Exploring the cognitive, emotional and sensory correlates of social anxiety in autistic and neurotypical adolescents

BACKGROUND

Social anxiety is common in autistic adolescents. While emerging evidence indicates the importance of several mechanisms (including intolerance of uncertainty (IU), alexithymia and sensory processing) for maintaining anxiety, limited research has explored how these factors are associated with social anxiety in autistic adolescents.

METHODS

We investigated whether IU, emotional and sensory processing are related to social anxiety in autistic and neurotypical adolescents, gathering experimental and questionnaire data from 61 autistic and 62 neurotypical 11- to 17-year-olds recruited to have similarly high levels of anxiety.

RESULTS

In autistic and neurotypical adolescents matched for social anxiety, similar significant associations were observed between social anxiety and IU, alexithymia, maladaptive emotion regulation, sensory hypersensitivity and interoceptive sensibility. Taking a dimensional approach, we found that child- and parent-reported IU, alexithymia and sensory hypersensitivity mediated the relationship between autistic traits and social anxiety symptoms in the combined group of adolescents.

CONCLUSIONS

Our findings indicate that similar correlates of social anxiety are evident in autistic and neurotypical youths experiencing social anxiety and further our understanding of mechanisms that may contribute towards social anxiety in both groups.

Social competence in newly diagnosed pediatric brain tumor patients

Brain tumors (BTs) are a common pediatric malignancy. Improved treatment has resulted in higher survival rates. There is, however, increasing concern about adverse effects of the disease and its treatment, including effects on social competence (i.e. effective social functioning in everyday life). The aim of this study is to examine multiple levels of social competence (i.e. social skills and social adjustment) in newly diagnosed pediatric BT patients. Thirty newly diagnosed BT patients aged 5-12 years were assessed shortly after diagnosis with a neuropsychological test battery focusing on social competence, including tests for IQ, social skills (i.e. social-affective and executive functioning) and social adjustment (rated by parents and teachers). Their performance was compared to 95 healthy controls who completed the same assessment. Patients and healthy controls were largely comparable with regard to demographic and environmental factors and did not differ on measures of IQ, social skills and social adjustment. Furthermore, age was found to have a positive significant effect on social skills independent of group. Shortly after diagnosis, pediatric BT patients did not perform different from healthy controls on IQ and measures of social skills and social adjustment. This is an encouraging finding. However, because of potentially neurotoxic adjuvant therapy and the ongoing development of social skills, longitudinal follow-up studies are needed to investigate long-term outcome regarding social competence in BT survivors.

Theory of mind as a predictor of maternal sensitivity in women with severe mental illness

BACKGROUND

Research has shown that maternal mental illness can affect mother-infant interactions with implications for infant outcomes. Severe and chronic mental illness (SMI), particularly schizophrenia, is associated with the greatest risk. Schizophrenia is also associated with impairments in attribution of mental states, 'theory of mind' (ToM). Recent attachment research has suggested that maternal mentalizing skills are strongly associated with attachment outcome in infants. To date, no research has explored the relationship between ToM and maternal sensitivity in mothers with SMI using standard tests of ToM. The present study was designed as an exploratory study in order to investigate this.

METHOD

A total of 40 women with SMI in the postpartum period were administered a battery of ToM tasks and general neuropsychological tasks. The women were also filmed in an unstructured play session with their infants, which was coded for maternal sensitivity using the Crittenden CARE-Index.

RESULTS

One ToM task, the Frith-Happé Animations, predicted maternal sensitivity across all diagnoses. There was also an effect of diagnosis, with lower sensitivity observed in women with schizophrenia. ToM impairments did not fully explain the effect of diagnosis on sensitivity. Mothers of girls were rated as being more sensitive than mothers of boys.

CONCLUSIONS

The results suggest that ToM is a significant predictor of maternal sensitivity across all mental health diagnoses, extending the results of studies focusing on healthy populations. Clinical interventions emphasizing the importance of understanding the perspective of the infant may enhance maternal sensitivity.

Developmental associations between traits of autism spectrum disorder and attention deficit hyperactivity disorder: a genetically informative, longitudinal twin study

BACKGROUND

Autism spectrum disorder (ASD) and attention deficit hyperactivity disorder (ADHD), and associated subclinical traits, regularly co-occur with one another. However, the aetiology of their co-occurrence remains poorly understood. This paper provides the first genetically informative, longitudinal analysis of the interaction between traits of ASD and ADHD, and explores their genetic and environmental overlap.

