Investigating Humor in Social Interaction in People With Intellectual Disabilities: A Systematic Review of the Literature

Background: Humor, both producing and appreciating, underpins positive social interactions. It acts as a facilitator of communication. There are clear links to wellbeing that go along with this form of social engagement. However, humor appears to be a seldom studied, cross-disciplinary area of investigation when applied to people with an intellectual disability. This review collates the current state of knowledge regarding the role of humor behavior in the social interactions of people with intellectual disabilities and their carers. Method: A systematic review utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was completed, which aimed to explore the current state of knowledge and quality of empirical evidence relating to humor in people with intellectual disabilities. Following this, articles were grouped thematically and summarized. A comprehensive search of four electronic databases (1954–2017) and additional search strategies yielded 32 articles which met the final inclusion criteria. Results: Humor played a significant positive and negative role in the social interactions of people with intellectual disabilities. Research had investigated humor in the classroom and humor expression in different groups including those with autism, Down syndrome, Angelman syndrome, Williams syndrome, and Rett syndrome. Few investigations directly studied humor appreciation and comprehension. Humor comprehension was reportedly supported by gestures. Some groups with intellectual disabilities found non-literal humor (e.g., sarcasm, irony) more difficult to understand, which may affect social relationships. Various types of humor were found to be appreciated. The role of humor in relationship development, social facilitation, creativity, and stigma had all received some limited attention. Humor also played a role for carer groups in coping with and enjoying the caring role. Research varied in quality with few experimental studies and mainly quasi-experimental and well-conducted, qualitative studies. Conclusions: This review revealed the importance of humor behavior in many aspects of the social lives of people with intellectual disabilities. Limited disparate research exists pertaining to humor in this group, suggesting the need for further robust research in this area, including more high quality primary research in the areas of humor production, appreciation, comprehension, and stigma.


Findings
Theme Quality Score (0-2) Adams et al. (2015) UK Changes, with age, in the laughing and smiling of individuals with AS Mixed 2 x 3 experiment, repeated on one factor.
12 participants with AS. VABS Time 1 = 12.4 (2.9), Time 2 = 32.9 (6.69) Time 1 = 6.6 yrs (2.9), Time 2 = 10.9 yrs (3.1) 64% 12 This study compares levels of laughing and smiling longitudinally at two time points and across three within group experimental conditions [full social interaction (with eye contact), social interaction with no eye contact, proximity only]. No differences were noted in frequency of laughing and smiling over time in any condition. However, with age as a covariate, the frequency of laughing and smiling decreased over time in the full social interaction (with eye contact) condition only.
UK Self-reported stigma and its association with sociodemographic variables and physical disability.
Cross-section survey study. Data was collected via a checklist designed to gather information from participants about their experiences of stigma and demographic characteristics.
40.9 yrs (11.4) 52% 229 This study investigated whether socio-demographic variables and physical disability (e.g. sensory impairment and mobility problems) were associated with self-reported stigma in people with ID, and examined whether age, sex and ethnicity modified the relationship between severity of intellectual disability and self-reported stigma.
Older participants reported more stigmatizing experiences. Participants with moderate ID were more likely to be made fun of and treated as children. Moderate ID males reported more stigma compared to females. Over 50 adolescent students classified as gifted or having a learning disability or having unique needs 14-18yrs 92% >50 The GOLD program was described after running for over an eight-year period. This program entailed GOLD students who had attended at least one GOLD class of three hours per week, as part of an eightclass timetable. The class taught assertiveness, self-advocacy and strategies to manage anger, panic attacks, unproductive work habits and ineffective studying via discussion and role-play. The environment reportedly encouraged hope, humor, trust, and student decision making. No empirical results formally reported. Findings appeared based on author report with no additional data gathered from users of the program to corroborate this. Findings suggested the greatest appreciation was expressed for physical and visual humor. Gestured jokes were understood better than verbally presented jokes. The greatest appreciation was expressed for physical and visual humor. Non-specific scenes (i.e. scenes with no particularly funny elements) were also rated highly. Jokes presented with gestures were understood more than jokes told without supports. These differences in comprehension, arising from supported/ unsupported jokes, were statistically significant. Affect attunement incidents were observed in 16 of the pairs. The presence of affect attunement may be an indicator of interactional quality. The disability support worker's attunement behavior was in response to subtle, short duration behaviors of participants with PIMD.
