Executive Functioning in High Functioning Autism

A review of: GILBERT, S., BIRD, G., BRINDLEY, R., FRITH, C., BURGESS, P. (2008). Atypical recruitment of medial prefrontal cortex in autism spectrum disorders: An fMRI study of two executive function tasks. Neuropsychologia DOI: 10.1016/j.neuropsychologia.2008.03.025

Executive functioning is an umbrella term used in clinical neuropsychology and cognitive neurosciences to refer to a series of “higher-order” cognitive processes usually associated with frontal lobe functioning. These include planning, organizing, categorizing, response inhibition, monitoring, multitasking, etc. Research on executive functioning and autism has provided mixed results likely due to differences in the area of executive function measured. In this functional MRI study, the authors used a new test of executive function used to assess for stimulus dependent vs. stimulus independent thoughts. Stimulus dependent refers to cognitive processing (thinking) that is associated with, or dependent on, a specific stimulus that is presented. For example, I may ask you to press the b key when you see a blue square or the r key when you see a red square. For this task the stimulus dependent phase consisted of capital letters presented in alphabetical order. Once a letter was presented, the person had to press one key if the letter contained only straight lines (such as the letter A) and a different key if the letter contained curves (such as the letter B). In the stimulus independent task, the person was presented with one letter and ask to follow the same response pattern (one key if straight lines – another key if curves). However, the second letter presented was random and did not follow the alphabetical order, yet the person was asked to respond based on the next alphabetical letter. For example, assume the first letter was “C”, then the next letter presented was the letter “H” (random) yet the person was asked to respond to the next alphabetical letter starting from the first letter presented (C), thus the next response was based on the characteristics of the letter D, even though the person was seeing the letter H. This task therefore, requires the person to continue to “think” of the characteristics of the letters in alphabetical order, independent of the letters presented (which now are distractors).

In the study the authors examined 15 adults with high functioning autism and 18 typically developing adults that were matched for age (mean 38) and IQ (mean 119). The participants performed the task while undergoing a functional magnetic resonance imaging scan (fMRI). There was no difference in accuracy or response times between the groups. Both groups showed more activation of the lateral frontal and parietal cortex on the more difficult stimulus-independent task. However, the autism group had significantly more activation of specific areas of the medial prefrontal cortex during the easier stimulus dependent condition than the typically developing group (this was interpreted as failure to deactivate these areas). The authors argued that these results suggest an atypical brain organization in HFA with limited deactivation of the rostral prefrontal cortex during easier task compared to typically developing individuals. However, the equivalent performance (both groups did just as well on the task) suggests that the fMRI findings simply reflect different approaches to cognitive performance between the two groups.

Autism and Inhibition of Return - A note about sample size

A review of: Rinehart, N.J., Bradshaw, J.L., Moss, S.A., Brereton, A.V., Tonge, B.J. (2008). Brief report: Inhibition of return in young people with autism and Asperger's disorder. Autism, 12(3), 249-260. DOI: 10.1177/1362361307088754

The authors designed an interesting experiment based on Minshew’s Complex Information Processing theory of autism, which seeks to understand the neuropsychological patterns of strengths and weaknesses in Autism as the foundations for the specific deficits in social cognition observed in Autism.

Side Note: Please note that the ‘Neuropsychological’ is usually misinterpreted, even by trained researchers and clinicians, as referring to physiological, as in ‘biological psychology’. Instead, neuropsychological refers in general to neurocognitive functioning – that is, cognitive and motor domains linked to brain processes. Thus, a test of neuropsychological functioning would include assessment of memory, attention, motor control, visual perception, auditory skills, general intelligence, language, etc.

Neuropsychological researchers have noted intact or superior abilities to detect unique patterns or items in visual search tasks in children with autism. This is inconsistent with the finding that these children also show difficulty with visual orientation and attentional set-shift (controlling the shifting of attention when needed from one set of items/tasks to others). Thus, how could children with autism have excellent item detection skills in light of their difficulty with attention and visual orientation? One possible explanation explored by the authors is that children with autism have a pronounced Inhibition of Return (IOR). IOR is a cognitive process that facilitates visual search by inhibiting searching on areas that have already been searched. For example, when looking for a letter ‘p’ on a poster full of letters ‘b’ and ‘d’, IOR allows you to search more effectively and those with a more pronounce IOR would be faster.

dbdbbdbbdbbdbbddbdbbdbd
bdbbdbbdbbbdbbdbdddbdbb
bbdbddbbdbbdbbbdbbdbbdb
bdbbdbbdbbdbdddbdbbdbdb
dbbdpdbdbbdbbdbbdbbdbdb
bdbbdbbbdbbdddbdbbdbbdb
bdbbdbbddbdbbdbbdbbdbdb

