Exploring the Components of Advanced Theory of Mind in Autism Spectrum Disorder

Executive function deficits in attention-deficit/hyperactivity disorder and autism spectrum disorder

Executive function deficits have been reported in both autism spectrum disorder (ASD) and attention-deficit/hyperactivity disorder (ADHD). However, little is known regarding which, if any, of these impairments are unique vs. shared in children with ADHD versus ASD. In this Review, we provide an overview of the current literature with a critical eye toward diagnostic, measurement, and third-variable considerations that should be leveraged to provide more definitive answers. We conclude that the field's understanding of ASD and ADHD executive function profiles is highly limited because most research on one disorder has failed to account for their co-occurrence and the presence of symptoms of the other disorder; a vast majority of studies have relied on traditional neuropsychological tests and/or informant-rated executive function scales that have poor specificity and construct validity; and most studies have been unable to account for the well-documented between-person heterogeneity within and across disorders. Currently, the most parsimonious conclusion is that children with ADHD and/or ASD tend to perform moderately worse than neurotypical children on a broad range of neuropsychological tests. However, the extent to which these difficulties are unique vs. shared, or attributable to impairments in specific executive functions subcomponents, remains largely unknown. We end with focused recommendations for future research that we believe will advance this important line of inquiry.

Complex ADHD Challenging Case: When Simple Becomes Complex: Managing Clinician Bias and Navigating Challenging Family Dynamics in a 6-Year-Old Girl with ADHD and Developmental Delays

CASE

Layla is a 6.7-year-old girl diagnosed with attention-deficit/hyperactivity disorder (ADHD)-predominantly hyperactive/impulsive type-delayed adaptive skills, enuresis, unspecified malnutrition, and feeding difficulties. She presented to developmental-behavioral pediatrics (DBP) in January 2022 due to caregiver concerns for autism spectrum disorder (ASD).Layla lives in a polyamorous family with her biological mother and father, mother's partner whom Layla refers to as her uncle, and her 2 half-siblings. There is a maternal history of special education services, schizoaffective disorder, bipolar disorder, multiple sclerosis, Wolff-Parkinson-White syndrome, and ADHD. Layla's father is a veteran diagnosed with post-traumatic stress disorder. Layla's siblings, aged 5 and 9 years, have established diagnoses of ADHD, ASD, global developmental delays, behavioral concerns, and poor sleep. There is a history of adverse childhood experiences, including parental mental health, poverty, and involvement with child protective services. Acknowledgement and inclusion of all members of this diverse family structure, as well as consistent validation from the DBP and social worker, allowed a strong treatment alliance to form and the mother continued to contact the DBP clinic, even for those questions related to other specialties. A social worker received weekly calls from the mother sharing grievances related to feeling misunderstood and spoke about the assumptions she felt external providers made about her family, culture, and parenting styles. For example, she recalls the pediatrician commenting about their family structure being "confusing for the children" and describing their home as "chaotic," assumptions that may not have been made of nuclear family structures. Behavioral therapies were a repeated recommendation, but the mother verbalized not being interested in these options as she had participated in parent management training several years earlier and felt that the strategies taught were not applicable to her unique family structure, to which the clinician replied, "this is the standard recommendation for all children this age with disruptive behaviors." Although the mother was initially hesitant to trial medications, she eventually agreed that Layla's symptoms were negatively affecting her school performance, and the DBP initiated a stimulant medication.Layla's initial evaluation included a developmental history, behavioral observations, and standardized testing. The results from developmental testing demonstrated age equivalents between 4 and 6 years across gross motor, adaptive, visual motor, and speech-language domains.On observation, Layla was extremely active. During the visit, she walked over to her mother, made eye contact, and showed her the picture that she had drawn. She engaged in imaginary play, reciprocal conversation, and responded to social bids. The mother felt strongly that Layla had ASD and reported symptoms such as motor stereotypies (hand flapping), covering ears with certain noises/sounds, and rigidity when it came to things being a certain way or a certain color. These behaviors did not occur in the initial or subsequent clinic visits with DBP, her general pediatrician, or during other outside evaluations the mother pursued. The DBP felt strongly that Layla was mimicking her siblings' symptoms and provided ongoing education regarding ADHD symptomology.In terms of behavior management, the mother did not attempt to redirect Layla's behaviors during the initial clinic visit and in subsequent visits, and both adult men yelled loudly, clapped, and hit their hands on the table as a form of redirection. The mother continued to voice her diagnostic disagreement with the DBP and the pediatrician and insisted that Layla met the criteria for ASD. When the mother reviewed the report, a statement insinuating that Layla's behaviors were "understandable given parental inconsistency and complicated family structure" upset her.What factors would you consider when thinking about caregiver disagreement with the diagnosis and treatment plan? Does diagnostic overshadowing apply here?

