Facial emotion training as an intervention in autism spectrum disorder: A meta-analysis of randomized controlled trials

A Randomized Trial Utilizing EEG Brain Computer Interface to Improve Facial Emotion Recognition in Autistic Adults

PURPOSE

Many individuals with autism spectrum disorder (ASD) experience challenges with facial emotion recognition (FER), which may exacerbate social difficulties in ASD. Few studies have examined whether FER can be experimentally manipulated and improved for autistic people. This study utilized a randomized controlled trial design to examine acceptability and preliminary clinical impact of a novel mixed reality-based neurofeedback program, FER Assistant, using EEG brain computer interface (BCI)-assisted technology to improve FER for autistic adolescents and adults.

METHODS

Twenty-seven autistic male participants (M age: 21.12 years; M IQ: 105.78; 85% white) were randomized to the active condition to receive FER Assistant (n = 17) or waitlist control (n = 10). FER Assistant participants received ten sessions utilizing BCI-assisted neurofeedback training in FER. All participants, regardless of randomization, completed a computerized FER task at baseline and endpoint.

RESULTS

Results partially indicated that FER Assistant was acceptable to participants. Regression analyses demonstrated that participation in FER Assistant led to group differences in FER at endpoint, compared to a waitlist control. However, analyses examining reliable change in FER indicated no reliable improvement or decline for FER Assistant participants, whereas two waitlist participants demonstrated reliable decline.

CONCLUSION

Given the preliminary nature of this work, results collectively suggest that FER Assistant may be an acceptable intervention. Results also suggest that FER may be a potential mechanism that is amenable to intervention for autistic individuals, although additional trials using larger sample sizes are warranted.

Enhancing emotion recognition in young autistic children with or without attention-deficit/hyperactivity disorder in Hong Kong using a Chinese App version of The Transporters

TRIAL REGISTRATION

This study was registered with the German Clinical Trials Register - Deutschen Register Klinischer Studien (DRKS) on 23 December 2018. The Trial Registration Number (TRN) is DRKS00016506.

LAY ABSTRACT

The Transporters App is an intervention programme with 15 animated episodes that teach emotion recognition skills to autistic children between 4 and 6 years of age. Each episode contains a story depicting social interactions between characters in the form of a vehicle, with human faces grafted on to each of them. Each episode teaches a specific emotion in a story context. Autistic children watched at least three episodes at home for about 15 min daily for a month, with parental guidance. Its automated, home-based format is cost-saving and readily accessible. This study translated The Transporters to a Cantonese-Chinese version. Results showed a significant improvement in emotion recognition following viewing The Transporters in a group of Hong Kong Chinese autistic children, between 4 and 6 years of age, with and without attention-deficit/hyperactivity disorder (n = 48) relative to a control group (n = 24). A non-autistic group (n = 23) showed that the autistic children scored lower in emotion recognition pre-intervention. Post-intervention, the autistic children had improved in emotion recognition to the level of the non-autistic children. The autistic children in the intervention groups also generalized their learning to novel situations/characters not taught within The Transporters. There was no dosage effect, with the standard recommended number of episodes viewed being sufficient to achieve significant improvement. This study confirms the effectiveness of The Transporters for Chinese autistic children and contributes to the literature/practice by expanding the range of applicability of The Transporters to autistic children with attention-deficit/hyperactivity disorder, which is important given the high rate of co-occurrence between autism and attention-deficit/hyperactivity disorder.

Assessing the effectiveness of online emotion recognition training in healthy volunteers

