"being autistic does not always make someone bad at seeing the world from another's viewpoint"

The quote titling today's post - "being autistic does not always make someone bad at seeing the world from another's viewpoint" - comes from the findings reported by Shisei Tei and colleagues [1].

Their research paper observing that "more careful attention should be paid to the idea of egocentricity in individuals with ASCs [autism spectrum conditions]" is part of a research mash-up post today that also includes the findings reported by Hidetsugu Komeda and colleagues [2]. Both papers help to put a 'real-life perspective' on to sweeping generalisations that everyone on the autism spectrum is completely egocentric and lack the capacity to help others.

The Tei study was initially based on the idea that: "Individuals with autism spectrum conditions (ASCs) often experience difficulty and confusion in acknowledging others' perspectives and arguably exhibit egocentricity." Egocentrism can mean a few things, but all have in common that self is the be-all-and-end-all, and the interests, beliefs and attitudes of others are of secondary regard. It's a concept that we all engage in to some degree at certain times of development and maturation, and from an evolutionary perspective, probably served (and continues to serve) as an important survival mechanism. But: "whether this egocentricity necessarily results in selfish behavior during social situations remains a matter of debate." Tei et al examined the possibility of a link between egocentricity and selfish behaviour in the context of autism...

I'm not totally au fait with all the ins-and-outs of the Tei study techniques - "derived from cognitive psychology and behavioral economics" - but it looks like it was quite a bit to do with response times to a "computerized visuospatial perspective-taking task (VPT)" and the use of a task to measure altruism ("disinterested and selfless concern for the well-being of others"). Compared with a non-autistic control group, they observed some differences among their tested groups but, and it is an important 'but', "having ASCs does not always exhibit selfish behavior during interpersonal communication."

Then we have the findings reported by Komeda et al. The starting point was a sweeping one: "Individuals with Autism Spectrum Disorder (ASD) often lack cognitive empathy, so they experience difficulty in empathizing with others." Their study was perhaps less complicated than the Tei study as a group of adults with autism and control non-autistic adults were asked to read a number of stories - "(12 stories featured protagonists with characteristics of ASD and the other 12 featured TD protagonists)" - and answer questions about said stories. Questioning included "How did the protagonist feel?" and "Would you help if the protagonist were in trouble?"

Results again were interesting. So: "individuals with ASD empathize with other people who have ASD and are motivated to help other people with ASD." Based also on examination of autism spectrum quotient (AQ) scores and when "controlling for alexithymia" (marked dysfunction in emotional awareness, social attachment, and interpersonal relating), authors concluded that: "the reason why individuals with ASD are considered to have limited cognitive empathy and helping behaviors could be related to alexithymia and the lack of social skills and attention to detail, which are related to atypical perception."

OK, both the Tei and Komeda findings have to be put into some perspective. They don't for example, completely exonerate the social cognition or perspective-taking issues that are seen in autism. They can't do so either, because issues with social interaction for example, are a core facet of a diagnosis of autism. In effect, they define autism. I should also add that the reliance on participants who were very much cognitively able in both the Tei and Komeda studies means that one has to be quite careful of generalising such findings to all quarters of the autism spectrum, particularly the under-studied and under-represented (see here) parts.

But as I mentioned earlier in this post, the combined findings do help to put a 'real-life perspective' on things; specifically that such core issues that have defined autism for many, many years - empathy and perspective-taking - don't always manifest in a uniform fashion across people or situations. They also suggest that various other variables also might serve to promote issues with empathy and perspective-taking in relation to autism, as per mention of alexithymia; something that has been noted before by other independent study (see here).

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[1] Tei S. et al. Egocentric biases and atypical generosity in autistic individuals. Autism Res. 2019 May 17.

[2] Komeda H. et al. Do individuals with autism spectrum disorders help other people with autism spectrum disorders?: An investigation of empathy and helping behaviors in adults with ASD. Front. Psychiatry. 2019. May 13.

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"results suggest that maternal CMV infections may influence ASD symptoms"

CMV infections mentioned in the title of this post - "results suggest that maternal CMV infections may influence ASD [autism spectrum disorder] symptoms" - refers to cytomegalovirus, a beta-herpes virus, that infects quite a percentage of the population, but is typically kept in check by a healthy immune system.

Although not usually a 'problem-causer', CMV infection under certain circumstances can have various unwanted adverse effects. One such circumstance is that of congenital CMV infection, where some infants acquire CMV during the nine months that makes us, and in some cases, it leads to an array of adverse physical and developmental outcomes. You probably won't be surprised to hear that congenital CMV infection has also been *linked* to some instances of autism (see here) and indeed, on more than one peer-reviewed research occasion (see here).

The findings reported by Brooke Slawinski and colleagues [1] add to this important area of autism science with their suggestion of a potentially important *correlation* between the presence of CMV infection and scores on one of the premier autism assessment tool, the Social Responsiveness Scale version 2 (SRS-2).