In this study the authors compared 12 kids with high functioning autism, 12 kids with Asperger’s, and 12 typically developing kids, all matched for age (mean 10), sex, and IQ. Diagnoses were confirmed via ADI. The participants completed a series of tasks to measure IOR. The authors found no significant differences in IOR between those with ASD and typically developing kids. However, there was a trend at the (p = .052) level suggesting a more pronounced IOR among children with Asperger’s than the other two groups. This is worth noting because the authors ability to find statistically significant results is directly affected by the number of participants in each group. Thus, if these same results had been obtained with more participants, it is very likely that the difference observed would be statistically significant. This sample size related effect is more of a concern when the N of participants is very small. Thus, I will be more likely to ‘trust’ non-significant findings from a study using 1,000 participants than those from a study using only 20. One rule of thumb you can use when examining studies with small sample size (number of participants) is that statistically significant results are more "informative" than results not showing statistical significance. Why? Because the small sample size makes it more difficult to find statistically significant differences, so they require greater differences between the groups you are comparing. Thus, when you see a study using a small sample size that found a statistically significant difference, you can assume that the difference between the groups is there (assuming no other methodological problems). However, when the results show no statistical difference, this could mean that the difference between the groups does not exist, or that they needed a larger sample size.

Perception of voice gender in high functioning autism

A review of: Groen, W.B., Orsouw, L., Zwiers, M., Swinkels, S., Gaag, R.J., Buitelaar, J.K. (2008). Gender in Voice Perception in Autism. Journal of Autism and Developmental Disorders DOI: 10.1007/s10803-008-0572-8

Social perception using non-verbal means, such as recognition of the social information embedded into facial expressions, voices, and gestures, play a key role in social communication. Unlike typically developing kids, babies that are later diagnosed with autism do not show a preference for their mother’s voice as apposed to other voice sound. The authors of this study reviewed this and other evidence of atypical sound processing in autism, specially the finding that people with high functioning autism have an atypical cortical processing of voices when compared to typically developing kids. Based on these findings, the authors wanted to explore if theses differences in sound processing result in impaired ability to recognize the gender of a speaker base solely on voice perception.

The study included 20 adolescents with high functioning autism and 20 typically developing adolescents who were matched for IQ, gender, and age. Diagnoses were based on DSM-IV criteria and confirmed via ADI. The participants were presented voice fragments via headphones and were instructed to determine whether the voice was of a male or a female. The authors used a specialized software to morph the gender of the voices and thus present fragments that slowly changed from stereotypically masculine to stereotypically feminine.

The authors did not find any group differences in the accuracy for identifying the correct gender. Typically developing kids and those with high functioning autism were as accurate when identifying the gender of voice fragments. However, significant differences were observed in the speed of responding but only for the originally male morphed voices (male to female morph).

Please note however, that the differences in response time were not simple a 'mean' difference with those with HFA responding slower than typically developing kids. Instead, typically developing kids had a linear increase in response time as the voices were morphed. For example, they responded much faster when the voice was not morphed (original male voice presented as male voice) but gradually increased their response time as the voices were morphed, so that the slowest response time was when the voice was completely morphed (original male voice presented as a female voice). However, for those with HFA the effect was not linear. They responded fast when the voice was not morphed, slowed as the voice began to get morphed, but then became fast again when the voice was completely morphed.

The authors conclude that children with high functioning autism are not impaired in the perception of voice gender, but instead use a different perceptual approach resulting in different response times.

Autism and the gender gap

Typically developing boys score higher than girls on autism scale.

A review of: Williams, J.G., Allison, C., Scott, F.J., Bolton, P.F., Baron-Cohen, S., Matthews, F.E., Brayne, C. (2008). The Childhood Autism Spectrum Test (CAST): Sex Differences. Journal of Autism and Developmental Disorders DOI: 10.1007/s10803-008-0558-6

This large-scale study examined gender differences in the Childhood Spectrum Test, a parental report of autism symptoms for use in primary schools. The test consists of 37 questions covering communication, social behaviors, and other symptoms of Autism Spectrum Disorder, but more specifically Asperger’s syndrome. A score of 15 or above is considered to be in the clinical range suggesting the presence of an ASD. The test was completed by 3,334 parents of typically developing kids attending elementary schools in England. There were equal number of boys and girls. The results were compelling. Boys had a statistically higher median score than girls (5 vs. 4, p < .001). But most notable, 103 kids (3%) had scores in the borderline range (12-14). This group was composed of 75 boys (73%) and 28 girls (27%). In addition, 102 kids (3%) had scores in the clinical range (>14). As you may expect, 79% (81) of these were boys.

Is the gender gap observed in the parental responses to this particular scale a reflection of true gender differences in the rate of ASDs – as predicted by the Extreme Male theory of Autism? Or do these results tell us more about a possible fundamental bias in our view of expected behaviors as they relate to ASDs? That is, gender differences may exist in communication styles, play preferences, and social behaviors, which are often view as ‘soft’ signs of autism spectrum disorders. Unfortunately this particular study will not give us the answer, for the results are consistent with both theories. It is also possible that both positions are not unique, or orthogonal, since the gender differences in communication styles, etc, may result from the underlying mechanisms proposed by the Extreme Male theory: a male tendency for systematizing and an impairment in empathizing.

