Thursday, June 30, 2016

Alexithymia, Empathy, and Autism

Autism spectrum disorder (ASD) is a neurodevelopmental condition characterized by impairment in (a) reciprocal social interaction and communication and (b) restricted and/or repetitive behaviors or interests. These delays or atypicality in social development, communication, neurocognition, and behavior vary in severity of symptoms, age of onset, and association with other disorders. However, it is deficits in social relatedness that are the major source of impairment and the core-defining feature of ASD, regardless of cognitive or language ability. This includes difficulties in communicating with others, processing and integrating emotional information, establishing and maintaining reciprocal social relationships, taking another person's perspective, and inferring the interests of others (Wilkinson, 2010).
An important aspect of social relatedness is the ability to empathize with the feelings of others. Empathy involves two major components: a cognitive component (e.g., theory of mind, perspective taking, or mindreading) and an affective component (emotional processing) which allows us to share the feelings of others. The affective component of sympathy involves having an appropriate emotional reaction to another person’s thoughts and feelings. When engaged in affective empathy, we vicariously experience the emotional states of others, understanding that our feelings are not ours but rather those of the other individual (Baron-Cohen, 2008).

While autism has been shown to be associated with a deficit in perspective taking (cognitive empathy), it is much less clear to what degree individuals with ASD also experience deficits in affective empathy. In fact, it is uncertain whether the empathy deficit commonly attributed to individuals with autism is a result of the disorder itself, or if it is a consequence of a comorbid (coexisting) subclinical condition known as alexithymia. Alexithymia is characterized by difficulties in identifying, describing, and processing one's own feelings, often marked by a lack of understanding of the feelings of others, and difficulty distinguishing between feelings and the bodily sensations of emotional arousal (Kooiman, Spinhoven, & Trijsburg, 2002). It is especially important to note that Alexithymia does not constitute a clinical diagnosis and is best conceptualized as a dimensional personality trait that is normally distributed in the general population (estimates of 10%). However, there is evidence to suggest that it is associated with an increased risk of psychopathology. For example, several studies indicate that even in childhood, alexithymia and problems in the domain of emotion processing are positively related to internalizing problems such as depression and anxiety.
Although alexithymia is not a core feature of autism, recent studies have found varying degrees of this trait in 50 to 85% of individuals with ASD (Hill, Berthoz, & Frith, 2004). The alexithymia trait appears to have the following properties: (a) it is more common in individuals with ASD than in the general population (b) it is more common in parents of individuals with ASD than in parents of individuals with another developmental disabilities, (c) it is stable over time in ASD, and (d) problems in the domain of emotion awareness are positively related to depression, anxiety, somatic complaints, worry and rumination (Rieffe et al., 2011). There is also evidence to suggest that the alexithymia trait might be part of the broader autism phenotype and a significant component of the emotion processing difficulties experienced by people with ASD (Szatmari et al., 2008). Although individuals with ASD experience alexithymia at much higher rates than the general population, autism and alexithymia appear to be distinct, unrelated, and overlapping conditions in which alexithymia seems to influence affective empathy. Therefore, the empathy deficits typically observed in autism may be due to the large comorbidity between alexithymic traits and autism, rather than representing an essential feature of the social impairments in autism (Bird et al., 2010).  

Research also indicates that alexithymia is linked to interoceptive difficulties in ASD. Interoception is known as the awareness of one’s body or the sense of the condition of the body.  The system of interoception relates to how we perceive feelings from our bodies that determine our mood, sense of wellbeing and emotions. Awareness of, and sensitivity to, internal physiological sensations is fundamental to how we conceptualize our affective experiences. There has been increasing theoretical interest in the possibility that interoception may be altered in ASD. It has been speculated that impaired interoception leads to the socioemotional deficits which are a diagnostic feature of the condition. However, research now indicates that alexithymia, not autism, is associated with atypical interoception. For example, Shah et al., 2016 examined the relative impact of autism and alexithymia on interoception and concluded that interoceptive impairments should not be considered a feature of ASD, but instead due to co-occurring alexithymia.
Future Research

An obvious question for future research relates to the prevalence of high levels of alexithymia in ASD compared to neurotypical individuals and how to explain the high comorbidity between alexithymia and ASD. Is alexithymia a neuroanatomical structural consequence or is the result of a neurobiological impairment, or is it a distinctive personality trait of individuals with ASD? Does the level of alexithymia predict symptom severity in ASD? Would interoceptive training be therapeutic for individuals with co-occurring alexithymia? Although not a feature of autism, would alexithymia be a useful diagnostic marker for ASD? Because alexithymia is associated with increased risk of psychopathology (e.g., anxiety and depression), should a measure of alexithymia be included in an assessment battery for ASD? As with most autism research, there are more questions than answers.
Baron-Cohen, S. (2008). Autism and Asperger syndrome: The facts. New York: Oxford University Press.
Bird, G., Silani, G., Brindley, R., White, S., Frith, U., & Singer, T. (2010).  Empathic brain responses in insula are modulated by levels of alexithymia but not autism. Brain, 133, 1515-1525.
Hill, E., Berthoz, S., & Frith, U. (2004). Brief report: Cognitive processing of own emotions in individuals with autistic spectrum disorder and in their relatives. Journal of Autism and Developmental Disorders, 34, 229–235.
Kooiman, C.G., Spinhoven, P. & Trijsburg, R.W. (2002). The assessment of alexithymia: A critical review of the literature and a psychometric study of the Toronto Alexithymia Scale-20, Journal of Psychosomatic Research, 53, 1083-1090.
Rieffe, C., Oosterveld, P., Meerum Terwogt, M., Mootz, S., van Leeuwen, E., & Stockmann, L. (2011). Emotion regulation and internalizing symptoms in children with autism spectrum disorders, Autism, 15, 655-670.

