Article

Autism
Friendship characteristics and 17(4) 481–500
Ó The Author(s) 2011
activity patterns of adolescents Reprints and permissions:
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with an autism spectrum DOI: 10.1177/1362361311416380

aut.sagepub.com

disorder
Melissa H. Kuo
University of Alberta, Canada

Gael I. Orsmond
Boston University, USA

Ellen S. Cohn
Boston University, USA

Wendy J. Coster
Boston University, USA

Abstract
This study compared perceptions of adolescents’ friendships between adolescents with an autism
spectrum disorder (ASD) and their parents, examined factors associated with friendship qualities,
and investigated the adolescents’ reports on the activities they did with friends and how activity
patterns differed by gender. Ninety-one adolescents with an ASD and their parents completed
mail-based surveys during the summer months. Adolescents with an ASD identified more friends
than did their parents, but they agreed on the friends’ characteristics. About half of the
adolescents spent an average of 4 hours per day with friends during the summer months. Male
adolescents with an ASD most frequently played video games with friends, whereas females most
frequently had conversations with friends. The findings suggest that adolescents with an ASD and
their parents identify different peers as the adolescent’s friends. The findings also reveal
similarities and differences in friendships between adolescents with an ASD and typically
developing adolescents.

Keywords
Autism spectrum disorder, friendships, parent and adolescent reports, activity patterns

Corresponding author:
Melissa Kuo, 2-64 Corbett Hall, Edmonton, Alberta T6G 2G4, Canada.
Email: melissa.kuo@ualberta.ca
482 Autism 17(4)

Social impairments and difficulties with social communication and interpersonal interaction
are core features of autism spectrum disorders (ASDs; American Psychiatric Association,
2000). These social impairments affect the ability of individuals with an ASD to develop and
maintain friendships, which require an ability to understand what another person is thinking
and feeling. Moreover, social skill impairments do not lessen over time. Impairment and
distress may increase as children with an ASD approach adolescence. Adolescence may be
particularly difficult for adolescents with an ASD as the social environment becomes more
complex and the adolescents become more aware of their social impairment (Tantam, 2003).
Difficulties in establishing peer relationships are frequently observed in adolescents with an
autism spectrum disorder (ASD), but friendships are not completely absent in individuals with
an ASD (Bauminger et al., 2008a, 2008b; Bauminger and Kasari, 2000; Bauminger and
Shulman, 2003; Howard et al., 2006; Orsmond et al., 2004). Bauminger and Kasari (2000)
found that children with an ASD have an average of two best friends, and children with an ASD
reported fewer friends than their mothers did. Bauminger and colleagues, based on maternal
reports, found that children and adolescents with an ASD were more likely to have friends who
were of similar age, gender and disability status (Bauminger et al., 2008a, 2008b; Bauminger
and Shulman, 2003). Their research also indicates that children and adolescents with an ASD
perceive less closeness, intimacy and help than do their peers who are typically developing
(Bauminger et al., 2008b; Solomon et al., 2011). In our previous research we found that
adolescents with an ASD spend less time with peers compared with the time spent with
adults and paid professionals (Orsmond and Kuo, 2011). Similarly, Solish et al. (2010) also
found that children with an ASD, as compared with typically developing children, were more
likely to engage in social activities with their parents and other adults than with their peers.
Previous research on friendships in adolescents with an ASD has been limited by small
sample sizes, the inclusion of only school-age children with an ASD or the use of mixed
samples with both children and adolescents, and the focus on individuals who had at least
one friend. The present study explored friendship characteristics of adolescents with an ASD
and their activity patterns with friends. We focused exclusively on adolescence because it is a
period when peer relationships are the most significant factor associated with adolescents’
quality of life and may take precedence over family relationships (Helseth and Misvær,
2010).
To our knowledge, only one study compared mother and child reports of number of
friends (Bauminger and Kasari, 2000), and there are no studies of whether individuals
with an ASD would identify the same people as their friends as their parents or caregivers
do. The first goal of this study was to investigate friendship characteristics of adolescents
with an ASD in terms of number of friends and friends’ characteristics (e.g. age, gender, with
or without disabilities). We also examined agreement between adolescent and parent
perceptions of the adolescents’ friendships, as well as the potential factors (e.g.
adolescents’ characteristics, friends’ characteristics) that may be associated with
adolescents’ friendships.
Companionship, or doing things together, is one of the features of friendship (Berndt,
1996). It helps maintain the relationship, and is a way to make the relationship stronger and
closer (Aboud and Mendelson, 1996). Research shows that typically developing adolescents
spend 52% of their waking time with friends and 19% with family per day (Csikszentmihalyi
and Larson, 1984). When with friends, typically developing adolescents are likely to attend
parties and dances; to attend popular entertainment events, such as movies and concerts,
and watch television; and to participate in sports and sporting events (Fuligni and
Kuo et al. 483