Autism and social perception: The possible role of attention

Can the difficulties in social perception in Autism be due to attention deficits?

A review of: Fine, J.G., Semrud-Clikeman, M., Butcher, B., Walkowiak, J. (2008). Brief Report: Attention Effect on a Measure of Social Perception. Journal of Autism and Developmental Disorders DOI: 10.1007/s10803-008-0570-x

The co-morbidity between autism spectrum disorders and attention disorders (ADHD or ADD) is very high, with rates ranging from 49% to 78%. Thus, a significant number of people with autism spectrum disorders also have attention difficulties. Yet, little is known about how these attention problems may contribute to the different social difficulties experienced by people with ASD. In this paper, the authors compared 37 children with ASD (no breakdown of ASD was provided), 30 children with ADHD, and 19 typically developing kids (age 6-16). All kids had IQ scores over 80. 20 of the kids in the ASD group also had a co-morbid diagnosis of ADHD. These children completed a measure of social perception: the Child and Adolescent Social Perception Measure (CASP). This measure consists of 10 video clips of children interacting with an adult. The kids could see the vingnettes but the audio of the video was modified so that the kids could hear the prosody but not the lexical content. Then the kids were asked to tell the story in their own words and then indicate how each of the characters was feeling and how they could tell how the characters felt. Additional measures of attention and cognition were also included.

The results: ASD and ADHD kids did not differ in their ability to correctly identify emotions, but both groups performed significantly worse than the typically developing group. The ASD and ADHD groups also did not differ on measures of inattention or impulsivity, but the ADHD group had higher levels of hyperactivity. Finally inattention was a significant predictor of poor performance on the CASP. Thus, for all groups, lower levels of inattention were associated with better performance on the social perception measure, suggesting that for children with austim spectrum disoder, inattention may play a key role in explaining difficulties in non-verbal social understanding.

High functioning autism vs. Asperger’s: the VIQ PIQ myth?

A review of: Spek, A.A., Scholte, E.M., Berckelaer-Onnes, I.A. (2008). Brief Report: The Use of WAIS-III in Adults with HFA and Asperger Syndrome. Journal of Autism and Developmental Disorders, 38(4), 782-787. DOI: 10.1007/s10803-007-0446-5

I have documented in previous posts that clinicians and researchers have often proposed that high functioning autism and Asperger’s present a significantly different neurocognitive profile (see here and here). The belief is that children with AS tend to have a significant discrepancy between verbal and non-verbal abilities, with relatively higher verbal functioning as compared to non-verbal skills. On the other hand, children with high functioning autism tend to have relatively equal verbal and non-verbal skills. However, recently I’ve been encountering several studies that suggest that this may not be the case. As reported in this brief yet very elegant study from the Leiden University in the Netherlands, the researchers conducted a cognitive assessment of 16 adults with high functioning autism and 27 adults with Asperger’s syndrome using the WAIS-III (the most common adult IQ assessment instrument). Diagnoses were confirmed via ADI using DSM-IV criteria to differentiate HFA vs. AS. There were no differences between the groups in verbal vs. non-verbal performance (VIQ vs. PIQ). There was no pattern of high-verbal low-non-verbal scores in the Asperger’s group, with both groups scoring in the High Average range for both verbal and non-verbal composite scales. However, one global factor scale difference was observed. Adults with high functioning autism showed a significantly lower Processing Speed as compared to other factor skills such as Verbal Comprehension, Perceptual Organization, and Freedom from Distractibility. This finding was not observed in the Asperger’s group. Despite this difference (and some additional task-specific differences I didn’t mention in this review), the general findings of this study fail to support the idea that people with high functioning autism and Asperger’s can be differentiated on the basis of relative strength and weaknesses in their verbal vs. non-verbal performance as measured by standard intellectual assessment batteries.

Limited processing of facial expressions may explain limited gaze following in children with Austim

A review of: de JONG, M.C., van ENGELAND, H., KEMNER, C. (2008). Attentional Effects of Gaze Shifts Are Influenced by Emotion and Spatial Frequency, but Not in Autism. Journal of the American Academy of Child & Adolescent Psychiatry, 47(4), 443-454. DOI: 10.1097/CHI.0b013e31816429a6

