On 'negative first impressions' and autism: even those on the autism spectrum are prone to them

The findings reported by Ruth Grossman and colleagues [1] talking about 'perceptions of self and others' in the context of autism are really quite intriguing. Researchers reported that when adolescents, either diagnosed with or without autism, were shown brief video clips of adolescents with and without autism (and not explicitly being told about whether actors were autistic or not), "all participants provided more negative judgments of autistic than neurotypical adolescents in the videos." I've hyperlinked that mention of the word 'neurotypical' to some previous discussions on this blog about how this term really is a misnomer...

OK, let's rewind a little. Grossman et al mention that: "Neurotypical adults often form negative first impressions of individuals with autism spectrum disorder and are less interested in engaging with them socially." Such sweeping sentiments are based on other research that she has been involved in (see here) observing that "the social presentations of individuals with ASD, particularly their non-verbal cues, including prosody, facial expressions, and body posture, are perceived less favorably and are associated with reluctance on the part of observers to pursue social engagement" [2]. I should add that 'undergraduates' were the "rating participants" on that research occasion; a participant group who may not be as representative of the general population [3] as many people might think.

Further study in this area [4] revealed that diagnostic disclosure and "increased autism understanding" seemed to improve such first impressions. They also revealed that once again, the diagnosis known as schizophrenia was viewed even less favourably; heaping yet more stigma and misery on to this label and those diagnosed with it.

The most recent Grossman findings added a new dimension to such 'first impression' research by including young adults with autism into their study. They specifically started out by mentioning that: "individuals with autism spectrum disorder actively seek out the company of others who share their diagnosis", I assume, on the basis that 'like attracts like' across various types of relationship, and 'shared' characteristics might be more likely to provide shared viewpoints and shared understanding. That's the [sweeping] theory anyway. The fact however that those on the autism spectrum were seemingly not immune to those initial negative judgements "without being explicitly informed of a shared diagnosis" kinda implies that at least when it comes to first impressions, those on the autism spectrum aren't so dissimilar from those results from the not-autism cohort.

Should anyone be surprised by these findings? Well, I was initially taken aback by them, particularly when so much was (and still is) made of the idea that society and it's 'reactions' to autism is part of the reason why some of those on the autism spectrum feel disabled. I don't want to get into any ideological debates or discussions about the application of the social model of disability to autism ("disability is caused by the way society is organised, rather than by a person’s impairment or difference") but I can think of some occasions where those original 'first impression' findings were suggested to be supportive of such a model. The Grossman findings also don't discount the social model of disability; indeed they're supportive of it from a first-impressions point of view. But they do blur the distinction between autism and 'neurotypical' in terms of who makes those first impression responses. In short, a diagnosis of autism does not seemingly mean prejudice-free nor does it necessarily mean that everyone on the autism spectrum probably wants to, or necessarily seeks out, the company of like-minded spectrum people. Yet again, sweeping generalisations about autism falls...

I would like to see more investigations done in this area. I've talked about the use of the student population in this post already, so the next step would be talking to your average Joe or Josephine who doesn't rely on getting a 'class credit' for their study participation to gauge their views. It's also important to see whether variables like baseline 'familiarity' with autism (if there is such a thing!) or chronological age of raters are also consistent with such findings: are older folk for example, who've lived a little longer and experienced a bit more in their lives, more or less likely to hold a particular 'first impression' view of autism? Does it also vary according to the 'severity' of autism presentation?

Assuming also that it is rather difficult to significantly impact on one persons first impression of another, I'd like to know further details about why those negative judgments were formed. 'Social skills' were part-and-parcel of the Grossman analyses but this covers quite a lot of ground. We are also told that: "Both participant groups spent less time gazing at videos of autistic adolescents" implying that poise, posture and other physical features/characteristics might similarly be important in grabbing and keeping someones (positive) attention. Going back to the previous research where the (mis)label of schizophrenia was mentioned, I'd also like to see the inclusion of autistic voices when it comes to this area too. So, do the same prejudices about something like schizophrenia hold for those on the autism spectrum? What about other mental issues and illnesses such as depression and/or anxiety? I say this also bearing in mind that labels like schizophrenia, depression and anxiety are sometimes not unfamiliar facets of the autism spectrum (see here and see here), in a world where autism typically does not exist in a diagnostic vacuum (see here)...