Examining whether adults with autism spectrum disorder encounter multiple problems in theory of mind: a study based on meta-analysis

Theory of mind (ToM) represents a complex ability, while persons with autism spectrum disorder (ASD) encounter difficulties in the processing of ToM. The present ToM-focused studies on adults with ASD report inconsistent results, possibly owing to the differences between tasks. For instance, different ToM-related tasks involve different cognitive abilities, but the development of these cognitive abilities is different among adults with ASD, thereby leading to different behaviors by the same individual with ASD in different tasks. Therefore, it is of vital significance to explore the potential reasons for inconsistencies in the existing studies based on the task classification perspective. Hence, this study primarily reviews the existing ToM tasks used in studies on adults with ASD; afterward, based on the forms and characteristics of the task, the current ToM tasks are classified into four categories-reading comprehension, perceptual scene comprehension, comprehensive scene comprehension , and self-other processing. Subsequently, a meta-analysis is undertaken to determine the difference in each ToM task category between the ASD group and the typically developing (TD) group. As a result, 110 research papers (including 3,205 adults with ASD and 3,675 TD adults) that fulfilled the stated criteria are examined in this study. The study findings suggest that adults with ASD demonstrate worse performance in terms of all four ToM task categories as compared to TD adults. Furthermore, compared with tasks of self-other processing and perceptual scene comprehension, adults with ASD perform worse in reading comprehension and comprehensive scene comprehension. This shows that the differences between tasks may exert a potential influence on the study results. Future studies should focus on different abilities involved in ToM processing and the choice of ToM tasks, in order to elucidate the critical problems of ToM in adults with ASD.

Relationships between Affect Recognition, Empathy, Alexithymia, and Co-Occurring Conditions in Autism

Prior studies show differences in empathy and affect-recognition ability between those with autism spectrum disorder (ASD) and typically developing (TD) individuals. Autistic individuals also exhibit increased behavioral, gastrointestinal, and sleep issues. In the current study, we explored the differences in empathy and affect recognition between the ASD and TD groups; and we investigated their associations with conditions co-occurring in ASD. A total of 54 TD and 56 ASD children (8-17 years) were included. As compared to the TD group, the ASD group showed lower scores for affect recognition and perspective taking (PT) and higher scores for personal distress (PD). Interestingly, results from hierarchical linear regressions suggested that disparities in the PD and PT between the groups were primarily attributable to attenuated levels of alexithymia, rather than being mediated by the presence of an autism diagnosis. Differences in affect-recognition ability, however, were mediated by both an autism diagnosis and alexithymia. We also found significant correlations between empathy and affect recognition and measures of related conditions common in ASD. Alexithymia, hence, contributes to difficulties in empathy while both alexithymia and autism are associated with affect-recognition ability in ASD. Additionally, the association between affect recognition and empathic ability with co-occurring conditions in ASD needs to be considered during assessments and interventions.

Mentalizing and narrative coherence in autistic adults: Cerebellar sequencing and prediction

BYLEMANS, T., et al. Mentalizing and narrative coherence in autistic adults: Cerebellar sequencing and prediction. NEUROSCI BIOBEHAV REV, 2022. - This review focuses on autistic adults and serves 4 purposes: (1) providing an overview of their difficulties regarding mentalizing (understanding others' mental states) and narrative coherence (structured storytelling), (2) highlighting the relations between both skills by examining behavioral observations and shared neural substrates, (3) providing an integrated perspective regarding novel diagnostic tools and support services, and (4) raising awareness of adult autism. We suggest that mentalizing and narrative coherence are related at the behavioral level and neural level. In addition to the traditional mentalizing network, the cerebellum probably serves as an important hub in shared cerebral networks implicated in mentalizing and narrative coherence. Future autism research and support services should tackle new questions within a framework of social cerebellar (dys)functioning.

