Link]
35. Akbari Bayatiani Z. [Autism spectrum disorder from diagnosis to treatment (Persian)]. Neurosci J Shefaye Khatam. 2018; 6(4):93-101. [Link]
36. Mondal A, Mukherjee S, Dar W, Singh S, Pati S. Role of glucose 6-phosphate dehydrogenase (G6PD) deficiency and its association to autism spectrum disorders.Biochim Biophys Acta Mol Basis Dis. 2021; 1867(10):166185.  [DOI:10.1016/j.bbadis.2021.166185] [PMID]
37. Mano-Sousa BJ, Pedrosa AM, Alves BC, Galduróz JCF, Belo VS, Chaves VE, et al. Effects of risperidone in autistic children and young adults: A systematic review and meta-analysis. Curr Neuropharmacol. 2021; 19(4):538-52. [DOI:10.2174/1570159X18666200529151741] [PMID]   
38. Da Fonseca D,  Santos A, Bastard-Rosset D, Rondan C, Poinso a F,  Deruelle C. Can children with autistic spectrum disorders extract emotions out of contextual cues? Res Autism Spectr Disord. 2009; 3(1):50-6. [DOI:10.1016/j.rasd.2008.04.001]
39. Chiang HM,  Wineman I. Factors associated with quality of life in individuals with autism spectrum disorders: A review of literature. Res  Autism Spectr Disord. 2014; 8(8):974-86. [DOI:10.1016/j.rasd.2014.05.003]
40. Hasanpour M, Moradi V, Yaghoubnezhad S, Haghani S. [To investigate the effect of face emotion recognition training to children with high-functioning Autism on their mother-child relationship (Persian)]. Razi J Med Sci. 2019; 26(6):54-63. [Link]
41. Gray C. Social assistance. In: Stratton J, Coyne Ph, Gray  C, Fullerton A, Thomas G, editors. Higher Functioning adolescents and young adults with autism: A teacher's guide. Austin: Pro-Ed; 1996. [Link]
42. Attwood T. Strategies for improving the social integration of children with Asperger syndrome. Autism. 2000; 4(1):85-100. [DOI:10.1177/1362361300004001006]
43. Karaminis T, Neil L, Manning C, Turi M, Fiorentini C, Burr D. Ensemble perception of emotions in autistic and typical children and adolescents": Erratum. Dev Cogn Neurosci. 2020; 45. [Link]
44. Alimardani M, Neve L, Verkaart A. Storytelling robots for training of emotion recognition in children with autism; opinions from experts. In: Stephanidis C, Antona M, Ntoa S, editors. HCI International 2021 - Late Breaking Posters. HCII 2021. Communications in Computer and Information Science, vol 1498. Cham: Springer; 2021. [DOI:10.1007/978-3-030-90176-9_30]
45. Cashin A, Browne G, Bradbury J, Mulder A. The effectiveness of narrative therapy with young people with autism. J Child Adolesc Psychiatr Nurs. 2013; 26(1):32-41. [DOI:10.1111/jcap.12020] [PMID]
46. Sephvandi S, Sahebalzamani M. [Investigating the effect of storytelling on role playing method on sensory-cognitive and interpersonal knowledge in children with autism spectrum disorder (Persian)]. Jundishapur Sci Med J. 2019; 17(6):621-30. [DOI: 10.22118/JSMJ.2019.159650.1533]
47. Samson AC, Hardan AY, Lee IA, Phillips JM, Gross JJ. Maladaptive behavior in autism spectrum disorder: The role of emotion experience and emotion regulation. J Autism Dev Disord. 2015; 45(11):3424-32. [DOI:10.1007/s10803-015-2388-7] [PMID]
48. Downs A, Smith T. Smith, emotional understanding, cooperation, and social behavior in high-functioning children with autism. J Autism Dev Disord. 2004; 34(6):625-35. [DOI:10.1007/s10803-004-5284-0] [PMID]
49. Moradi V,  Naderi M, Rasheki H, Esfehani H. [Asperger Syndrome & Autism (Persian)]. Tehran: Anateb; 2021. [Link]
50. Martínez-González AE, Cervin M, Piqueras JA. Relationships between emotion regulation, social communication and repetitive behaviors in Autism Spectrum Disorder. J Autism Dev Disord. 2022; 52(10):4519-27. [DOI:10.1007/s10803-021-05340-x] [PMID]   
51. Sagar-Ouriaghli I, Lievesley K, Santosh PJ. Propranolol for treating emotional, behavioural, autonomic dysregulation in children and adolescents with autism spectrum disorders. J Psychopharmacol. 2018; 32(6):641-53.[DOI:10.1177/0269881118756245] [PMID]
52. Conner CM, White SW, Scahill L, Mazefsky CA. The role of emotion regulation and core autism symptoms in the experience of anxiety in autism. Autism. 2020; 24(4):931-40. [DOI:10.1177/1362361320904217] [PMID]