Facial emotion recognition (ER) difficulties are associated with mental health and neurodevelopmental conditions, including autism and poorer social functioning. ER interventions may therefore have clinical potential. We investigated the efficacy of ER training (ERT). We conducted three online studies with healthy volunteers completing one ERT session. Studies 1 and 2 included active and control/sham training groups and tested the efficacy of (i) four-emotion ERT (angry, happy, sad and scared) (n = 101), and (ii) six-emotion ERT (adding disgusted and surprised) (n = 109). Study 3 tested generalizability of ERT to non-trained stimuli with groups trained and tested on the same stimuli, or different stimuli (n = 120). Training effects on total correct hits were estimated using linear mixed effects models. We did not observe clear evidence of improvement in study 1 but note the effect was in the direction of improvement (b = 0.02, 95% confidence interval (CI) = -0.02 to 0.07). Study 2 indicated greater total hits following training (b = 0.07, 95% CI = 0.03-0.12). Study 3 demonstrated similar improvement across groups (b = -0.01, 95% CI = -0.05 to 0.02). Our results indicate improved ER (as measured by our task), which generalizes to different facial stimulus sets. Future studies should further explore generalizability, longer-term effects and ERT in populations with known ER difficulties.

Social media interventions for autistic individuals: Systematic review

Background

Research on the use of digital technologies for delivering behavioral interventions has shown mixed evidence on their efficacy for improving both autistic symptoms and co-occurring psychiatric disorders. Little knowledge exists on the specific use or efficacy of using social media in interventions aimed at autistic individuals.

Objective

To review and describe the current existing evidence-based research on the use of social media in interventions aimed at autistic individuals.

Methods

A search was conducted across 8 databases (PubMed; EMBASE; Cochrane Library; PsycInfo; ERIC; Education Source; Web of Science; and IEEE Xplore). We included primary studies and reviews that dealt with autism spectrum disorder (ASD); described interventions that use social media; and reported results from the intervention. The quality of the evidence of the included primary studies was graded according to the GRADE criteria, and the risk of bias in systematic reviews was assessed by drawing on the AMSTAR guidelines. Results were synthesized and sorted by quality of evidence.

Results

A total of nine articles were included in this review: eight primary studies (five non-randomized interventions and three randomized interventions) and one systematic review. The total number of participants with an ASD-diagnosis in the included studies was 164 (aged 5 to 22 years old). Studies weighted as being of moderate quality of evidence have reported significant positive effects in the groups that received the social media interventions: increased social engagement and participation in life situations; increased physical activity level; increased improvement on occupational performance, specified goals, and behavioral problems; and decreased plaque scores coupled with parent reports of intervention success. None of the studies have reported any negative effects linked to social media interventions.

Conclusion

There is very little evidence of good quality on the use of social media in interventions aimed at autistic individuals. While there is a need for more high-quality studies, all the included studies, with one exception found positive results of the interventions. These findings are encouraging, suggesting that social media-based interventions may in fact be useful for supporting behavioral changes in autistic individuals.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=337185, identifier CRD42022337185.

Neural Mechanisms of Facial Emotion Recognition in Autism: Distinct Roles for Anterior Cingulate and dlPFC

OBJECTIVE

The present study sought to measure and internally validate neural markers of facial emotion recognition (FER) in adolescents and young adults with ASD to inform targeted intervention.

METHOD

We utilized fMRI to measure patterns of brain activity among individuals with ASD (N = 21) and matched controls (CON; N = 20) 2 s prior to judgments about the identity of six distinct facial emotions (happy, sad, angry, surprised, fearful, disgust).

RESULTS

Predictive modeling of fMRI data (support vector classification; SVC) identified mechanistic roles for brain regions that forecasted correct and incorrect identification of facial emotion as well as sources of errors over these decisions. BOLD signal activation in bilateral insula, anterior cingulate (ACC) and right dorsolateral prefrontal cortex (dlPFC) preceded accurate FER in both controls and ASD. Predictive modeling utilizing SVC confirmed the utility of ACC in forecasting correct decisions in controls but not ASD, and further indicated that a region within the right dlPFC was the source of a type 1 error signal in ASD (i.e. neural marker reflecting an impending correct judgment followed by an incorrect behavioral response) approximately two seconds prior to emotion judgments during fMRI.

CONCLUSIONS

ACC forecasted correct decisions only among control participants. Right dlPFC was the source of a false-positive signal immediately prior to an error about the nature of a facial emotion in adolescents and young adults with ASD, potentially consistent with prior work indicating that dlPFC may play a role in attention to and regulation of emotional experience.