METHOD

Parents of approximately 5000 twin pairs completed questionnaires assessing traits of ASD and ADHD when twins were aged 8 and 12 years. Cross-lagged longitudinal modelling explored their developmental association, enabling a consideration of phenotypic-driven processes. Overlapping aetiological influences on traits at age 12 years were explored using bivariate twin modelling.

RESULTS

Traits of ADHD at age 8 years were more strongly predictive of traits of ASD at 12 years than traits of ASD at 8 years were of traits of ADHD at 12 years. Analysis of traits by subscales assessing specific symptom domains suggested that communication difficulties were most strongly associated with traits of ADHD. Bivariate modelling suggested moderate genetic overlap on traits in males (genetic correlation = 0.41), and a modest degree of overlap in females (genetic correlation = 0.23) at age 12 years.

CONCLUSIONS

Traits of ADHD at age 8 years significantly influence traits of ASD at age 12 years, after controlling for their initial relationship at age 8 years. In particular, early ADHD traits influenced later communication difficulties. These findings demonstrate the dynamic nature of co-occurring traits across development. In addition, these findings add to a growing body of literature suggesting that traits of ASD and ADHD may arise via similar aetiological processes.

Defining the cognitive phenotype of autism

Although much progress has been made in determining the cognitive profile of strengths and weaknesses that characterise individuals with autism spectrum disorders (ASDs), there remain a number of outstanding questions. These include how universal strengths and deficits are; whether cognitive subgroups exist; and how cognition is associated with core autistic behaviours, as well as associated psychopathology. Several methodological factors have contributed to these limitations in our knowledge, including: small sample sizes, a focus on single domains of cognition, and an absence of comprehensive behavioural phenotypic information. To attempt to overcome some of these limitations, we assessed a wide range of cognitive domains in a large sample (N=100) of 14- to 16-year-old adolescents with ASDs who had been rigorously behaviourally characterised. In this review, we will use examples of some initial findings in the domains of perceptual processing, emotion processing and memory, both to outline different approaches we have taken to data analysis and to highlight the considerable challenges to better defining the cognitive phenotype(s) of ASDs. Enhanced knowledge of the cognitive phenotype may contribute to our understanding of the complex links between genes, brain and behaviour, as well as inform approaches to remediation.

Association between extreme autistic traits and intellectual disability: insights from a general population twin study

BACKGROUND

Autism is associated with intellectual disability. The strength and origin of this association is unclear.

AIMS

To investigate the association between extreme autistic traits and intellectual disability in children from a community-based sample and to examine whether the association can be explained by genetic factors.

METHOD

Children scoring in the extreme 5% on measures of autistic traits, IQ and academic achievement were selected from 7965 7/8-year-old and 3687 9-year-old twin pairs. Phenotypic associations between extreme autistic traits and intellectual disability were compared with associations among the full-range scores. Genetic correlations were estimated using bivariate DeFries-Fulker extremes analyses.

RESULTS

Extreme autistic traits were modestly related to intellectual disability; this association was driven by communication problems characteristic of autism. Although this association was largely explained by genetic factors, the genetic correlation between autistic traits and intellectual disability was only modest.

CONCLUSIONS

Extreme autistic traits are substantially genetically independent of intellectual disability.

Inferring thought and action in motor neurone disease

The traditional assumption that classical motor neurone disease (MND) invariably spares cognitive function is now recognised to be incorrect. Deficits have most commonly been demonstrated on executive tasks suggesting impaired function of frontal systems. Yet, crucial aspects of frontal lobe function have not hitherto been explored. The study used tests of theory of mind (ToM) (interpretation of cartoons and stories) to examine the ability of 16 patients with MND to interpret social situations and ascribe mental states to others. Only minor differences were elicited in the MND group as a whole compared to controls, and performance was not differentially affected for cartoons and stories requiring inference of another's mental state (mental) compared to control (physical) cartoons and stories. However, abnormalities were elicited on both mental and physical tasks in a subgroup of patients with bulbar signs. Moreover, examination of individual patient scores revealed a spectrum of performance ranging from normal to severely impaired. Errors were qualitatively similar to those seen in frontotemporal dementia (FTD). Performance on the ToM tasks was significantly correlated with conventional, untimed measures of executive function, suggesting that ToM deficits in MND are likely to be linked to a more general executive failure. The findings contribute to the understanding of ToM performance in neurodegenerative disease and provide further evidence of the association between MND and FTD.