Identify aberrant white matter microstructure in ASD, ADHD and other neurodevelopmental disorders: A meta-analysis of diffusion tensor imaging studies

BACKGROUND

Neurodevelopmental disorders (NDDs) usually present overlapping symptoms. Abnormal white matter (WM) microstructure has been found in these disorders. Identification of common and unique neural abnormalities across NDDs could provide further insight into the underlying pathophysiological mechanisms.

METHODS

We performed a voxel-based meta-analysis of whole-brain diffusion tensor imaging (DTI) studies in autism spectrum disorder (ASD), attention-deficit/hyperactivity disorder (ADHD) and other NDDs. A systematic literature search was conducted through March 2020 to identify studies that compared measures of WM microstructure between patients with NDDs and neurotypical controls. Peak voxel coordinates were meta-analyzed via anisotropic effect size-signed differential mapping (AES-SDM) as well as activation likelihood estimation (ALE).

RESULTS

Our final sample included a total of 4137 subjects from 66 studies across five NDDs. Fractional anisotropy (FA) reductions were found in the splenium of the CC in ADHD, and the genu and splenium of CC in ASD. And mean diffusivity (MD) increases were shown in posterior thalamic radiation in ASD. No consistent abnormalities were detected in specific learning disorder, motor disorder or communication disorder. Significant differences between child/adolescent and adult patients were found within the CC across NDDs, reflective of aberrant neurodevelopmental processes in NDDs.

CONCLUSIONS

The current study demonstrated atypical WM patterns in ASD, ADHD and other NDDs. Microstructural abnormalities in the splenium of the CC were possibly shared among ASD and ADHD.

Exploring social emotion processing in autism: evaluating the reading the mind in the eyes test using network analysis

BACKGROUND

Features of autism spectrum disorder (ASD) include difficulties in processing and interpreting socioemotional information. The "Reading the Mind in the Eyes" test (RMET) is a validated measurement for processing socioemotional ability. However, previous RMET studies did not explore patterns of incorrect answers and the emotional valence of the test items. This study used the Taiwanese version of the RMET and the network analysis methods to examine the differences in underlying mechanisms of socioemotional processes between 30 males with autism spectrum disorder (ASD) (mean age = 18 years) and 30 healthy control males (mean age = 17 years). For each test item, a picture of a person's eyes and partial face was shown with four words describing the emotional status on picture corners. Participants were instructed to choose one of the four words that best matched the person's thinking or feeling. We further classified the words into three valences of emotional categories to examine socioemotional processes.

RESULTS

Our results showed that ASD males performed poorer on the RMET than the controls. ASD males had higher network density and in-degree scores, especially in negative words, than control males.

CONCLUSIONS

The findings suggest that males with ASD might have deficits in mapping the best emotional concept words to the target item, especially for processing negative emotion.

Assessment of theory of mind in Tunisian verbal children with autism spectrum disorder

The present study examined performance in Theory of Mind (ToM) in a group of 31 Arabic-speaking verbal children (7-12 years-old) with autism spectrum disorder (ASD), in comparison with neurotypical controls (NT) matched for age and for cognitive abilities. An innovative task in a digital format named "The Tunisian Social Situations Instrument" (TSSI) was used and allowed us to study four different subdomains of ToM: attribution of intention and epistemic ToM (cognitive ToM), affective ToM, and detection of faux pas (advanced ToM). Our study showed impairments in ToM in children with ASD, similar to those reported in the literature. Our findings additionally suggested that affective and advanced ToM, specifically the detection of faux pas, might be more challenging for ASD children than other components of ToM. Future studies with larger number of children may lead us to specify which subdomains are the most impaired in order to develop specific tools targeting these specific impairments.