Sex differences in automatic emotion regulation in adolescents with autism spectrum disorder

Autism may be underdiagnosed in females because their social difficulties are often less noticeable. This study explored sex differences in automatic facial emotion processing in 45 adolescents with autism spectrum disorder (22 female, 23 male), age 10-16 years, performing active target detection task and Go/NoGo tasks where faces with positive and negative emotional expressions served as irrelevant distractors. The combined sample demonstrated more accurate performance on the target detection (response initiation) than the Go/NoGo task (response inhibition), replicating findings previously reported in typical participants. Females exhibited greater difficulty than males with response initiation in the target detection task, especially in the context of angry faces, while males found withholding a response in the Go/NoGo block with happy faces more challenging. Electrophysiological data revealed no sex differences or emotion discrimination effects during the early perceptual processing of faces indexed by the occipitotemporal N170. Autistic males demonstrated increased frontal N2 and parietal P3 amplitudes compared to females, suggesting greater neural resource allocation to automatic emotion regulation processes. The associations between standardized behavioral measures (autism severity, theory of mind skills) and brain responses also varied by sex: more adaptive social functioning was related to the speed of perceptual processing (N170 latency) in females and the extent of deliberate attention allocation (P3 amplitudes) in males. Together, these findings suggest that males and females with autism may rely on different strategies for social functioning and highlight the importance of considering sex differences in autism. LAY SUMMARY: Females with autism may exhibit less noticeable social difficulties than males. This study demonstrates that autistic females are more successful than males at inhibiting behavioral responses in emotional contexts, while males are more likely to initiate a response. At the neural level, social functioning in females is related to the speed of automatic perceptual processing of facial cues, and in males, to the extent of active attention allocation to the stimuli. These findings highlight the importance of considering sex differences in autism diagnosis and treatment selection.

The structural neural correlates of atypical facial expression recognition in autism spectrum disorder

Previous studies have demonstrated that individuals with autism spectrum disorder (ASD) are worse at recognizing facial expressions than are typically developing (TD) individuals. The present study investigated the differences in structural neural correlates of emotion recognition between individuals with and without ASD using voxel-based morphometry (VBM). We acquired structural MRI data from 27 high-functioning adults with ASD and 27 age- and sex-matched TD individuals. The ability to recognize facial expressions was measured using a label-matching paradigm featuring six basic emotions (anger, disgust, fear, happiness, sadness, and surprise). The behavioural task did not find deficits of emotion recognition in ASD after controlling for intellectual ability. However, the VBM analysis for the region of interest showed a positive correlation between the averaged percent accuracy across six basic emotions and the grey matter volume of the right inferior frontal gyrus in TD individuals, but not in individuals with ASD. The VBM for the whole brain region under each emotion condition revealed a positive correlation between the percent accuracy for disgusted faces and the grey matter volume of the left dorsomedial prefrontal cortex in individuals with ASD, but not in TD individuals. The different pattern of correlations suggests that individuals with and without ASD use different processing mechanisms for recognizing others' facial expressions.

Therapeutic applications of transcutaneous auricular vagus nerve stimulation with potential for application in neurodevelopmental or other pediatric disorders

Non-invasive transcutaneous auricular vagus nerve stimulation (taVNS) as a newly developed technique involves stimulating the cutaneous receptive field formed by the auricular branch of the vagus nerve in the outer ear, with resulting activation of vagal connections to central and peripheral nervous systems. Increasing evidence indicates that maladaptive neural plasticity may underlie the pathology of several pediatric neurodevelopmental and psychiatric disorders, such as autism spectrum disorder, attention deficit hyperactivity disorder, disruptive behavioral disorder and stress-related disorder. Vagal stimulation may therefore provide a useful intervention for treating maladaptive neural plasticity. In the current review we summarize the current literature primarily on therapeutic use in adults and discuss the prospects of applying taVNS as a therapeutic intervention in specific pediatric neurodevelopmental and other psychiatric disorders. Furthermore, we also briefly discuss factors that would help optimize taVNS protocols in future clinical applications. We conclude from these initial findings that taVNS may be a promising alternative treatment for pediatric disorders which do not respond to other interventions.