This elegant experimental study comes to us from the Rudolf Magnus Institute of Neuroscience in the Netherlands. The researchers wanted to address a paradox in the Autism research literature: Although gaze following difficulties (specifically limited or absent gaze following) is a clinical hallmark of ASDs, many experimental studies have failed to replicate this phenomena in the laboratory (see for example Kemmer et al., 2006 & Senju et al., 2004). Gaze following refers to the re-direction of one’s attention towards the same location of someone else’s gaze direction. For example, if you are talking to a 2-year-old child and abruptly turn your head (or you eyes) to your left to see something, the child will immediately turn, arguably “to see what you are looking at.” The authors hypothesized that a possible explanation for problems with gaze following in children with ASDs is that these children have difficulty processing the emotional content intrinsic to facial expressions, and that such emotional content plays a critical role in triggering a re-orientation of attention by the observer. Specifically, the authors argued that this difficulty in the processing of emotional information is due to a bias towards processing local (detail) information instead of global information. So when looking at a face, research suggests that children with ASDs focus on details such as wrinkles and shapes, etc) instead of the ‘whole’ expression of the face. To test this hypothesis, the researchers examined 30 children with ASDs (diagnosed by a psychiatrist via ADI) with IQ over 80 and matched controls (matched for sex, age, and IQ). The children were presented with naturalistic pictures of faces with either a neutral of fearful expression and with straight or averted eye direction. Two conditions were presented, a neutral-to-fear condition and a fear-to-neutral condition. In the neutral-to-fear condition, a neutral face with straight gaze was followed by a fearful face with averted gaze. In the fearful-to-neutral condition, a fearful face with straight gaze was followed by a neutral face with averted gaze. An additional condition was also added: blurriness. In some pictures the face was blurry, making it more difficult to focus on the details of the picture (I did not review the results of these last conditions). The overall results were in partly line with the researchers' hypotheses. Although the authors concluded that "impaired gaze following in ASDs is related to impaired emotion processing," this conclusion was based on 1) a pattern of neruphysiological data that I did not review in this summary and 2) a differential pattern in 'cue validity' effect. Although a full explanation of cue validity effects goes beyond the scope of this review, the findings suggest that for typically developing children, when a discrepant emotional cue was presented (incorrect cue)a delay in reaction time in gaze following was observed when comparing reaction time to a fear face with the divergent gaze vs. a neutral face with divergent gaze. The children with ASDs did not show this pattern. That is, the speed of gaze following of typically developing children was affected when the presentation of the fear face was preceded by an incorrect cue. This is the traditional effect that you expect. However, the children with autism did not seem to be affected by this incorrect cue.

Challenges and needed supports: Perspectives from people with Asperger’s and other ASDs.

A review of:Muller, E., Schuler, A., Yates, G.B. (2008). Social challenges and supports from the perspective of individuals with Asperger syndrome and other autism spectrum disabilities. Autism, 12(2), 173-190. DOI: 10.1177/1362361307086664

This is an excellent example of research that makes a commendable effort to breach the gap between the Autism and research communities. This succinct study examined the reported challenges and supports needed as reported by people with Asperger’s syndrome or high functioning autism (HFA). The study included 18 people with ASDs (15 with a diagnosis of Asperger’s, 2 with HFA, and 1 with PDD-NOS). The participants were over 18 years old with normative intellectual functioning. The participants were interviewed using a semi-structured clinical interview that was created with the input from other people with ASDs, parents, and clinicians. The responses to the interviews were analyzed with a focus on two specific domains: reported positive and negative social experiences, and recommendations for effective social support services and strategies for improving social connectedness. In regards to social experiences, 6 common themes were identified: intense isolation, difficulty initiating social interactions, challenges relating to communication, longing for intimacy and social connectedness, desire to contribute to one’s community, and effort to develop greater social/self-awareness. In regards to recommendations for social support services and strategies, 4 common themes were noted: external supports (structured social activities, small groups and dyads, etc), communication supports (assistance with alternative forms of communication such as email and other web based applications, etc), self-initiated support (physical and outdoor activities, spirituality, etc), and attitudinal supports (teaching of tolerance of differences, willingness to initiate social interactions, etc). The authors discussed how these findings “counter a number of culturally reinforced stereotypes about ASDs – particularly the characterization of individuals with ASDs as socially aloof, deliberately self-isolating, affectively flat, and lacking consciousness of their social skills deficits.” It is also important to note that this study was conducted with mostly people with Asperger’s syndrome. We have discussed in the past how one possible difference noted between people with Asperger’s vs. functioning autism is in regards to a need for social connectedness. Thus, although this research is an excellent example of the type of inclusive research that is needed, I believe it is important that future research examine how social experiences and reported effective support systems may differ between people with Asperger’s and people with HFA, so that support systems can be better designed to meet the specific needs of these communities.

High Functioning Autism vs. Asperger’s: You say tomato I say tomahto

A review of:Kuusikko, S., Pollock-Wurman, R., Jussila, K., Carter, A.S., Mattila, M., Ebeling, H., Pauls, D.L., Moilanen, I. (2008). Social Anxiety in High-functioning Children and Adolescents with Autism and Asperger Syndrome. Journal of Autism and Developmental Disorders DOI: 10.1007/s10803-008-0555-9