Stevenson, 1995). Generally, the amount of time with friends increases throughout
adolescence for girls but not for boys, who spend a stable amount of time with friends
(Larson and Richards, 1991). As adolescents get older, they, especially girls, spend more
time with opposite-gender peers than with same-gender peers (Csikszentmihalyi and Larson,
1984; Richards et al., 1998).
Companionship has been reported to be a primary focus in the friendships of adolescents
with disabilities (Matheson et al., 2007). Research, based on maternal reports, shows that
adolescents with an ASD spend only 14% of their waking time with friends and peers
(Orsmond and Kuo, 2011), which is considerably less than typically developing
adolescents (Fuligni and Stevenson, 1995). Bauminger and Shulman (2003), also based on
maternal reports, found that children with an ASD spent time with friends less frequently
than typically developing children. When together, they frequently played board games,
talked together, played on the computer, and watched video and/or television with their
friends.
Information on how children and adolescents with an ASD spend time with friends has
previously been based mainly on qualitative data collected from mothers (Bauminger and
Shulman, 2003). Because mothers are not together with their adolescents all day, they are not
able to account for the adolescents’ time as accurately as the adolescents themselves.
Accordingly, the second goal of this study was to collect data directly from adolescents
with an ASD to explore the activities they engage in with their friends, the gender
differences in activity patterns, and the types of friends with whom the adolescents spend
time. By conducting this study, we hoped to expand current knowledge on friendships of
individuals with an ASD. We also hoped to better understand the opportunities and social
environments that adolescents with an ASD encounter.

Methods
Procedures
Participants were recruited through clinical practitioners or private school teachers who were
working with adolescents with an ASD, advertisements posted on autism-related web pages,
forums, or e-newsletters. Participants were also recruited with the assistance of the
Interactive Autism Network (IAN) Research Database at the Kennedy Krieger Institute
and Johns Hopkins Medicine – Baltimore, sponsored by the Autism Speaks Foundation.
A short telephone interview with the parents of the adolescent was conducted to assess
whether the adolescent met the inclusion criteria: (1) the adolescent had a reading level at 5th
grade or higher, so that the adolescent could complete the measures independently (a 5th-
grade reading level criterion was chosen because it is the lowest required reading level for our
measures); (2) the adolescent had been diagnosed with an ASD by a licensed professional;
and (3) the adolescent scored 15 points or higher on the lifetime form of the Social
Communication Questionnaire (SCQ; Rutter et al., 2003) administered during the phone
interview. Adolescents and parents each received a $20 gift card as compensation for their
participation in the research.

Participants
One hundred and nineteen screens via phone interview were conducted with parents;
113 adolescents qualified for the study and 6 adolescents did not meet inclusion criteria.
484 Autism 17(4)

Table 1. Demographic characteristics of adolescents with an ASD (N ¼ 91).

Variables Descriptive statistic

Age (in years)

Mean  SD 14.8  1.9
Range 12.0–18.0
Gender (n,%)
Male 74 (81%)
Female 17 (19%)
Education level (n,%)
Grade 6 – Grade 9 58 (64%)
Grade 10 – Grade 12 25 (28%)
Higher than grade 12 7 (7%)
Ungraded special education 1 (1%)
Reading levela
>Education level 39 (43%)
<Education level 30 (33%)
¼Education level 22 (24%)
Primary diagnosisa (n,%)
Asperger’s syndrome 58 (64%)
Autistic disorder 17 (19%)
PDD-NOS 16 (18%)
Comorbiditya (n,%)
ADHD 44 (48%)
Anxiety 27 (30%)
Obsessive-compulsive disorder 19 (21%)
Depression 15 (17%)
Intellectual disability 6 (7%)
Other 28 (31%)
Speaking skillsa (n,%)
Speaks in full sentences 86 (95%)
Speaks in phrases of several words 5 (5%)
Clarity of speecha (n,%)
Could be understood by most everything he/she says 83 (91%)
Could be understood by some words 8 (9%)
US region (n,%)
Northeast 45 (50%)
South 18 (20%)
Midwest 15 (16%)
West 13 (14%)
a
Parental report.
Note: PDD-NOS ¼ Pervasive developmental disorder—not otherwise specified.

A total of 91 adolescents and their parents completed the surveys, resulting in an 81%
completion rate. The data were collected during summer months (May 2009 to August
2009). Participants were from 27 states in the United States. Tables 1 and 2 show the
demographic characteristics of the adolescents with an ASD and their parents, respectively.
Kuo et al. 485

Table 2. Demographic characteristics of parents (N ¼ 91).

Variables Descriptive statistic

Age (in years)

Mean  SD 46.7  6.0
Range 31.4–59.9
Relationship to adolescent (n,%)
Biological mother 80 (88%)
Biological father 7 (8%)
Adoptive mother 3 (3%)
Stepmother 1 (1%)
Marital status (n,%)
Married 75%
Divorced 18%
Other 7%
Number of children in family
Mean  SD 2.5  1.26
Range 1–7
Ethnicity (n,%)
White non-Hispanic 90 (99%)
African American 1 (1%)
Education status (n,%)
High school graduate 3 (3%)
1–3 years of college but not Associate’s degree 18 (20%)
Associate’s degree 5 (5%)
Bachelor’s degree 21 (23%)
Post BA/BS but no graduate degree 18 (20%)
Graduate degree (including master’s and doctoral degrees) 26 (29%)
Employment status (n,%)
Unemployed 22 (24%)
Full-time 40 (30%)
Part-time 57 (44%))
Seasonally/temporarily 2 (2%)
Household income in 2008
$10,000 –$49,999 22%
$50,000–$89,999 30%
$90,000–$159,999 32%
 $160,000 17%
Median $85,000

Adolescents with an ASD. Adolescents with an ASD ranged in age from 12 to 18 years and
were on average 14.8 years old. More boys (n ¼ 74) than girls (n ¼ 18) participated, which
corresponds to the epidemiology of this population. Most adolescents attended junior high or
middle school, and only one adolescent attended an ungraded special education program.
About half of them had a reading level higher than their education level by parent report.
More than half were diagnosed with Asperger’s syndrome. They were diagnosed on average at
7 years old, mostly by psychologists. Almost half of them were co-diagnosed with attention-
deficit hyperactivity disorder (ADHD). Only six adolescents had intellectual disability.
486 Autism 17(4)

Almost all adolescents could speak in full sentences, and almost everything they said could be
understood by a stranger. All adolescents were co-residing with their parent(s).