Neural-level associations of non-verbal pragmatic comprehension in young Finnish autistic adults

This video-based study examines the pragmatic non-verbal comprehension skills and corresponding neural-level findings in young Finnish autistic adults, and controls. Items from the Assessment Battery of Communication (ABaCo) were chosen to evaluate the comprehension of non-verbal communication. Inter-subject correlation (ISC) analysis of the functional magnetic resonance imaging data was used to reveal the synchrony of brain activation across participants during the viewing of pragmatically complex scenes of ABaCo videos. The results showed a significant difference between the ISC maps of the autistic and control groups in tasks involving the comprehension of non-verbal communication, thereby revealing several brain regions where correlation of brain activity was greater within the control group. The results suggest a possible weaker modulation of brain states in response to the pragmatic non-verbal communicative situations in autistic participants. Although there was no difference between the groups in behavioural responses to ABaCo items, there was more variability in the accuracy of the responses in the autistic group. Furthermore, mean answering and reaction times correlated with the severity of autistic traits. The results indicate that even if young autistic adults may have learned to use compensatory resources in their communicative-pragmatic comprehension, pragmatic processing in naturalistic situations still requires additional effort.

Altruistic helping in young children with ASD: A preliminary study

It has long been claimed that individuals with an autism spectrum disorder (ASD) show impaired prosocial behavior, however there is little direct evidence in support of this claim and inconsistencies have been reported in the literature. Therefore, the goal of this study was to compare the levels of altruistic behavior in 15 young children with an ASD and 14 children with Down syndrome, paired in chronological age (age range between 2 years and 8 months and 6 years and 2 months) and non-verbal intellectual ability. Our results showed that children with an ASD engaged less frequently in altruistic behavior compared to the DS group. In addition, we found a significant negative correlation between the severity of autism symptoms and altruistic behavior in the ASD group, suggesting that the more severe the symptoms of ASD, the less frequent the altruistic behaviors. Conversely, no significant correlations were found between non-verbal IQ level and performance in the altruistic behavior tasks, in either group. Overall, our results suggest that, regardless of intellectual skills, the ability to engage in altruistic behavior is compromised in young children with ASD.

Autism and Hidden Imagination: Raising and Educating Children Who Cannot Express Their Minds

This is a reflection on an article written in 2007, entitled Autism and the Artistic Imagination: The Link between Visual Thinking and Intelligence. The author is a parent of a 6-year-old with autism who is now 19 and is non-verbal who has trouble expressing his thoughts, feelings and desires, and discusses some theories behind autism spectrum communication disorders and seeks to understand why there is so much difficulty with communication with some on the spectrum. The 2007 article employed Howard Gardner’s Multiple Intelligence Theory as a framework to discuss the visual and spatial learning abilities of kids with autism, and this update posits that the nonspeaking population of the autism community do indeed have different ways of understanding the world, theories of mind and awareness enough to be able to communicate if only the proper links and opportunities are provided. The lack of communication is not due to a lack of a sense of self, but of a lack of understanding of the neuro-typical community that people with autism are speaking a second language, and need help with the translation.

Examining the relationship between measures of autistic traits and neural synchrony during movies in children with and without autism

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Neural synchrony during movie watching was measured in children with and without ASD.

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The ASD group had significantly less neural synchrony across the whole brain.

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The ASD group also had significantly less synchrony in the theory of mind network.

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Autistic traits did not predict neural synchrony in non-ASD children.

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These results suggest children with ASD process movies in a unique way.

Children who have been diagnosed with autism spectrum disorder (ASD) often show a marked deficit in measures of social cognition. In autistic adults, measures of social cognition have been shown to relate to differences in brain synchronization (as measured by fMRI) when individuals are processing naturalistic stimuli, such as movies. However, whether children who differ in their degree of autistic traits, with or without a diagnosis of ASD, differ in their neural responses to movies has not yet been investigated. In the current study, neural synchrony, measured using fMRI, was examined in three groups of children aged 7 to 12, who differed with respect to scores on a measure of autistic traits associated with social impairment and whether or not they had been diagnosed with ASD. While watching the movie ‘Despicable Me’, those diagnosed with ASD had significantly less neural synchrony in areas that have been previously shown to be associated with social cognition (e.g. areas related to ‘theory of mind’), and plot following (e.g. the lateral prefrontal cortex), than those who did not have an ASD diagnosis. In contrast, two groups who differed in their degree of autistic traits, but did not have a diagnosis of ASD, showed no significant differences in neural synchrony across the whole brain. These results shed some light on how autistic traits may contribute to an individual’s conscious experience of the world, and how, for children with ASD, that experience may differ markedly from that of those without ASD.