When I first picked up this article I was excited because it seemed to directly address a clinical feature that some researchers and many clinicians have used to differentiate children with High Functioning Autism vs. Children with Asperger’s. We know that technically, based on DSM-IV diagnosis, the main difference between HFA and AS is the presence or absence of language delays. Kids with HFA, by definition, experience language delays, while kids with Asperger’s have typical language development. But in all clinical settings I have practiced, we have discussed other possible differences between these kids, specifically in regards to their neuropsychological profile and the nature of their limited social interaction with other peers. As for neuropsychological profile, HFA tend to have even verbal vs. non-verbal skills, while children with AS tend to have much higher verbal than non-verbal skills, consistent with the profile of children with “non-verbal learning disabilities”. In regards to their social interactions, in my clinical experience and interaction we colleagues, we see a difference in their ‘relative’ need for social companionship. In general children with HFA seem to just want to be by themselves without an explicit desire to interact with peers. They interact when necessary and when such interaction is functional, but not for the “intrinsic joy” of having social interactions. On the other hand, children with AS tend to desire close relationships with peers and explicitly talk about wanting more friends, but their social uniqueness make the establishing of such relation more difficult. Based on this last apparent clinical difference, you would expect that children with AS would experience more social anxiety due to a relative high need for social acceptance as compared to children with HFA. To test these hypotheses, a group in Finland compared 35 kids with AS, 21 kids with HFA (diagnosed via ADI and ADOS), and a large group of 353 typically developing kids of the same age (8-16 years old). The results were surprising: There was NO difference between the AS and the HFA in anxiety, social anxiety, social phobia, etc. As a group, the children with HFA/AS experienced higher level of anxiety and social phobia than the typically developing children. Furthermore, a developmental trajectory was observed. The anxiety problems tended to decrease with age in typically developing kids, but these problems increased with age in the children with HFA/AS. In summary, the data suggest that children with AS and HFA experience the same levels of social anxiety and phobias, which does not support the clinical view that these children may differ in regards to relative levels of social desirability.

Gaze following in young adults with Autism.

Title:Brief Report: Young Adults with Autism Spectrum Disorder Show Normal Attention to Eye-Gaze Information—Evidence from a New Change Blindness Paradigm.
Source:Fletcher-Watson, S., Leekam, S.R., Findlay, J.M., Stanton, E.C. (2008). Brief Report: Young Adults with Autism Spectrum Disorder Show Normal Attention to Eye-Gaze Information—Evidence from a New Change Blindness Paradigm. Journal of Autism and Developmental Disorders DOI: 10.1007/s10803-008-0548-8

One of the most common features of children with autism is limited shared attention, and in particular gaze following. That is, when a typically developing child sees another person change eye direction towards a particular object or region (to the left or right) the typically developing child will usually turn "to see" what the other person is seeing. However, it is common for children with autism to have limited gaze following (not turning), which sometimes has been seen as evidence for limitations in Theory of Mind. The basic idea is that gaze following reflects an understanding that "the other person" is thinking that there is something interesting in the direction of the gaze, therefore I should turn and see what the other person is seeing (although there is controversy as to whether this is a reflexive behavior instead).

The authors of this study wanted to examine if young adults with autism have the same gaze following limitations as children. They compared a group of 36 young adults with high functioning autism or Asperger’s to a comparison group of typically developing young adults of equal IQs. The participants were shown sets of two identical pictures separated by a blank image. They were asked to identify the difference between the pictures. In some pictures the difference was simply the gaze direction of the subject presented on the pictures. Other changes included the presence or absence or eye glasses (or “spectacles” since this was a British study) or a change in a piece of clothing. Results: There was no difference between the two groups. People with Autism and those with typical development were both more accurate at identifying eye gaze than the presence of eye glasses. In addition, they were both faster in identifying eye gaze than eye glasses. What is most interesting about this study is that the presence/absence of eye glasses is more visually evident (bigger change of features on the picture) than changes in eye gaze. Yet, both groups were able to identify eye gaze faster. The results speak to the importance of eye gaze as a social signal and the tendency to direct attention to eye gaze when the eyes are visible. It seems that young adult with high functioning autism appear to have a normative attention bias towards eye gaze and can recognize it as well as typically developing young adults.

Adults more tolerant when informed about Autism diagnosis?

Title: Adult Attitudes Toward Behaviors of a Six-year-old Boy with Autism
Source: Chambres, P., Auxiette, C., Vansingle, C., Gil, S. (2008). Adult Attitudes Toward Behaviors of a Six-year-old Boy with Autism. Journal of Autism and Developmental Disorders DOI: 10.1007/s10803-007-0519-5

A common experience reported by parents of children with autism is the perception of being ‘judged’ by other adults about their parenting skills or the appropriateness of behaviors displayed by their children. In order to understand this phenomenon, at team of French researchers conducted a very clever study using a methodology popular in social psychology research. The team showed clips of a video of a six year old boy with high functioning autism to 88 French adults. The clips showed the boy engaging in 4 different behaviors, namely: leaning back on a chair and moaning, having a temper tantrum without clear reasons, using a computer, and sitting at a table talking in front of a camera. One half of the adult participants were told that the child had Autism while the other half was not informed of the diagnosis. After showing the clips of each behavior, the adult participants were instructed to rate the child on 10 continuous dimensions (unruly, nice, alert, anxiety-ridden, etc). The authors found that when participants knew the clinical diagnosis of the child, they were more tolerant of the “negative” behaviors shown in the clips. Likewise, these informed adults were also more likely to rate the child positively in cognitive dimensions (intelligent, quick-minded, alert). The authors also found a gender effect. When the adults were informed, there was no difference between male and female participants. However, when the participants were uninformed, males were more harshly in the evaluation of the child than females. The authors commented that one possible reason that adults tend to show judgment towards parents of children with autism is that these children “look” like any typically developing child, so most people unfamiliar with the child would not know that the child had autism. The results are consistent with that idea indicating that when adults know that the child has autism they are more tolerant of behaviors that "do not conform to social norms" and see the child more positively in many dimensions. The results of this study could provide needed empirical support for the need of educational campaigns about ASDs targeted to the general population.