Parents. Parents were on average 47 years old. Ninety-two percent of parents who
completed the surveys were mothers, and 2% were fathers. Only one parent was African
American, and the others were white non-Hispanic. Most parents had at least a bachelor
degree, were married, and had either a full-time or a part-time job. The median household
income of our participants in 2008 was $85,000, which is considerably higher than the 2008
US median household income ($52,029; U.S. Department of Commerce, 2009), although a
range of incomes was represented.

Measures
In this study, we collected data from adolescents with an ASD and their parents through
mail-based paper-and-pencil questionnaires. Adolescents were asked to complete two
activity reports about their time spent with friends and one questionnaire about their
relationship with their best friend. Parents were asked to complete one questionnaire
about family background information and adolescents’ friends, as well as the current
form of the SCQ about the adolescents’ autism symptoms. Parents completed the lifetime
form of the SCQ during the phone screening interviews.

Background information and friend’s characteristics. The questionnaire for the parents
asked comprehensive background information, including adolescent characteristics (e.g. age,
gender, language skills), and family characteristics (e.g. parental education status, household
income). The parent questionnaire also contained a friendship grid, which was based on the
Playmates and Friends: Questionnaire for Teachers, Revised (Goldman and Buysse, 2005).
The friendship grid queried information about the adolescent’s first three closest friends. The
information included the friend’s first name, age, gender, type of friend (friend from school,
friend from the neighborhood, friend from sports or leisure, childhood friend, friend of the
family, cousin, brother/sister, boyfriend/girlfriend), the duration that the adolescent and the
friend have known each other, and whether the friend had a disability or not. Adolescents
with an ASD were also asked to report their first three closest friends’ names, ages, genders,
and types of friends (friend from school, friend from the neighborhood, friend from sports or
leisure, childhood friend, friend of the family, cousin, brother/sister, boyfriend/girlfriend).
Parents and adolescents were instructed to report the friends in the order of closeness,
beginning with the closest friend.

Activities engaged in with friends. Adolescents were asked to complete one activity report
for an upcoming weekday and one for an upcoming weekend day. They were instructed to
fill out the activity reports at the end of their chosen day. The activity reports asked
adolescents about their time spent with friends. First, adolescents were asked whether
they spent time with friend(s); if yes, they were asked to report what activities they did
with the friend(s). They were asked to report the gender of the friend(s) with whom they
engaged in activities by choosing one of the following categories: a male friend, a female
friend, a group of male friends, a group of female friends, and a group of male and female
friends. A total of 175 activities done with friends were reported by the adolescents. The
reported activities were coded by the first author and a graduate student (who was blind to
Kuo et al. 487

the study purposes). The activities were coded into the following categories: eating, doing
physical activities, doing outdoor activities, doing education-related activities, having a
conversation, surfing websites, watching TV/movies, visiting, playing, reading, listening to
music, hanging out, participating in a community excursion, doing artistic activities, playing
video games, and other. Appendix A shows the definition of each category.
An inter-rater reliability analysis using the Kappa statistic was performed to determine
consistency among the two raters. The inter-rater reliability Kappa was .939 (p < .001), which
indicated an almost perfect agreement (Landis and Koch, 1977). Discrepancies were coded by
a second graduate student using the same coding scheme. The codes that the majority of raters
chose were used in the analyses. When three coders chose different codes, the first and the
second authors made a consensus decision about which code was the most appropriate.

Autism symptoms. The lifetime form and the current form of the SCQ (Rutter et al., 2003)
were used as a screener to verify diagnosis and as a tool to evaluate adolescents’ current level
of symptoms, respectively. Both the lifetime form and the current form of the SCQ include
40 yes-no items. The lifetime form of the SCQ was used to screen participants during the
phone interview. The items in the lifetime form include questions regarding reciprocal social
interaction; language and communication; and repetitive, stereotyped patterns of behavior.
A cutoff score of 15 was established and it was determined that individuals scoring at or
above that level are likely to have an ASD (Rutter et al., 2003).
The items in the current form of the SCQ examined adolescents’ symptoms over the most
recent 3-month period. Parents were asked to complete the current form when they
completed the mailed questionnaire. The scoring method in the current form is similar to
that in the lifetime form. Also, the sub-scores in the current form were developed on the basis
of three domains of the Autism Diagnostic Interview-Revised (ADI-R): the reciprocal social
interaction domain; the communication domain; and the restricted, repetitive, and
stereotyped patterns of behavior domain (Rutter et al., 2003). Studies have reported good
psychometric properties of the SCQ in terms of its sensitivity and specificity (Chandler et al.,
2007; Witwer and Lecavalier, 2008) and correlations with the ADI-R (Witwer and
Lecavalier, 2008). In the present study, alpha reliabilities of the lifetime form and the
current form of the SCQ were .77 and .80, respectively.