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[1] Grossman RB. et al. Perceptions of self and other: Social judgments and gaze patterns to videos of adolescents with and without autism spectrum disorder. Autism. 2017. July 17.

[2] Sasson N. et al. Neurotypical Peers are Less Willing to Interact with Those with Autism based on Thin Slice Judgments. Scientific Reports. 2017; 7: 40700.

[3] Hanel PHP. & Vione KC. Do Student Samples Provide an Accurate Estimate of the General Public? PLoS ONE. 2016;11(12):e0168354.

[4] Sasson NJ. & Morrison KE. First impressions of adults with autism improve with diagnostic disclosure and increased autism knowledge of peers. Autism. 2017 Oct 1:1362361317729526.

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Video Interaction for Promoting Positive Parenting in autism: yes but not quite...

"Video feedback may help babies ‘at risk of autism’" went one write-up of the study results published by Jonathan Green and colleagues [1] (open-access available here). Continuing a theme of kids at risk of autism potentially 'avoiding' an autism diagnosis (see here) following the use of "a 12-session parent-mediated social communication intervention delivered between 9 and 14 months of age (Intervention in the British Autism Study of Infant Siblings-Video Interaction for Promoting Positive Parenting)" there is some degree of optimism from these latest results together with a pinch of 'not-so-fast'...

Including data from some 54 families - "28 intervention, 26 nonintervention" - researchers reported on the effects of interventions vs. no intervention on various aspects of functioning primarily the "severity of autism prodromal symptoms." Prodromal means early symptoms and is more readily associated with other labels/conditions. The authors reported that results were not completely cut-and-dried in terms of effect(s) of intervention on diagnostic outcome for example (i.e. there were "no intervention effects on diagnostic outcome") but potentially something to see when it comes to the 'severity' of autism prodromal symptoms and "parent-dyad social communication." The authors also noted that measures of communication and language did show something of a trend towards some benefit observed in the intervention group, but did not yield any significant difference when comparing intervention with no intervention over the quite long study period (39 months). This contrasts with their previous results [2] possibly indicating something rather more adverse when it came to intervention and aspects of language/communication. I might also draw your attention to the fact that from a bank of some 84 families invited to join the study, just over half actually agreed or fulfilled the criteria for joining.

I know this is an area of research that people really want to see work. Alongside other early intervention research in relation to autism (see here for example), the idea that some small adjustments to early interactions might affect the presentation of autism still enjoys quite a lot of support in various quarters. The thing is that these and other results whilst suggesting that things like 'parental responsiveness' can improve as a result of intervention(s), have so far shown that important outcomes for young children are far less impressive. This is something evident across quite a lot of the research literature in this area even when meta-analysed (see here including some chatter about effect sizes).

I'm not suggesting that we everyone just 'gives up' when it comes to early interventions like the one described by Green and colleagues. I do however think science and clinical practice needs to be a little more focused on things like potential best-responders to such interventions (as it does for many other aspects of autism science) and not so focused on creating grand media headlines. I might also throw in the idea that study design is something that needs to be improved particularly in light of other recent findings [3] talking about how "placebo-like effects represent substantial challenges for randomized controlled trials (RCTs) that use treatment as usual" (guess what many studies in this area use as their comparator?) Accepting that variables such as the plural autisms (see here) are inevitably going to affect results from such studies, I'm minded to suggest that quite a few more resources need to be committed to looking at the possible 'hows and whys' of autism coming about before any talk about early parent-mediated intervention becoming widespread. So, questions like whether screening for inborn errors of metabolism in relation to autism (see here) could be a good first step as part of the mantra 'diagnosis is a starting point not the finishing line' and then taking things from there...

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[1] Green J. et al. Randomised trial of a parent-mediated intervention for infants at high risk for autism: longitudinal outcomes to age 3 years. J Child Psychol Psychiatry. 2017 Apr 10.

[2] Green J. et al. Parent-mediated intervention versus no intervention for infants at high risk of autism: a parallel, single-blind, randomised trial. Lancet Psychiatry. 2015. Jan 22.

[3] Jones RM. et al. Placebo-like response in absence of treatment in children with Autism. Autism Res. 2017. 12 April.