Laughing was a valued part of interactions with the person with PMLD, it was viewed something of a leveler within interactions as both the support staff and person with PMLD could share laughter on more of an equal footing and it became a positive part of interactions. Support staff enjoyed seeing the person they were supporting laughing and felt that smiles and signs of positive affect made the more negative aspects of the support worker role worthwhile. The reported outcome was that this film was important for people without ID to see. Not only did the film show how those with ID are devalued, it also showed people with ID as capable, heroic, brave, and smarter than people think. The possibility of mockery of characters with ID in film highlighted the tension between positive representations and stigma and may make protagonists with ID less relatable for people with ID.  The two groups were similar in the mechanics of play, for example in making one thing stand for another and using materials flexibly. Differences were found for the children with ASD who showed less playful pretend, for example investment in the symbolic meanings given to play materials, creativity, and fun. Playful pretend and the mechanics of pretend play did not differ across the two play conditions. The study depicting 23 cartoons from which participants had to say what was funny. Findings reveal that compared to the TDCA group lower levels of humor comprehension were evident in participants with WS and DS but these two groups did not differ from their TDMA control groups. Fewer physical emotion terms such as laughing, crying and screaming were evident in the participants with WS compared with the TDCA and the participants with DS but were equivalent with TDMA group. The use of cognitive words, such as thinking showed a difference with both the participants with WS and DS using fewer than TDCA controls, but they performed similarly to each other and to their relative TDMA. The importance of intellectual ability in processing humor is highlighted. The likelihood of families using respite care was not significantly related to presence of challenging behaviors or level of support required by children. Also, not significantly related to family size and social support. With regard coping strategies, a high proportion of carers identified 'keeping a little free time for myself' as a helpful strategy to manage stress. The results also indicated that a high proportion of carers derived considerable help from managing meaning coping strategies such as 'seeing the funny side of the situation' and 'realizing that the person I care for is not to blame for the way they are', particularly male carers. Female carers tended to use 'problem solving' strategies, establishing routines, finding information and trying out solutions until one works. Hence maintenance of a sense of humor was a key coping strategy used. Differences in what the two groups laughed at were reported though. Both groups enjoying tactile events (including tickling rough and tumble play and chasing and more subtle tactile contact), visual events or auditory events, though children with AS laughed less at the latter two sensory events. Significantly more children with DS laughed at socially inappropriate acts and funny faces and children with ASD laughed significantly more for no apparent reason. Children with DS were reportedly more likely to engage in clowning and teasing. Observational Data: Laughter where the content was not shared was observed significantly more in the children with ASD. Shared laughter at an external target, reacting to the laughter of others and responding to laughter directed at the child were all observed significantly more in children with DS. Total laughs, solitary laughs and laughs in response to the behavior of an interactional partner did not significantly differ between the two groups. Aged 20-50 years 62.5% 8 Findings suggest complex individual and shared responses of working with sec offenders with ID with challenges about how to empathise with this group of people who are also offenders and ongoing experiences of stress and anxiety. Coping and emotional defences were used by participants, this included shared humor being reported as one of the most important ways of dealing with the negative emotions experienced as part of this role. However, use of humor could also be used as a defence mechanism to prevent exploration of the emotional and personal impact of this type of support work.

USA
The purpose was to evaluate the effects of FCT on nontargeted destructive and disruptive behavior.
This within participant case series involved identification of specific destructive responses (e.g., self injury) and a specific disruptive (e.g., stereotypy) responses, identified by the parent and shown to occur in the demand context of a functional analysis.