Authors looked for "CMV IgG and HSV2 [herpes simplex virus 2] IgG in serum from the mothers of 82 children whose ASD symptoms were assessed at 3-6 years of age using the Social Responsiveness Scale version 2 (SRS-2)." The presence of IgG antibodies typically indicates past and/or recent exposure to a pathogen (in this case, CMV) with results expressed as seropositivity or seronegativity. Authors observed that those children whose mothers were seropositive for CMV IgG antibodies scored marginally higher on the SRS than those who were seronegative for CMV IgG antibodies. They did not find a similar relationship / correlation when looking at past / recent exposure to HSV2. Ergo, children *potentially exposed* to CMV infection during pregnancy showed a more severe autism presentation than those that weren't, at least in relation to the SRS measured social aspects of autism.

Of course you can see the issues with this work as it stands. Two variables (albeit "robust to several statistical adjustments") have been brought together and a possible 'connection' made. Not for the first time I might add, where one needs to be slightly cautious about making too much of any relationship given the wide array of potentially influencing variables / confounders. There is also an inference in the Slawinski work that a positive results means that maternal CMV infection during pregnancy was present and that "prenatal exposure to maternal infections" plays a role with [some] autism in mind. That is of course, if you assume that infections post-pregnancy might not also play a role in some autism (see here for example)...

The authors sensibly announce that their findings are "being further evaluated in ongoing prospective studies with larger population samples" so there should be more to see on this topic. For now however, I think it's important to stay mindful of the fact that exposure to various infective agents - viral, bacterial and otherwise - seem very much able to influence both physiology and behaviour in a wide variety of contexts including autism. Oh, and response to infection *might* also play a role in behaviour too (see here).

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[1] Slawinski BL. et al. Maternal cytomegalovirus sero-positivity and autism symptoms in children. Am J Reprod Immunol. 2018 Mar 9.

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Music therapy for social skills in autism: RCT says not...

"Adding IMT [improvisational music therapy] to the treatment received by children with ASD [autism spectrum disorder] did not improve social affect or parent-assessed social responsiveness."

So said the report published by Crawford and colleagues [1] commenting on recent research [2] observing that IMT might be 'music to the ears' but seemingly not so when it comes to altering symptom severity in the social affect domain of autism.

I'm no expert on IMT in any context so approach this topic with some caution. I remember quite a few years back watching and hearing about sessions where IMT was used as part of a schedule of interventions in the context of autism (see here) and thinking at the time, that it's inclusion seemed like quite a good idea. The data from Bieleninik and colleagues [2] perhaps urge caution that 'sounding good' might not necessarily translate into better outcomes when put under the scientific microscope.

So, 360 or so children diagnosed with ASD were randomised to receive either 'enhanced standard care' (ESC) or ESC + IMT (IMT delivered at high- and low-frequency among this group). I have to say that whilst ESC initially sounded pretty good, I was a little disappointed to hear that it meant "usual care as locally available plus parent counseling to discuss parents' concerns and provide information about ASD." Parent counselling? Remind me what year we're in if this is all we've got under the label of ESC.

After 5 months of ESC and ESC+IMT the scores on the Autism Diagnostic Observation Schedule (ADOS) social affect domain showed... no significant difference between the groups. Even most of the secondary outcomes (17 of 20) showed no significant difference. In short, IMT added to that ESC failed to significantly impact on social affect compared to ESC alone.

An accompanying editorial on the Bieleninik findings [3] talked about the implications of the trial results particularly in light of a previous Cochrane review [4] which suggested that "music therapy may help children with ASD to improve their skills in primary outcome areas that constitute the core of the condition including social interaction, verbal communication, initiating behaviour, and social-emotional reciprocity." The authors urge caution that the previous Cochrane review examined various different types of music therapies for example and whilst coming out on the side of music therapy for autism, determined the scientific quality of available research at that time to be "as either moderate or low quality."

Where next for IMT? Well, I'm going to be a bit more up-beat about this intervention that usual. I say that on the basis that music therapy is probably going to be one of the more 'risk-averse' interventions put forward for autism (first, do no harm and all that). Whilst social affect was not seemingly 'statistically' affected by its inclusion as an intervention option, this does not mean that other facets of autism - whether core or peripheral - might not benefit from its use with some people on the autism spectrum. On this note, I'll refer you to the paper by Pavlicevic and colleagues [5] and the suggestion that "long-term shared therapeutic musicking provides young adults with ongoing opportunities for experiencing confidence and self-esteem, with feelings of shared acceptance and success." Music to the ears eh?

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[1] Crawford MJ. et al. International multicentre randomised controlled trial of improvisational music therapy for children with autism spectrum disorder: TIME-A study. Health Technol Assess. 2017 Oct;21(59):1-40.

[2] Bieleninik L. et al. Effects of Improvisational Music Therapy vs Enhanced Standard Care on Symptom Severity Among Children With Autism Spectrum Disorder: The TIME-A Randomized Clinical Trial. JAMA. 2017 Aug 8;318(6):525-535.

[3] Broder-Fingert S. et al. Music Therapy for Children With Autism Spectrum Disorder. JAMA. 2017; 318(6): 523-524.

[4] Geretsegger M. et al. Music therapy for people with autism spectrum disorder. Cochrane Database Syst Rev. 2014 Jun 17;(6):CD004381.

[5] Pavlicevic M. et al. Making music, making friends: Long-term music therapy with young adults with severe learning disabilities. J Intellect Disabil. 2014 Mar;18(1):5-19.

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