Cognitive and Affective Aspects of Theory of Mind in Greek-Speaking Children with Autism Spectrum Disorders

Substantial research indicates that individuals with Autism Spectrum Disorder (ASD) have difficulties with Theory of Mind (ToM) abilities, but rarely have studies used a comprehensive battery to measure both the cognitive and affective aspects of ToM. The present study tested this ability in 24 Greek-speaking children with ASD (ages 7-14), and their performance was compared to 24 age-, gender- and language-matched typically developing controls. Results showed that ASD children's performance was selectively impaired in both ToM aspects, supporting the distinction between ToM components. This is the first study of ToM abilities among Greek-speaking children with ASD, and the findings confirm that children with ASD are experiencing difficulties with socio-emotional understanding across languages and cultures.

Prediction of social behavior in autism spectrum disorders: Explicit versus implicit social cognition

LAY ABSTRACT

Difficulties with social communication and interaction are a hallmark feature of autism spectrum disorder. These difficulties may be the result of problems with explicit social cognition (effortful and largely conscious processes) such as learning and recalling social norms or rules. Alternatively, social deficits may stem from problems with implicit social cognition (rapid and largely unconscious processes) such as the efficient integration of social information. The goal of this study was to determine how problems in explicit and implicit social cognition relate to social behavior in 34 youth with autism spectrum disorder. We measured aspects of implicit and explicit social cognition abilities in the laboratory using behavioral, cognitive, and brain (electrophysiological) measures. We then used those measures to predict "real-world" social behavior as reported by parents, clinicians, and independent observers. Results showed that overall better aspects of implicit and explicit social cognition predicted more competent social behavior. In addition, the ability to fluidly integrate social information (implicit social cognition) was more frequently related to competent social behavior that merely knowing what to do in social situations (explicit social cognition). These findings may help with the development of interventions focusing on improving social deficits.

La comprensión de las meteduras de pata en escolares con autismo. Su relación con variables cognitivas y de teoría de la mente

El presente estudio tiene una doble finalidad. La primera es analizar dos de las variables implicadas en la comprensión de las meteduras de pata (MP) en el autismo (Cociente Intelectual; CI, y la Falsa Creencia; FC). La segunda, examinar en detalle las dificultades encontradas en la tarea de MP, dividida la población con autismo en dos grupos según su CI (Grupo 1= rango CI 100-120, Grupo 2 = rango CI 70-85). De dicha tarea de MP, se adaptaron cuatro historias (viñetas y narración) de Baron-Cohen, O’Riordan, Stone, Jones y Plaisted (1999), y se administraron a los dos grupos de niños y pre-adolescente con autismo (N = 34) de entre 7 y 12 años (M = 9.6, DE = 1.55), que las resolvieron a partir de respuestas de elección dicotómica y de explicación verbal. Los resultados demuestran la capacidad predictiva del CI total (r = 0.53; p < 0.001; R2 = 0.28) y de la FC (r = 0.51; p < 0.001; R2 = 0.26). El 40 % de la variabilidad de la tarea de MP se vio explicada por las variables predictores FC y Vocabulario. Además, se encontraron diferencias significativas entre grupos (el Grupo 1 respondió mejor que el Grupo 2) tanto en respuestas de elección forzada personaje (ii) e ignorancia (vii) y la suma total como en su explicación verbal. Estos resultados se discuten más detalladamente debido a su posible repercusión en la vida diaria de las personas con autismo.

Theory of Mind Performance in Broad Autism Phenotype Groups: Between-Group Differences and Predictor Variables

Investigated between-group differences in cognitive/affective theory of mind (ToM) and predictors of cognitive ToM both within broad autism phenotype/non (BAP/Non-BAP) groups as well as across the sample. The BAP group (n = 45) performed worse than the Non-BAP group (n = 102) on the unexpected outcomes test (UOT), but groups were similar regarding reading the mind in the eyes test (RMET). Stepwise regression indicated RMET best predicted UOT for the BAP group; block design best predicted UOT in the Non-BAP group. BAP traits did not mediate the relation of RMET to UOT performance. While RMET and UOT appear similarly related in BAP/Non-BAP samples, use of emotion recognition abilities in a cognitive ToM task may reflect over-reliance on this skill in the BAP.