Friendship qualities. The Friendship Qualities Scale (FQS; Bukowski et al., 1994) was used
to assess adolescents’ perceptions of their friendship qualities. Adolescents were asked to
answer the questions on the FQS in reference to the relationship with their best friend. If the
adolescent did not have a best friend, they could skip the FQS. This 23-item self-report scale
measures five dimensions of friendship – companionship, closeness, helpfulness, security,
and conflict. Each item is rated on a 5-point scale ranging from 1 (strong disagree) to 5
(strongly agree), and the total score is calculated using the mean score in each dimension.
High scores reflect friendships perceived to be high in the named dimension. Scores on
companionship, closeness, helpfulness, and security were averaged to create a single
variable measuring the ‘positive qualities’ of friendship. The conflict subscale was not
aggregated with the others. Good validity and reliability of the FQS have been reported
by the authors (Bukowski et al., 1994). The FQS has been successfully completed by children
and adolescents with an ASD (Bauminger et al., 2008a, 2008b; Whitehouse et al., 2009).
In the present study, alpha reliability for the total scale was .87.
488 Autism 17(4)

Results
Friendship characteristics
We examined friendship characteristics in terms of the number of friends, the agreement of
the people who were identified as adolescents’ friends, and friends’ characteristics by
comparing adolescents’ first three closest friends reported separately by adolescents with
an ASD and their parents.

Number of friends. Almost all adolescents with an ASD (96%) reported that they had at
least one friend, and 86% of parents reported that the adolescents had at least one friend.
A Wilcoxon signed-ranks test was used to compare adolescent and parental reports. As
shown in Table 3, adolescents identified a significantly greater number of friends than did
their parents (Z ¼ 3.36, p ¼ .001). That is, more adolescents reported that they had at least
three friends than did parents (79% versus 65%), and fewer adolescents reported they had
no friends than did parents (4% versus 14%).

Agreement of friendships. To examine the agreement of the people who were identified as
the adolescents’ friends, we calculated the number of the same people listed by the adolescent
and the parent. We used friends’ first names as a cue to identify the same friends. The
agreement between adolescents and parents was 60% on the adolescent’s best friend, and
24% on the adolescent’s first three closest friends in order. For 21% of the cases, the
adolescent and parent listed completely different names of friends. We further examined
whether these adolescents had different characteristics as compared with the adolescents
who had at least one similar friend as reported by their parents. We found that the severity
of autism symptoms was the only significant factor. The adolescents who reported completely
different friends had more severe autism symptoms than those who reported at least one
similar friend to their parents (SCQ scores 20.3  6.3 versus 16.0  5.6; t (89) ¼ 2.86, p ¼ .005).

Friend’s characteristics – first three closest friends. We also examined the characteristics of
adolescents’ first three closest friends (see Table 3). About half of adolescents reported their
first three best friends were all males. According to adolescent reports, their friends were on
average 14 years old. The average age span between adolescents and their friends was 1 year.
About two-thirds of friends were younger than the adolescent with an ASD, and most friends
were the same gender as the adolescent. About half of the friends were from school, and a
small proportion of the friends were cousins, siblings or either a boyfriend or a girlfriend.
Friends’ characteristics reported by parents were similar to adolescent reports. When
comparing adolescent and parental reports on friends’ characteristics, paired t-tests were
used to compare parametric data, including age and age span. Wilcoxon signed-ranks tests
were used to compare non-parametric data, including age order (younger versus older),
friends’ gender and gender composition (same gender versus opposite gender). As shown
in Table 3, adolescents with an ASD and parents reported similar characteristics of the
friends. On the basis of the parental reports, the mean friendship duration between
adolescents with an ASD and their friends was 4 years, and about a half of the friends
had a disability, with ASDs as the most common disability, followed by ADHD and learning
disabilities. Other disabilities included Down syndrome, bipolar disorder, depression,
dyslexia, epilepsy, hand dysfunction, Tourette syndrome, and hemiplegia. Over half (56%)
of the adolescents had at least a friend with a disability.
Kuo et al. 489

Table 3. Comparison of friends and their characteristics between adolescents and parents.

Variables Adolescent report Parent report Test

Number of friends
None 4 (4%) 13 (14%) z ¼ 3.36
One friend 5 (6%) 9 (10%) p ¼ .001
Two friends 10 (11%) 10 (11%)
Three friends 72 (79%) 59 (65%)
Age of friends (in years)
Mean 14.5 14.4 t (49) ¼ .780
SD 2.1 2.2 p ¼ .439
Age spacing
Mean 1.0 1.0 t (49) ¼ .135
SD 0.9 0.7 p ¼ .893
Age order
Friends were younger 66% 70% z ¼ .775
Friends were older 34% 30% p ¼ .439
Gender
All male(s) 46% 51% z ¼ 1.072
All female(s) 20% 18% p ¼ .284
Mixed gender 34% 31%
Gender composition
Same-gender 80% 84% z ¼ 1.316
Opposite-gender 20% 16% p ¼ .188
Type of friends
From school 51% 55% N/A
From the neighborhood 11% 16%
From sports or leisure 9% 8%
Childhood friends 15% 6%
Friends of the family 10% 7%
Cousin 2% 3%
Brother/sister 2% 4%
Boyfriend/girlfriend 1% 0.4%
Duration of friendships (months)
Mean N/A 49.0 N/A
SD 26.2
Friend has a disability
No N/A 44% N/A
Yes 43%
Don’t know 13%
Type of disability
ASD N/A 55% N/A
ADHD 12%
Learning disability 6%
Other 15%
Don’t know 13%
490 Autism 17(4)

Associations between number of friends and adolescents’ characteristics

We used bivariate correlations and t-tests to examine the associations between the number of
friends reported by adolescents with an ASD and their own characteristics, including age,
gender, and severity of autism symptoms. Older adolescents with an ASD reported fewer
friends (r ¼ .24, p ¼ .021). Age was also associated with the number of same-gender friends.
Older adolescents reported fewer same-gender friends (r ¼ .27, p ¼ .009), but there was no
clear association between age and number of opposite-gender friends (r ¼ .07, p ¼ .509).
Neither gender (t (89) ¼ .70, p ¼ .489) nor severity of autism symptoms (r ¼ .09, p ¼ .423)
were significantly associated with the number of friends. Similarly, the adolescents’ diagnosis
(Asperger’s syndrome versus other diagnoses) was not significantly associated with the
number of friends (t (89) ¼ .97, p ¼ .335).