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Green J, Pickles A, Pasco G, Bedford R, Wan MW, Elsabbagh M, Slonims V, Gliga T, Jones EJ, Cheung CH, Charman T, Johnson MH, & British Autism Study of Infant Siblings (BASIS) Team. (2017). Randomised trial of a parent-mediated intervention for infants at high risk for autism: longitudinal outcomes to age 3 years. Journal of child psychology and psychiatry, and allied disciplines PMID: 28393350

At-risk kids avoiding an autism diagnosis?

The paper from Jonathan Green and colleagues [1] (open-access) discussing results based on a "two-site, two-arm assessor-blinded randomised controlled trial of families with an infant at familial high risk of autism aged 7–10 months, testing the adapted Video Interaction to Promote Positive Parenting (iBASIS-VIPP) versus no intervention" caught quite a few eyes recently. With accompanying media headlines such as 'Parents May Be Able to Lower Kids’ Autism Risk' you can imagine the interest created in such a study. I'll also at this point refer you to a commentary on the study from Cathy Lord [2].

Video interaction to promote positive parenting is by no means a new thing to autism research as per the paper by Poslawsky and colleagues [3]. The adapted - BASIS - program "works with parents using video-feedback to help them to understand and adapt to their infant's individual communication style to promote the best possible social and communicative development." Further: "the therapist makes videotapes of interactions between the parent and child in the home setting and uses video excerpts to work with the parent in a series of sessions that are developmentally sequenced to improve the quality of parent understanding of infant's communication." Treading carefully in this area, the idea that family processes can impact on autism presentation is gaining traction (see here).

Green and colleagues reported results based on 54 families with an infant deemed at high-risk of autism by virtue of having a sibling diagnosed with an autism spectrum disorder (ASD). Twenty eight families were randomly allocated to the intervention group and 26 to a "no intervention" group and participants were monitored and assessed over 5 months. Various measures were used during the trial including the "Manchester Assessment of Caregiver–Infant interaction (MACI)...  to measure infant attentiveness to parent and other interaction variables" and "the Autism Observation Scale for Infants (AOSI)" for the assessment of "early behavioural risk markers for children with ASD."

Results: "point estimates suggest that the intervention increased the primary outcome of infant attentiveness to parent." The authors are rightly careful about this result however because "CIs [confidence intervals] sometimes include the null" across various results. Wide CI's crossing the null are to be viewed with some degree of caution. Likewise other results such as "the intervention reduced autism-risk behaviours" carry the same optimistic yet guarded message.

That all being said, the headline about such intervention potentially 'lowering autism risk' are perhaps a little premature based on the current results. As per some of the media on the study and Prof. Green commenting: "He stressed that the babies have not been tested yet for autism, which will occur when they are around 3 years old, but that the changes he and his team saw strongly suggest that the path to autism may have been interrupted, or at least suppressed in some way." So we wait to see what actually happened to those infants at high-risk and whether intervention actually provided some protection against receipt of a diagnosis of ASD.

I have to say that I was really quite interested in these findings. I am cautious following some of the other findings reported by the authors as per the potential effect of such an intervention on "developmental language measures" and possible "reduced responsiveness to language sounds in the intervention group" but await further results on how this might eventually pan out. Early intervention such as this is a up-coming area in autism research (see here) and the idea that brain and behaviour are plastic and development not potentially as immutable as was once thought. I personally would like to see this area developed further bearing in mind the concept of differing developmental trajectories being associated with autism, and I assume similarly pertinent to high-risk siblings too. I'd also be minded to suggest that a greater focus on the broader autism phenotype (BAP) might be implied in further research (see here) as well as some additional data on the possible genetic/epigenetic/biochemical/neurological correlates which might coincide with the potential efficacy of such early intervention.

Given the previous not-so-effective results of the PACT initiative by some of the authors (see here) I can also imagine the current results were probably received in a more optimistic fashion by the team involved. We wait for further research...

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[1] Green J. et al. Parent-mediated intervention versus no intervention for infants at high risk of autism: a parallel, single-blind, randomised trial. Lancet Psychiatry. 2015. Jan 22.

[2] Lord C. Infant autism: parents' role in ameliorating risk? Lancet Psychiatry. Jan 22.

[3] Poslawsky IE. et al. Development of a Video-feedback Intervention to promote Positive Parenting for Children with Autism (VIPP-AUTI). Attach Hum Dev. 2014;16(4):343-55.