Autism, IQ, and the Stanford–Binet

Title: Brief Report: Data on the Stanford–Binet Intelligence Scales (5th ed.) in Children with Autism Spectrum Disorder
Source: Coolican, J., Bryson, S.E., Zwaigenbaum, L. (2008). Brief Report: Data on the Stanford–Binet Intelligence Scales (5th ed.) in Children with Autism Spectrum Disorder. Journal of Autism and Developmental Disorders , 38(1), 190-197.

In 2003 the Stanford-Binet-Intelligence Scales published a new edition (The SB-5). The SB is one of the most commonly used IQ scales for the assessment of children with special needs because it is believed to provide a more valid estimate of the child’s cognitive capacities. Although such assertion is still debated, in my experience working at several outpatient and hospital settings, the SB was always the tool of choice when conducting assessment with children with autism. Now, the problem that clinicians and researchers encounter is that when a new version of the test is launched, there is little information, apart for what is provided by the publisher, about how children with specific neurodevelopmental disorders are expected to perform. Thus, a team a Dalhousie University in Canada provided this brief report on the performance on the SB-5 by children with ASDs. The study included 63 children (12 girls and 51 boy) who have received a diagnosis of Autism, Asperger’s, or PDD-NOS via ADI or ADOS evaluation. The final count included 32 children with autism, 20 children with Asperger’s, and 11 children with PDD-NOS. Here are the most relevant results: Age was not significantly associated with performance as expected. This means that when compared to very large population sample of peers of the same age, younger children and older children perform at the same level in relation to their peers. Thus, differences between these children and the population sample do not change with age. The average full scale IQ scores using the entire SB-5 for the groups were 67.75 for Autism, 105.60 for Asperger’s, and 82.18 for PDD-NOS. When using an abbreviated version of the SB-5, the results were slightly higher but this varied significantly by individual. When comparing the Verbal vs. Non-Verbal subscales, it was surprising that in all three groups the scores in these scales were very similar, without any major discrepancy between verbal and non-verbal performance. This is surprising because traditionally children with Asperger’s show a pattern of performance consistent with a Non-verbal learning disability. That is, you would expect a significant discrepancy with much higher verbal scores as compared to non-verbal scores.

Commentary: The issue of IQ and intellectual assessment in children with Austim is highly controversial. However, the controversy is largely political and outside the research and clinical world. I want to address two issues that seem to be commonly debated in the autism community. First I want to briefly explain when, why and how an intellectual assessment test is used. An intellectual assessment is never, or should never, be provided in isolation. That is, an IQ test for the sake of knowing an IQ score provides no clinical utility. IQ scores, outside the larger scope of a full neurocognitive or educational evaluation conducted to answer specific clinical questions, are simply meaningless. Instead, an intellectual assessment is provided as part of a larger evaluation to understand the specific patterns of relative neurocognitive strengths and weaknesses with the ultimate goal of providing recommendations for services, treatment, accommodations, etc , which will maximize the functional capacities of the child and will facilitate growth and improvement. Second, there is usually a debated as to whether these intellectual assessment tools truly reflect the capacities of the child. This is a very, very, very important question. For example, performance in these types of tests is highly influenced by social desirability (wanting to please). A typically developing child may be attentive to instructions in order to please the clinician. But what if the child simply has other priorities at that particular moment than to listen to the clinicians explain how to do this clearly boring task? Does poor performance on this task reflect limited capacity in the area of functioning assessed? That is, did the child performed poorly because he/she couldn’t do it, or simply because he/she didn’t want to do it? So to the extent that IQ tests measure TRUE capacity, or are reflective of the child’s TRUE abilities, we simply have to say we don’t know. We hope that our assessment tools tap and real capacities as much as possible, but it is nearly impossible to ascertain why someone did not perform well in a particular task. HOWEVER, what the test does, at least more accurately, is to assess for FUNCTIONAL capacity. From a purely theoretical perspective, we can say that it does not matter why the child performed poorly if such performance generalizes into other contexts and affect the functional capacity of the child (not being able to do school work, difficulty keeping a job, etc). Thus, to the extend that neurocognitive assessment tools reflect functional capacities and help us provide recommendations that result in REAL benefits for the child, then I see these tests as important tools if used correctly for the right reasons and in the right context.