Associations between friendship characteristics and friendship qualities

Bivariate correlations and t-tests were used to examine the associations between friendship
characteristics (the number of friends and the best friend’s characteristics) reported by
adolescents with an ASD and their perceived friendship qualities, as measured by the
FQS (Bukowski et al., 1994). Having more friends was significantly associated with more
positive friendship quality with the listed best friend (r ¼ .23, p ¼ .026) and greater
companionship in this friendship (r ¼ .21, p ¼ .047). No significant associations were
found between the adolescents’ severity of autism symptoms (SCQ scores) and positive
friendship quality (r ¼ .11, p ¼ .317) or conflict in the friendships (r ¼ .13, p ¼ .899).
Similarly, we did not find significantly associations between adolescents’ diagnosis
(Asperger’s syndrome versus other diagnoses) and either their positive friendship qualities
(t (89) ¼ .92, p ¼ .361) or conflict (t (89) ¼ .67, p ¼ .504).
Friends’ age (based on adolescent self-reports) was not significantly related to friendship
qualities, but the friend’s gender was. That is, with female friends, adolescents with an ASD
reported greater helpfulness (t (85) ¼ 2.5, p ¼ .014) and greater closeness (t (85) ¼ 2.45,
p ¼ .016) in friendships, compared with male friends. The types of friends were significantly
associated with adolescents’ perceived conflict. Adolescents reported less conflict with school
friends (t (84) ¼ 2.09, p ¼ .040), and more conflict with friends who were either childhood
friends (t (84) ¼ 2.27, p ¼ .026) or identified as siblings (t (84) ¼ 2.25, p ¼ .027).

Time spent with friends

Amount of time. As shown in Table 4, 47% of adolescents with an ASD (n ¼ 43) did
activities with their friends on weekdays, and 33% of adolescents with an ASD (n ¼ 30)
did activities with their friends on weekend days. Adolescents who spent time with friends
spent an average of 4 hours with friends on weekdays and 5 hours with friends on weekend
days. A McNemar test showed no significant difference between weekdays and weekend days
in whether adolescents spent time with friends (p ¼ .500), and a paired t-test showed no
significant difference in the amount of time they spent with friends between weekdays and
weekend days (t (90) ¼ .52, p ¼ .603). Therefore, we combined weekday and weekend data.
For the amount of time on any given day, we calculated the average daily hours spent with
friends across the weekday and weekend activity reports by multiplying the weekday hours
by 5 and multiplying the weekend hours by 2, and then dividing the sum of these two
Kuo et al. 491

Table 4. Amount of time adolescents with an ASD spent with friends on weekdays, weekend days, and any
given day (hours) (N ¼ 52).

Adolescents who spent time with friends All adolescents

N Meana SD Range Test Meanb SD Range Test

Weekday 43 (47%) 3.93 2.42 0.17–11.50 t (20) ¼ .414 1.86 2.57 0–11.50 t (90) ¼ .523
Weekend 30 (33%) 5.18 3.28 0.58–12.33 p ¼ .683 1.65 3.04 0–12.33 p ¼ .603
Any given day 52 (57%) 3.14 1.92 0.36–8.38 1.80 2.13 0–8.38
a
Mean value represents average time for adolescents who spent time with friends, excluding the zero values for those who
did not spend time with friends.
b
Mean value represents average time for all adolescents, including the zero values if no time was spent with friends.

Table 5. Frequency of activities adolescents with an ASD engaged in with friends (N ¼ 52)
(number of adolescents,%).

Activity All adolescents n ¼ 52) Males n ¼ 45) Females n ¼ 7)

Video games 27 (52%) 27 (60%) 0 (0%)

Physical activity 19 (37%) 15 (33%) 4 (57%)
Watching TV/movie 13 (25%) 13 (29%) 0 (0%)
Playing 13 (25%) 13 (29%) 0 (0%)
Conversation 12 (23%) 7 (16%) 5 (71%)
Eating 10 (19%) 10 (22%) 0 (0%)
Other 7 (13%) 5 (11%) 2 (29%)
Surfing websites 6 (12%) 6 (13%) 0 (0%)
Education-related 6 (12%) 6 (13%) 0 (0%)
Outdoor activity 6 (12%) 5 (11%) 1 (14%)
Hanging out 4 (8%) 3 (7%) 1 (14%)
Community excursion 4 (8%) 2 (4%) 2 (29%)
Reading 2 (4%) 2 (4%) 0 (0%)
Visiting 2 (4%) 1 (2%) 1 (14%)
Listening to music 2 (4%) 2 (4%) 0 (0%)
Artistic activity 2 (4%) 2 (4%) 0 (0%)

calculations by 7. Thus, the average time shown in Table 4 is not merely an average of the
weekday and weekend hours, but is weighted to reflect more weekday than weekend days in
a week. On any given day, a total of 52 adolescents with an ASD (57%) spent time with
friends. Adolescents who reported that they did activities with friends spent an average of 3.1
hours with them on any given day.