8 male and 2 female children. These 10 participants were preschool-aged children with DD who engaged in both destructive (property destruction, aggression, self-injury) and disruptive (hand flapping, spinning in circles, shrill laughter, screaming, crying) behaviors.
2.8 years 80% 10 A 71% reduction was observed between the initial and final baseline conditions for destructive behavior, and a 90% reduction was observed for non-targeted disruptive behavior. Both destructive and non-targeted disruptive behavior occurred at lower levels during all FCT conditions, representing a 94% overall decrease in destructive and non-targeted disruptive behavior when compared to the functional analysis demand condition. Similarly, across all FCT conditions, a 95% overall decrease in destructive behavior and an 84% overall decrease in non-targeted disruptive behavior (including shrill laughter) were observed across children when compared to the initial baseline condition. 24 pupils constituting the intervention and 24 pupils constituting the control group. Two classes with the highest rates of behavioral problems were purposively selected to be in the intervention condition. There were 16 boys in each group.
Age ranged between 11 and 13 years 67% 48 A marked increase in some cognitive functions (hypothetical thinking, perception and understanding of humor) was found between pre and post measures for the intervention group. Differences between experimental and control groups were not statistically significant for all cognitive functions and social-cognitive processes. Children in the intervention group showed a significantly higher understanding of 'complex humor'. Quantitative accounts from class 1 intervention participants did not feel that the intervention was effective, however, the accounts of the personal changes of class 2's participants confirmed that there were positive outcomes from the programs. Positive changes were not always attributed to the program. Humor appreciation, comprehension and production scores were positively and moderately related. Humor production and comprehension related moderately to intellectual ability. Humor comprehension was lower for the groups with disabilities. No differences in humor production were observed between those with learning disability and neurotypic students. Developmental disabled participants lacked sensitivity in humor appreciation. The appreciation measures mirth and funniness related to funny and neutral cartoons but only minimally related to intellectual ability. Group differences were found for comprehension of humor, which mirrored development (highest comprehension for normally achieving 4th graders, followed by the 2nd graders). Comprehension for both the children with developmental handicaps and those with learning disabilities were lower than the typically achieving children, with those children with developmental disabilities having the lowest humor comprehension. The children with ASD produced significantly less humor overall (165 humor episodes vs. 547 from children with DS. The amount of humor produced significantly increased with age for both the children with ASD and DS but did not vary significantly with IQ and language levels. Children with ASD produced verbal incongruity humor aligned to typical development of humor. The only jokes in the study were told by two of the children with DS, these were riddles. The children with ASD produced and appreciated humor to a limited extent in a naturalistic setting, at a significantly reduced level compared to matched controls with DS. Children with ASD appreciated and produced less humor involving nonverbal incongruity. Within group and within child variability in type of humor produced was more prevalent in children with ASD. Most humor (80%) produced by both groups was at a nonverbal level, with 125 out of 712 humor episodes being verbal incongruity, of which 100 were produced by participants with DS. With regard to initiation of humor interactions, 12% of all humor episodes were initiated by mothers, 75% by children and 13% as a joint interaction. Mothers initiated more for the children with ASD (21% vs. 6% for the children with DS). Finally in the intentionality dimension, children with DS produced humor at all 3 levels of intentionality and all except one child with ASD also produced humor at all three levels. 0.82 When deciding the form of the nonliteral utterance and justifying their responses, almost none of the participants in any of the groups were found to be able to correctly classify the ironic jokes. Instead they judged ironic jokes to be lies because they did not correspond to reality. For the joke stories only, adolescents with WS provided significantly more reality justifications than did adolescents with PWS and MRU adolescents suggesting that despite the lack of group differences on the lie/joke discrimination question the adolescents with PWS and MRU focused more on the mental states of the story characters, whereas the adolescents with WS justified their lie/joke decisions by judging the statement against what really happened. ^ Where provided or calculable from the data provided in the paper.