Update - Clarification: I was asked to clarify the statement “the controversy is largely political and outside the research and clinical world”. I apologize and agree that I should have been more precise about what I meant with that statement. I did not mean to imply that there is no controversy regarding the relative utility or appropriates of particular instruments (SB vs. WISC vs. TONY vs. other non-verbal assessment tool, etc). I was making a commentary about the commonly accepted position that in the right context, intellectual assessment as part of a comprehensive evaluation provides useful clinical information that could benefit the child or adult with autism. In my experience, the utility of using intellectual assessment tools has not been an issue of major controversy in any of the clinical settings I have worked in, including large university-based hospitals and autism clinics. In addition, I just conducted another superficial review of the two top journals in autism during the last 24 months and I was unable to find articles that provide appropriate empirical support for the idea that intellectual assessments should not be conducted in children with autism, although there are compelling articles discussing the appropriateness of specific tests. However, I accept that it is possible that the controversy in the research and clinical arena about this issue could more pronounced than how I characterized it, and if that is the case I stand corrected.

Autism, Services, and Co-morbidity: Insights from Kansas. PART II

Title: Characteristics of children with autism spectrum disorders who received services through community mental health centers.
Authors: Stephanie A. Bryson, Susan K. Corrigan, Thomas P. Mcdonald, and Cheryl Holmes
Source: Autism 2008 12: 65-82. (January).

I apologize for the lack of posts since Friday. I was in Washington at a National Institutes of Health round table discussion on research in childhood-onset disorders. Although the meeting was focused on child depression, there are several issues that were debated that apply to Autism research and I will post some observations later this week.

This is the second part of my summary of the Kansas community mental health study. Please see the previous post for some background and basic description of the methodology. As you may remember, the authors compared children with autism to children with other ASD, all of whom had received services at community mental health centers in Kansas. The researchers explored differences in a variety of demographic factors but they were most interested in examining differences in rates of co-morbid disorders. Here are their basic findings: Children with PDD and Asperger’s, when compared to children with autism, had higher rates of co-morbid ADHD, Depressive Disorders, Oppositional Defiant Disorder, Bi-Polar Disorder, and Post Traumatic Stress Disorder. Children with Asperger’s and PDD were also more likely to have experienced a psychiatric hospitalization. Yet, children with Autism were more likely to receive special education services than children with other ASDs.

Brief Commentary: The authors discussed some possible interpretations of the data, and I want to reiterate one major point. At least 2 things may be at play here. It is possible that children with PDD and Asperger’s do in fact experience higher rates of these disorders. Some of the findings are consistent with our current understanding of ASDs. For example, some researchers have characterized the differences between Asperger’s and Autism (especially high functioning autism) to be mostly related to differences in social desirability. The basic premise is that children with Asperger’s HAVE a desire for social interactions and relationships with peers, but they have social limitations that make it difficult for them to develop such social interactions. One the other hand, children with autism are believed to lack an “explicit or apparent” desire to establish and maintain relationships with peers. This limited social desirability may actually be “protective” for depression and other disorders in children with Autism; while the apparent social affiliation needs of children with Asperger’s, coupled with their social limitations, may lead to higher levels of frustration and possibly more emotional distress. HOWEVER, the results may also be a byproduct of our clinical diagnostic practices. There are many reasons why clinicians may provide a co-morbid diagnosis. In my own clinical experience, most often a second diagnosis is provided only when such diagnosis serves a function that helps the child. For example, up to 70% of children with autism score in the mental retardation range of standard IQ tests, yet most kids with Autism do not receive a second diagnosis of Mental Retardation. Why? Because it serves no purpose (in addition to other theoretical consideration). However, I have seen children receive a second diagnosis of MR when such diagnosis served a purpose, such as allowing the family and child to receive extended services, insurance coverage, etc. Thus it is possible that the differences in diagnoses observed by the researchers are not differences in ACTUAL rates of the disorders but instead in the relevant utility of providing a co-morbid diagnosis to children with PDD, Asperger’s, and Autism.

Diminished Cingulate Respose in Children with High Functioning Autism: A possible neural marker?

Title: Self Responses along Cingulate Cortex Reveal Quantitative Neural Phenotype for High-Functioning Autism
Authors: Pearl H. Chiu, M. Amin Kayali, Kenneth T. Kishida, Damon Tomlin, Laura G. Klinger, Mark R. Klinger and P. Read Montague
Source: Neuron 57, 463–473, February 7, 2008

I first heard about this article at the Autism Vox, which led to an interesting discussion on the difficulty in applying findings from basic science into the creation of diagnostic tools. This was a very interesting piece, but as I mentioned on the Autism Vox discussion, I think we are far from the creation of an FMRI test of autism (see the Autism Vox discussion). In summary, the researchers examined 16 adolescents with high functioning autism and 20 typically developing adolescents in their responses to a computer game called the Multi-round Trust Game. In this game the children received computer money (points) from another player in the form of an investment. During the transaction, the investment increased, so the receiving child obtained more than what the “investor” actually sent. Then the receiving child must decide how much of what he received should be returned to the investor. The key finding was that both groups of kids (Children with autism and typically developing) looked the same, in regards to their brain activation as seen on an fMRI, when the “Other” person was making a decision. The authors refer to this as the “Other Response”. However, when the children were making their own responses (called “Self Response”) the children with Autism lack a particular activation in the Cingulate Cortex (located deep in the center of the brain and usually activated during some social interactions including TofM tasks). This pattern of response was similar to the pattern presented by typically developing kids when playing against a computer instead of an actual person. The conclusion from the authors is that these children with autism may be “impaired in the capacity to represent the social intend of their OWN behavior” while understanding the actions of other (but not necessarily the intentions of others).