Social cognition in frontotemporal dementia and Huntington's disease

Frontotemporal dementia (FTD) and Huntington's disease (HD) are degenerative disorders, with predominant involvement, respectively of frontal neocortex and striatum. Both conditions give rise to altered social conduct and breakdown in interpersonal relationships, although the factors underlying these changes remain poorly defined. The study used tests of theory of mind (interpretation of cartoons and stories and judgement of preference based on eye gaze) to explore the ability of patients with FTD and HD to interpret social situations and ascribe mental states to others. Performance in the FTD group was severely impaired on all tasks, regardless of whether the test condition required attribution of a mental state. The HD group showed a milder impairment in cartoon and story interpretation, and normal preference judgements. Qualitative differences in performance were demonstrated between groups. FTD patients made more concrete, literal interpretations, whereas HD patients were more likely to misconstrue situations. The findings are interpreted as demonstrating impaired theory of mind in FTD, as one component of widespread executive deficits. In HD the evidence does not suggest a fundamental loss of theory of mind, but rather a tendency to draw faulty inferences from social situations. It is concluded that social breakdown in FTD and HD may have a different underlying basis and that the frontal neocortex and striatum have distinct contributions to social behaviour.

Mind reading: neural mechanisms of theory of mind and self-perspective

Human self-consciousness as the metarepresentation of ones own mental states and the so-called theory of mind (TOM) capacity, which requires the ability to model the mental states of others, are closely related higher cognitive functions. We address here the issue of whether taking the self-perspective (SELF) or modeling the mind of someone else (TOM) employ the same or differential neural mechanisms. A TOM paradigm was used and extended to include stimulus material that involved TOM and SELF capacities in a two-way factorial design. A behavioral study in 42 healthy volunteers showed that TOM and SELF induced differential states of mind: subjects assigned correctly first or third person pronouns when providing responses to the stimuli. Following the behavioral study, we used functional magnetic resonance imaging (fMRI) in eight healthy, right-handed males to study the common and differential neural mechanisms underlying TOM and SELF. The main factor TOM led to increased neural activity in the anterior cingulate cortex and left temporopolar cortex. The main factor SELF led to increased neural activity in the right temporoparietal junction and in the anterior cingulate cortex. A significant interaction of both factors TOM and SELF was observed in the right prefrontal cortex. These divergent neural activations in response to TOM and SELF suggest that these important differential mental capacities of human self-consciousness are implemented at least in part in distinct brain regions. Press

Acquired mind-blindness following frontal lobe surgery? A single case study of impaired 'theory of mind' in a patient treated with stereotactic anterior capsulotomy

Social insight, specifically the ability to represent thoughts and feelings ('theory of mind'), may have a circumscribed and dedicated neurological substrate. Evidence of deficits in 'theory of mind' following acquired lesions would support this idea. Previous studies of lesions resulting from stroke or head injury have been hampered by lack of detailed lesion information and pre-lesion documentation. We report the case of a 76-year-old man who, following a standard surgical procedure to treat bipolar affective disorder, showed evidence of impaired 'theory of mind'. This case, which is the first of its type, may contribute to the search for the brain basis of social insight.

Exploring the cognitive phenotype of autism: weak "central coherence" in parents and siblings of children with autism: I. Experimental tests

Previous twin and family studies have indicated that there are strong genetic influences in the etiology of autism, and provide support for the notion of a broader phenotype in first-degree relatives. The present study explored this phenotype in terms of one current cognitive theory of autism. Parents and brothers of boys with autism, boys with dyslexia, and normal boys were given tests of "central coherence", on which children with autism perform unusually well due to an information-processing bias favouring part/detail processing over processing of wholes/meaning. Results indicated that fathers of boys with autism, as a group, showed piecemeal processing across four tests of central coherence. This was not true for any other group. These findings raise the possibility that the broader autism phenotype may include a "cognitive style" (weak central coherence) that can confer information-processing advantages.