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Jonathan Green, Tony Charman, Andrew Pickles, Ming W Wan, Mayada Elsabbagh, Vicky Slonims, Carol Taylor, Janet McNally, Rhonda Booth, Teodora Gliga, Emily J H Jones, Clare Harrop, Rachael Bedford, Mark H Johnson, & the BASIS team (2015). Parent-mediated intervention versus no intervention for infants at high risk of autism: a parallel, single-blind, randomised trial The Lancet Psychiatry : http://dx.doi.org/10.1016/S2215-0366(14)00091-1

ADOS via YouTube for autism 'triage'?

The paper by Vincent Fusaro and colleagues [1] and some accompanying press attention about this study caught my eye recently. Based on an analysis of 100 home videos posted on YouTube, some tagged with words leading to the assumption of the presence of autism, undergraduate researchers used scoring measures from the gold-standard autism assessment schedule ADOS (Autism Diagnostic Observation Schedule) to quite accurately grade whether children appearing in the videos could be classified as autistic or not.

Testing, testing, 1, 2.. @ Wikipedia 

Having quite recently attended a conference where autism screening and assessment was a big talking point, including some chatter specifically about the ADOS and it's relationship to DSM-5 (see here for some background), it is timely that this paper was published when it was. That also one of the authors is Dennis Wall - he of the machine-learning work on ADOS (see here) and ADI (see here) - was also of some interest. This is a man who seems to be looking very closely at the ADOS (and ADI).

The Fusaro paper is open-access so there is little point in me just repeating the results. A few aspects however caught my eye:

• The focus on "non-clinical raters" is interesting. Anyone who knows a little bit about the ADOS will know about the training required to administer it and indeed, CPD to maintain those all-important inter-rater reliability figures. The Fusaro results suggested that: "Raters were purposely given minimal instructions to code only when the video clearly depicted a behavior and/or contained opportunities for the child to exhibit the behavior in question, and otherwise to code the behavioral item as not applicable (N/A)". The mean rater agreement in the Fusaro paper is quoted at 73.3% "despite the diversity of environmental contexts represented in the videos". That's not bad at all given that a typical ADOS relies on specific cues and scenarios to score behaviours. 
• That being said: "Because two of the raters helped to locate videos appropriate for this study, they were not always naïve to the diagnoses". So, not everyone scoring the videos was completely in the dark about whether autism was mentioned or not when it came to some of the videos examined. Remember also that these videos were tagged with words pertinent to the presentation of autism meaning that parents or caregivers already potentially recognised some of the symptoms being displayed. Fair-dos to the authors though as they relied on a professionally-trained ADOS practitioner completely blinded to the suggestion of autism or not in videos to score a selection of videos and showing agreement "between each non-clinical and clinical rater [in] 71.3%".
• Raters only scored behaviours according to module 1 of the ADOS. Module 1 ADOS is normally reserved for those children who have little or no phrase speech. Given that children in the videos ranged in ages between 1 and 15 years and were only included for analysis if the video was under 10 minutes long, I'd be minded to say that we have to be a little bit careful when talking about accuracy of the results obtained.

That all being said, I don't want to take anything away from the Fusaro results and their conclusion: "it is possible for non-clinical raters to correctly detect the presence of autism with high inter-rater reliability and >94% accuracy". In these days of increasing pressures to recognise and diagnose autism as early as possible, anything that might potentially highlight children where further observations and assessments might be required should be welcomed. That also there is a rather large bank of undergraduate students around the world studying psychology or related degrees who might be able to provide a lay first-sweep assessment of children perhaps requiring more formal inquiry is an untapped resource that, at the very least, is worthy of more detailed research inspection.

And just in case you'd like some more discussion about this study, have a look here... complete with a response from the Dr Fusaro too.

Music y'say. Well, alrighty... Heart of Glass by Blondie.

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[1] Fusaro VA. et al. The Potential of Accelerating Early Detection of Autism through Content Analysis of YouTube Videos. PLoS ONE. 2014; 9: e93533.

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Fusaro, V., Daniels, J., Duda, M., DeLuca, T., D’Angelo, O., Tamburello, J., Maniscalco, J., & Wall, D. (2014). The Potential of Accelerating Early Detection of Autism through Content Analysis of YouTube Videos PLoS ONE, 9 (4) DOI: 10.1371/journal.pone.0093533