Commentary: Here is where the logic gets fussy. Since the two groups of children had a similar response patterns to the “Other” response, the authors argued that such “other” response must refer to a representation of the simple actions of others, but not the “intentions” of others. So the lack of cingulate cortex activation during “self” responses are interpreted as a diminished capacity to understand you own social “intentions” (or I interpret this that as “consequences”) and this is used to explain why children with autism have difficulty on theory of mind tasks. The authors argued that if you can’t represent your own social intentions, it will be difficult to represent the social intentions of others. Now, the problem is that in this game there was no difference between the two groups of kids when the “Other” was responding. Why? If children with autism have difficulty representing the social intentions of others, you would expected to see a difference between these two groups, unless you assume that 1) the typically developing kids also had problems representing the social intentions of others OR 2) during this game there was no need to represent the social intentions of others. In conclusion, what this study clearly shows is reduced Cingulate Cortex activation during “self” responses, suggesting that children with autism have a different brain activation pattern when performing actions that have social intentions, or consequences on someone else. Here is a review from MIT.

Parents of Children with High Functioning Autism and the Broader Autism Phenotype

Title: Broader Autism Phenotype in parents of Autistic Children: Reality or Myth
Authors: Anke M Cheeren & Johannes E. A. Stauder. University of Maastricht. Neatherlands.
Source: Journal of Autism and Developmental Disorders, (2008), 38, 276-287

This relatively short and focused article was published in the last issue of the Journal of Autism and Developmental Disorders. The authors wanted to test the hypothesis that parents of children with Autism Spectrum Disorders have mild autistic features, a finding that has been labeled the “Broader Autism Phenotype” (BAF). The authors compared the parents of 25 children with "high functioning autism" with the parents of 25 typically developing children. These parents were compared in regards to their performance to the block design task (a visual-motor spatial perception task that is part of a standard IQ test), the Autism-Spectrum Quotient (AQ - a test of common autistic features), and a reaction time task designed to measure how fast a person respond to social vs. non-social cues (gaze vs. arrows). The authors found that parents of children with high functioning autism scored similarly than parents of typically developing children on the bock design task and the AQ task, suggesting no clear differences between these parents in visual-motor spatial perception and global traits of autism. However, parents of children with high functioning autism were slower to react to social cues (as compared to non-social cues) than parents of typically developing children, an effect that was particularly strong for Fathers. There are a few things worth discussing. First, the authors examined parents of "high functioning autism" kids, however the group included a mix of children with autism, Asperger’s syndrome, and PPD NOS. Why is this significant? First because some researchers have discussed the Broader Autism Phenotype as a phenomenon possibly common among parents of children with Asperger’s disorder only. I believe this is in line with the author’s selection of the block design as a measuring tool. There is some evidence that suggests that children with Asperger’s disorder, but not children with high functioning autism, present a cognitive profile indicative of a Non-Verbal Learning Disability. In fact, this effect has been used as a possible marker of the proposed difference between Asperger’s and High Functioning Autism. Another interesting result is that reduced reaction time to social cues was more pronounced in fathers of children with ASD, which is consistent with some suggestions that the BAF is mostly limited to fathers and not mothers. The idea of differences in some measures of social cue processing amongst parents of children with autism is not necessarily novel or out of sync with the rest of the literature. We know there is a higher familial risk for autism when a parent or a sibling has an ASD (autism runs in families), and we know that there is a genetic component to these disorders. Thus, some differences (and in this case very mild and limited to reaction time) between parents of children with ASD (especially fathers and likely only in regards to Asperger’s) and typically developing children could be expected.

Small Group Training in High Functioning Autism

Title: Improving question asking in high-functioning adolescents with autism spectrum disorders.
Source: Autism 2008; 12; 83

An interesting study by Annemiek Palmen, Robert Didden and Marieke Arts in the Neatherlands. They implemented a 6-weeks small group training program with young adults with high functioning autism. The sessions were 60 minutes long once per week. The focus of the sessions was improving “question asking” techniques, which were practiced mostly during role play situations. The authors found that the total number of appropriate questions asked by the participants during mock naturalistic conversations increased significantly after the short training program.

There was something very unique about this study and training method. The clinicians taught the participants to use a flowchart that helped them make decisions regarding when and how to ask questions during conversations. The flowchart was not specific to any topic so that the participants could apply it to any conversation. It is promising that, not only there was a clear improvement in how well the participants asked questions during normal conversations, but that this improvement seemed stable, at least 3 weeks following the study. That is, the researchers conduced a follow up evaluation 3 weeks later and found that the participants continued to show improvements in their question asking skills.