Autism and Faux Pas. Influences of Presentation Modality and Working Memory

People diagnosed with an autism spectrum disorder (ASD) often have difficulties on Theory of Mind (ToM) tasks involving social situations, such as 'faux pas'. The objective of this study was to find the modality of presentation (visual, verbal, or mixed) that yields the best understanding of a 'faux pas', and the possible influence of other variables, including intelligence (IQ), age, and working memory. Thirty autistic children and 30 neurotypical children, all aged 7 to 12 years old and comparable in age and IQ, participated in this study. They were asked to resolve nine 'faux pas' stories (three per modality). Significant between-groups differences were found in the visual (t = 2.99, p = .004) and verbal modalities (t = 2.64, p = .011), such that the neurotypical (NT) group had higher scores than the ASD group. The ASD group's comprehension was better via the mixed modality than the verbal modality (t = 2.48, p = .019). In addition, working memory had a bigger impact on Faux Pas understanding in cases of autism than in typical development (R2 explained between .19 and .28 of variance in Faux Pas test outcomes), and could therefore explain some of the difficulties previously reported in this area. Future research should include a measure of working memory and a control among the stimuli presented to test for group differences in faux pas understanding.

Autism Spectrum Disorders and ADHD: Overlapping Phenomenology, Diagnostic Issues, and Treatment Considerations

PURPOSE OF REVIEW

Autism spectrum disorder (ASD) and attention deficit/hyperactivity disorder (ADHD) are both increasing in prevalence and commonly co-occur with each other. The goal of this review is to outline what has been published recently on the topics of ASD, ADHD, and the comorbid state (ASD+ADHD) with a particular focus on shared phenomenology, differential diagnosis, and treatment considerations.

RECENT FINDINGS

ASD and ADHD have shared genetic heritability and are both associated with shared impairments in social functioning and executive functioning. Quantitative and qualitative differences exist, however, in the phenotypic presentations of the impairments which characterize ASD and ADHD. For ASD interventions to be maximally efficacious, comorbid ADHD needs to be considered (and vice versa). The research on ASD and ADHD suggests some overlap between the two disorders yet enough differences to indicate that these conditions are sufficiently distinct to warrant separate diagnostic categories.

Social functioning in youth with attention-deficit/hyperactivity disorder and autism spectrum disorder: transdiagnostic commonalities and differences

Attention-Deficit/Hyperactivity Disorder (ADHD) and Autism Spectrum Disorder (ASD) are both neurodevelopmental disorders originating in childhood with high associated impairments and public health significance. There has been growing recognition of the frequent co-occurrence, and potential interrelatedness, between ADHD and ASD without intellectual disability. In fact, the most recent (5th) edition of the DSM is the first to allow ADHD and ASD to be diagnosed in the same individual. The study of transdiagnostic features in ADHD and ASD is important for understanding, and treating, these commonly co-occurring disorders. Social impairment is central to the description and prognosis of both disorders, and many youth with some combination of ADHD and ASD present to clinics for social skills training interventions. However, the aspects of social functioning that are impaired may have both shared and distinct features between the two disorders, relating to some overlapping and some diverse etiologies of social problems in ADHD compared to ASD. These findings have implications for interventions to address social problems in youth with these conditions. We conclude with a discussion about areas for future research and novel intervention targets in youth with ADHD, ASD, and their comorbidity.

Diseño de un software para estimulación del componente socio-emocional en niños con trastorno del espectro autista

Los trastornos del espectro autista se caracterizan por la presencia de limitaciones en la reciprocidad emocional e interacción social. En esta investigación se diseñó y validó por contenido un software para la estimulación de habilidades de comprensión emocional y social en niños con trastorno del espectro autista de alto nivel de funcionamiento. El software está conformado por tres dimensiones: reconocimiento emocional, comprensión emocional y comprensión de creencias; cada dimensión cuenta con niveles de complejidad baja, media y alta. La investigación se desarrolló bajo un diseño instrumental de corte psicométrico donde las unidades de análisis fueron las actividades validadas por 9 jueces, 8 de ellos expertos en neuropsicología e intervención en autismo y un juez experto en ingeniería y desarrollo de software. Los datos fueron analizados mediante la fórmula de coeficiente de razón de validez de contenido y los resultados muestran que se valida sin modificaciones el 99.06% de los ítems; el 0.4% de los ítems se conservan con modificaciones. Se concluye  que el software cuenta con un contenido válido para la estimulación del componente social y emocional en niños con trastorno del espectro autista de alto funcionamiento.