Activities with friends. We analysed how the 52 adolescents spent time with friends by
categorizing the amount of time in various activities on a given day. Table 5 shows the 16
most frequent joint activities. Adolescents with an ASD most frequently spent time with
friends playing video games, which accounted for approximately 50% of adolescents who
spent time with friends. About 20–40% of adolescents with an ASD spent time with friends
doing physical activities (including swimming), watching television, playing, and engaging
492 Autism 17(4)

in conversation. About 10–20% of adolescents ate, surfed websites, and engaged in

education-related activities and outdoor activities with friends. They less frequently ‘hung
out’ with friends, engaged in artistic activities, listened to music, visited, or read.
We also examined whether the activity patterns with friends differed by gender. As shown
in Table 5, male adolescents with an ASD most frequently played video games with friends,
whereas female adolescents most frequently engaged in conversation with friends. Also, on
any given day, male adolescents were more likely to play video games than girls (36.5%
versus 0%; x2 (1) ¼ 8.82, p ¼ .003), whereas female adolescents were more likely to engage in
conversations with friends than boys (24.9% versus 9.5%; x2 (1) ¼ 4.81, p ¼ .028). When
playing video games and having conversations were excluded, doing physical activities was
the category that both male and female adolescents most frequently engaged in with friends.
Generally, male adolescents were more likely to engage in indoor activities (such as playing
video games, watching television, eating) with friends, and female adolescents were more
likely to spending time with friends outside the house (such as hanging out, doing outdoor
activities, doing community excursion). We also used t-tests to see whether the activity
patterns and the amount of time spent with friends differed by the regions where the
adolescents lived, as well as whether these two variables differed by the adolescents’
diagnosis. We found that neither the amount of time spent with friends nor the activity
patterns with friends differed by the four regions or the adolescents’ diagnosis.

Friend companionships
Table 6 shows the gender of friends with whom adolescents with an ASD did activities. Both
male and female adolescents most frequently spent time with one same-gender friend,
followed by a group of same-gender friends, a group of mixed-gender friends, one
opposite-gender friend, and then a group of opposite-gender friends. In terms of the
activities with friends by gender compositions, adolescents with an ASD most frequently
played video games with same-gender friends, and did physical activities with opposite-
gender friends and mixed-gender friends on any given day.

Associations between activity engagement and friendship qualities

We examined whether engaging in activities with friends was associated with friendship
qualities reported by adolescents with an ASD. On any given day, adolescents with
an ASD who spent time with friends reported more overall positive friendship qualities

Table 6. Gender composition between adolescents with an ASD and the friends with whom
adolescents engaged in activities (N ¼ 52) (number of adolescents,%).

Friends All adolescents n ¼ 52) Males n ¼ 45) Females n ¼ 7)

One same-gender friend 28 (54%) 22 (49%) 6 (86%)

Same-gender group 23 (44%) 21 (47%) 2 (29%)
Mixed-gender group 19 (27%) 17 (38%) 2 (29%)
One opposite-gender friend 9 (17%) 8 (18%) 1 (14%)
Opposite-gender group 3 (6%) 3 (7%) 0 (0%)
Kuo et al. 493

(t (89) ¼ 2.33, p ¼ .22) and greater companionship with their best friend (t (89) ¼ 3.49,
p ¼ .001) than those who did not spend time with friends.
We also examined the associations between friendship qualities and each of activities that
adolescents with an ASD engaged in with friends. Playing video games was the only activity
significantly associated with adolescents’ perceptions of friendship qualities. Adolescents
with an ASD who played video games with friends on any given day reported more
overall positive friendship qualities (t (89) ¼ 2.20, p ¼ .030) and greater companionship
(t (89) ¼ 2.91, p ¼ .005) with their best friend than those who did not play video games
with friends.

Discussion
This study expands our knowledge about friendships of adolescents with an ASD by
comparing adolescents’ and parents’ perceptions of friendship characteristics, as well as
by collecting data directly from adolescents with an ASD on their time spent with friends.
The findings reveal characteristics of people whom adolescents with an ASD and their
parents recognize as the adolescents’ friends, and show that adolescents with an ASD and
their parents may have different ideas about who the adolescent’s friends are. In terms of
time spent with friends, about a half of adolescents with an ASD spend time with friends on
any given day during the summer months, and the activities that they engaged in together
differed by gender. The findings also reflect some similarities and differences in friendships
between adolescents with an ASD and typically developing adolescents.
Despite the fact that adolescents with an ASD and their parents tended to list friends with
similar characteristics, they differed in the number of peers perceived to be friends and in the
people whom they identified as the adolescents’ friends. The differences may be explained by
different descriptions of friendships of the adolescents and their parents. Previous research
indicates that adolescents with an ASD most frequently describe friends as other peers who
have similar interests and with whom they can do or talk about the same things together
(Carrington et al., 2003). However, research indicated that most parents reported that the
relationships between adolescents and adults with an ASD and their peers lacked reciprocity,
and often only occurred during prearranged settings, which may not represent true
friendships (Orsmond et al., 2004). Therefore, with respect to friendships, adolescents with
an ASD may consider friends to be peers who have similar interests and with whom they
spend time, whereas their parents may only consider a friendship if it includes mutual
interactions and emotion interchanges.
We also found that adolescents who reported completely different friends had more severe
autism symptoms than those who reported at least one similar friend to their parents. It is
possible that the adolescents with more severe autism symptoms were more likely to
overestimate their relationships with other peers than those with less severe autism
symptoms. It is also possible that the parents of these adolescents were more likely to
underestimate the adolescents’ friendships than the parents of the adolescents with less
severe autism symptoms.
We found that most adolescents with an ASD reported friends of the same gender, and
most frequently spent time with same-gender friends. However, older adolescents reported
fewer same-gender friends, but the number of opposite-gender friends remained relatively
constant. This pattern of change of gender-based friend preferences is different from that of
typically developing adolescents, whose same-gender peer networks remain about the same
494 Autism 17(4)