Shah, P., Hall, R., Catmur, C., & Bird, J. (2016). Alexithymia, not autism, is associated with impaired interoception. Cortex, 81, 215-220.
Silani, G., Bird, G., Brindley, R., Singer, T., Frith, C., Frith, U. (2008). Levels of emotional awareness and autism: An fMRI study. Soc Neuroscience, 3, 97-112.
Szatmari, P., Georgiades, S., Duku, E., Zwaigenbaum, L., Goldberg, J., & Bennett, T. (2008). Alexithymia in Parents of Children with Autism Spectrum Disorder. Journal of Autism and Developmental Disorders, 38, 1859-1865.

Tuesday, June 7, 2016

Preferred Play Activities of Children on the Autism Spectrum

Play is critical to children's development in all domains (social-emotional, communication, physical, adaptive, cognitive). Consequently, introducing and designing appropriate play opportunities for all children, but especially for children with ASD, is a primary concern for educators, clinicians, and parents. Educators and parents of children with ASD often struggle to identify and design appropriate play activities to promote learning. Thus, it is challenging yet critical to find meaningful play activities and experiences to accommodate children’s specific interests and ability levels. 

What type of play do children with ASD prefer? 

A study published in the North American Journal of Medicine and Science investigated the types of play most often preferred by children with ASD in a controlled but authentic setting, where direct observation and data collection would be possible. This research study was novel in the area of studying the free play choices of children with ASD because it was conducted in a naturalistic setting (public museum) without adult prompting, or contrived situations. The children were allowed to freely select from among 20 play activities, and did not recognize they were being observed, so responses and behaviors were authentic.
Data collected over six months resulted in a sample size of 1,506 observations for children with ASD and 985 without ASD. Informal observation established an ASD- participant age range of 3-18, with the most common age range being 5-10 years old. Data were combined for each of 20 different play stations. The five play exhibits most significantly preferred by children with ASD were 1) Climbing Stairs, 2) the Netherlands Windmill, 3) Vietnam rice table, 4) Loop the Loop, and 5) Make it Roller-Ball. Each exhibit preferred by children with ASD offered strong sensory input and feedback to the participant, while many featured repetitive movement or motion (Make it Roller-Ball), and cause/effect attributes, such as propelled balls (Loop the Loop), and spinning objects (Netherlands Windmill).
The most popular (strongly preferred) activity among children with ASD was the exhibit "Climbing Stairs." Children who climbed a short staircase could then drop a ball and watch it descend. Another popular activity involved a windmill. Children can push its arms, causing it to spin. A table filled with rice completed the top three most preferred exhibits among children with ASD. In contrast, the five least popular exhibits for children with ASD were pretend play activities, and play activities which focused on arts/crafts. This confirmed the researchers’ hypothesis that children would prefer play activities with a strong sensory component and are far less likely to engage in activities involving pretend play.
"Children with ADS sometimes tend to crave motion, and if they can't be moving, they like to look at moving objects," said researcher Kathy Ralabate Doody, noting that motion engages the vestibular, proprioceptive, and visual senses. "So just watching the windmill engaged them. When the windmill turned in response to their push, it also provided cause-and-effect play. And the repetition of the spinning movement provided a third level of satisfaction." Climbing the stairs also satisfied multiple senses. Playing with rice provided both tactile and visual stimulation as children felt and watched the rice pour through their fingers.
Identifying the types of play preferred by children with ASD has practical and important implications for educators, clinicians, and parents. For example, the information from this study could also be utilized in the formation of inclusive programs and services to encourage social interaction between children with ASD and their typical peers. Educators and clinicians can also utilize this information in designing treatment sessions and intervention strategies for children with ASD. Preferred activities and manipulatives are frequently used as tangible and concrete positive reinforcement in the teaching of children with ASD. Further, parents could make use of this information in selecting toys and family activities to appeal to the interests and abilities of a child with ASD. The ability to engage in preferred play promotes independence for the child with ASD, thereby providing a parent or caregiver an opportunity to prepare dinner, attend to another child, or just take a break for a few moments. Prior research indicates the need for leisure activities to support families living with a child on the spectrum.
Lastly, additional research is needed before generalizing the results of this study to all children with ASD. Possible directions for future research include following individual children with ASD, and measuring the time spent by an individual child at each play activity. The researchers note that they are currently conducting a secondary study, comparing the play preferences of children with ASD to children with typical development in the same naturalistic environment.
Kathy Ralabate Doody, Jana Mertz. Preferred Play Activities of Children with Autism Spectrum Disorder in Naturalistic Settings. North American Journal of Medicine and Science, 2013 DOI: 10.7156/najms.2013.0603128
Lee A. Wilkinson, PhD, CCBT, NCSP is author of the award-winning book, A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools, published by Jessica Kingsley Publishers. He is also editor of a text in the American Psychological Association (APA) School Psychology Book Series, Autism Spectrum Disorder in Children and Adolescents: Evidence-Based Assessment and Intervention in Schools, and author of the book, Overcoming Anxiety and Depression on the Autism Spectrum: A Self-Help Guide Using CBT. His latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).

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