but whose opposite-gender peer networks increase in size with age (Richards et al., 1998).
For typically developing adolescents, one feature of adolescence is a transition from extreme
engagement with same-gender friends to opposite-gender friendships. That is, their
preferences for same-gender friends decline in adolescence relative to childhood (Poulin
and Pedersen, 2007), and the time spent with opposite-gender friends increases from early
to mid-adolescence (Richards et al., 1998). Because spending time with opposite-gender
friends prepares an individual to develop future romantic relationships (Mehta and
Strough, 2009), the lack of opposite-gender friends may prevent adolescents with an ASD
from developing the skills or experiences that provide the foundation for deeper romantic or
marital relationships (Stokes et al., 2007). Because adolescents with an ASD have been
reported to desire romantic relationships (Stokes and Kaur, 2005), there may be a need to
develop supports to help them gain the knowledge, skills, and experiences needed to relate
more successfully with opposite-gender peers.
Moreover, we found that when adolescents with an ASD spent time with mixed- or
opposite-gender friends, they most frequently engaged in physical activities. Most of these
physical activities (e.g. playing basketball, playing softball, swimming) are structured
activities, which involve rules and often have a formally designated coach or instructor
(King et al., 2009). We suspect that these types of activities may create a more
comfortable context for adolescents with an ASD to interact with opposite-gender peers.
However, future studies are needed to further explore adolescents’ perspectives about their
activities.
Consistent with research on typically developing adolescents’ friendships (Poulin and
Pedersen, 2007; Sears et al., 2009), female adolescents with an ASD perceived higher
levels of help from their same-gender friends, and male adolescents perceived more help
and closeness from their opposite-gender friends. Previous studies have suggested that
females are socialized to be more supportive (Poulin and Pedersen, 2007), and are often
perceived as a better source of help than males regardless of the gender composition of the
friendship (Rose and Rudolph, 2006). Therefore, adolescents with an ASD may turn to their
female friends with problems because they anticipate receiving support from them. Females
have been reported to be less likely to ridicule or judge people who ask them for help as weak
(Sears et al., 2009). This lack of judging may be another reason motivating adolescents with
an ASD to seek assistance from their female friends. It is also possible that female friends are
more likely to actively provide support to adolescents with an ASD when these adolescents
require assistance.
Similar to typically developing adolescents, both male and female adolescents with an
ASD perceived more closeness with their female friends than with their male friends. The
femaleness principle can be used to explain this finding. Akiyama et al. (1996) proposed that
the gender differences in personal relationships are a function of the ‘femaleness’ of the dyad.
For example, female siblings are the closest and most involved sibling dyads, followed by
female-male sibling pairs, with male dyads being the least close (Cicirelli, 1993).
We also found that adolescents with an ASD perceived less conflict in friendships if the
friend was from school, whereas they perceive more conflict if the friend was identified as a
sibling. The nature of different types of relationships may explain this finding. Relationships
with school friends may be likely to dissolve if frequent conflict occurs. To maintain
friendships, adolescents with an ASD and their school friends need to develop strategies
to prevent the conflict from occurring frequently (Furman and Buhrmester, 1985).
Adolescents with an ASD and their school friends have more opportunities than other
Kuo et al. 495

types of friends to collaborate to complete school projects or homework, and collaboration

between friends has been found to reduce conflict in friendships (Shulman and Laursen,
2002). In contrast to friendships among school friends, siblings are bound by involuntary ties
that are primarily based on kinship and have long histories of interactions. Siblings have
been found to frequently have conflict during adolescence (Furman and Buhrmester, 1985).
Sibling relationships can withstand conflict without fear of dissolution of the relationships
(Furman and Buhrmester, 1985) and, therefore, siblings may be less likely to work on
resolving the conflict.
Consistent with findings reported by Bauminger and Shulman (2003), playing, watching
television, and playing with a computer were the most frequent activities that adolescents
with an ASD engaged in with friends. It was interesting to find that playing video games
(either on a computer or on a video-game console) was the most common activity that
adolescents with an ASD engaged in with their friends, and playing video games with
friends was associated with overall positive friendship qualities. Adolescents with an ASD
have been found to frequently play video games and surf websites containing information
about video games during their leisure time (Kuo et al., 2010; Orsmond and Kuo, 2011).
Kuo et al. (2010) suggest that the intense engagement in video-game activities could be
associated with one of their autism symptoms – repetitive and stereotyped interests.
Because adolescents with an ASD often spend time with friends engaging in activities of
special interests (Carrington et al., 2003), playing video games with friends may enable
adolescents with an ASD to pursue their intense and restricted interests. Moreover,
adolescents with an ASD have reported that video games serve as a social bridge for
them to fit in with peers (Winter-Messiers, 2007). Thus, it is possible that video-game
playing creates a context for adolescents with an ASD to socialize. Future studies are
needed to explore the social context of this activity.
Gender differences were also found in the activities that adolescents with an ASD engaged
in with their friends. Male adolescents with an ASD frequently spent time with friends
engaging in passive activities (e.g. playing video games, watching television) that were less
likely to involve direct social interactions than other activities (e.g. having conversation,
hanging out). However, female adolescents with an ASD most frequently spent their time
with friends on conversations. These gender differences in activity patterns with friends are
similar to those of typically developing adolescents, who also have different activity
preferences. Typically developing female adolescents tend to socialize more than males,
whereas males tend to be more interested in computers, television, and sports (Larson and
Verma, 1999). Moreover, longitudinal data show that typically developing female
adolescents increase their time spent socializing with age (McHale et al., 2004). The
gender patterns in social activities in adolescents with an ASD are similar to typically
developing adolescents.
Our study was limited in that we did not know the adolescents’ and parents’ definitions of
friendships, such as what criteria they used to identify a person as a friend, and thus we were
unable to examine the factors associated with their different perceptions of friendships. We
did not collect data from the adolescents’ nominated friends, and therefore we were unable
to validate whether these adolescent friendships were reciprocal. Although we knew the
kinds of activities that adolescents and their friends engaged in, we did not know the
social contexts within which these activities occurred. For example, we did not know
where they engaged in activities together (e.g. adolescent’s home, friend’s home,
somewhere else), the person who initiated the interactions (e.g. adolescents themselves,
496 Autism 17(4)

friends, parents), how they interacted with each other (e.g. playing adjacent to each other but
not trying to influence one another’s behavior or playing cooperatively to solve problems),
or whether there were any adults involved in guiding their interactions. Another limitation is
that we did not include a typically developing adolescent comparison sample to investigate
the similarities and differences in their activity patterns with friends. Without these data, it is
difficult to know whether the adolescents with an ASD experienced similar or different
activity patterns as compared with typically developing counterparts. Also, our findings
are limited to higher functioning individuals, as they had to have the reading skills to
independently participate in the study. The ethnic homogeneity of our sample may also
limit the generalizability of the results.
A strength of this study is that data were collected when the adolescents were away from
school during summer months so they had more discretionary time and opportunities to
engage in activities of their own choice, and were not restricted by academic work. Thus, we
were able to learn more about their activity engagement with friends outside of prearranged
settings. The findings of this study strengthen links to research on friendships among
adolescents with an ASD. Moreover, the gender differences in activity patterns were also
taken into consideration. The sample size of this study was larger than most of previous
studies on friendships of children and adolescents with an ASD (e.g. Bauminger and Kasari,
2000; Bauminger and Shulman, 2003; Bauminger et al., 2008a, 2008b).
There are important implications to be drawn from the findings for practitioners and
for future research directions. Helping individuals with an ASD participate in social
activities is often a professional’s goal; however, professionals also have a responsibility
to recognize and value different people’s perspectives about friendship. In order to
support friendship desires among adolescents with an ASD, it is important to explore
how they define friends and what characteristics of friendships they value. There is also
a need to develop a better understanding of the social opportunities offered by
participation in different activities with friends. Future intervention programs could
build on this information to better use the social opportunities embedded in the
adolescents’ activities to scaffold and promote opportunities to support friendships.
Finally, the low rates of opposite-gender friends in adolescence cannot be neglected.
Future studies are needed to investigate the interests, knowledge and peer interaction
skills needed by adolescents with an ASD to interact effectively with peers of different
genders.

Acknowledgements
We thank teachers, therapists, and ASD-related organizations and support groups for their assistance
with participant recruitment. We are grateful for the participation of the adolescents and their parents
in our research.

Funding
This work was supported by the Boston University Dudley Allen Sargent Research Fund, and by the
American Occupational Therapy Foundation Dissertation Research Grant to the first author.
Kuo et al. 497

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Appendix
Definitions of the activity categories

Categories Definitions

Community excursion
Doing artistic activity
Doing education-related activities
Doing outdoor activities
Doing physical activities
Eating
Hanging out
Having a conversation
Listening to music
A short trip made for pleasure (with specific destination)
The conscious production or arrangement of sounds, colors,
forms, movements, or other elements in a manner that affects
the sense of beauty
Any activity that is related to learning or school
Any unstructured activity that is done in nature, or any activity
that is practiced for the purposes of enjoying scenery and nature,
relieving stress, finding peace in nature, enjoying life and relaxing
Any activity that involves physical exertion or skill that is governed
by a set of rules or customs
Taking food into the body by the mouth
Spending time in a certain location or with certain people (without
specific destination)
Expressing or exchanging ideas by means of spoken and written
words
Any activity that is related to listen to a series of sounds made by
instruments or through an electronic device, or voice in a way that
is pleasant or exciting
(continued)
500 Autism 17(4)

Continued

Categories Definitions

Playing Any spontaneous or organized activity that provides enjoyment,

entertainment, amusement, or diversion
Playing video games A game that involves interaction with a user interface to generate
visual feedback on a videogame console, handheld devices, or a
computer
Reading The act of reading written or printed matter
Surfing website Looking at the contents shown on the Internet
Visiting Going to see or spend time at a place with a certain intent, or to
stay with as a guest
Watching TV/movies Watching TV programs or watching movies in a place other than
theater
Other Any activity that cannot be coded in the above categories
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