Exploring the cognitive phenotype of autism: weak "central coherence" in parents and siblings of children with autism: II. Real-life skills and preferences

Information on everyday life activities and preferences in both social and nonsocial domains was obtained from parents and children who had taken part in an experimental study of central coherence. Comparisons were made between parents who had a son with autism, parents with a dyslexic son, and families without a history of developmental disorder, as well as the male siblings in these families. Data on everyday preferences and abilities were elicited by means of an experimental questionnaire. Significant group differences in social and nonsocial preferences were found, suggesting that some parents showed similarities with their son with autism, in preference for nonsocial activities and ability in detail-focused processing. A similar experimental questionnaire, completed by parents on behalf of their sons, discriminated between autism group probands and controls, but did not differentiate sibling groups. The relevance of the nonsocial items to central coherence is discussed in the light of the findings in Part I: autism parents who reported more autism-related nonsocial (but not social) preferences, tended to show a piecemeal processing style on the experimental tasks.

Movement and mind: a functional imaging study of perception and interpretation of complex intentional movement patterns

We report a functional neuroimaging study with positron emission tomography (PET) in which six healthy adult volunteers were scanned while watching silent computer-presented animations. The characters in the animations were simple geometrical shapes whose movement patterns selectively evoked mental state attribution or simple action description. Results showed increased activation in association with mental state attribution in four main regions: medial prefrontal cortex, temporoparietal junction (superior temporal sulcus), basal temporal regions (fusiform gyrus and temporal poles adjacent to the amygdala), and extrastriate cortex (occipital gyrus). Previous imaging studies have implicated these regions in self-monitoring, in the perception of biological motion, and in the attribution of mental states using verbal stimuli or visual depictions of the human form. We suggest that these regions form a network for processing information about intentions, and speculate that the ability to make inferences about other people's mental states evolved from the ability to make inferences about other creatures' actions.

High "intelligence," low "IQ"? Speed of processing and measured IQ in children with autism

The uneven profile of performance on standard assessments of intelligence and the high incidence of savant skills have prompted interest in the nature of intelligence in autism. The present paper reports the first group study of speed of processing in children with autism (IQ 1 SD below average) using an inspection time task. The children with autism showed inspection times as fast as an age-matched group of young normally developing children (IQ 1 SD above average). They were also significantly faster than mentally handicapped children without autism of the same age, even when these groups were pairwise matched on Wechsler IQ. To the extent that IT tasks tap individual differences in basic processing efficiency, children with autism in this study appear to have preserved information processing capacity despite poor measured IQ. These findings have implications for the role of general and specific cognitive systems in knowledge and skill acquisition: far from showing that children with autism are unimpaired, we suggest that our data may demonstrate the vital role of social insight in the development of manifest "intelligence."

Good test--retest reliability for standard and advanced false-belief tasks across a wide range of abilities

Although tests of young children's understanding of mind have had a remarkable impact upon developmental and clinical psychological research over the past 20 years, very little is known about their reliability. Indeed, the only existing study of test-retest reliability suggests unacceptably poor results for first-order false-belief tasks (Mayes, Klin, Tercyak, Cicchetti, & Cohen, 1996), although this may in part reflect the nonstandard (video-based) procedures adopted by these authors. The present study had four major aims. The first was to re-examine the reliability of false-belief tasks, using more standard (puppet and storybook) procedures. The second was to assess whether the test-retest reliability of false-belief task performance is equivalent for children of contrasting ability levels. The third aim was to explore whether adopting an aggregate approach improves the reliability with which children's early mental-state awareness can be measured. The fourth aim was to examine for the first time the test-retest reliability of children's performances on more advanced theory-of-mind tasks. Our results suggest that most standard and advanced false-belief tasks do in fact show good test-retest reliability and internal consistency, with very strong test-retest correlations between aggregate scores for children of all levels of ability.

Reading the mind in cartoons and stories: an fMRI study of 'theory of mind' in verbal and nonverbal tasks

Previous functional imaging studies have explored the brain regions activated by tasks requiring 'theory of mind'--the attribution of mental states. Tasks used have been primarily verbal, and it has been unclear to what extent different results have reflected different tasks, scanning techniques, or genuinely distinct regions of activation. Here we report results from a functional magnetic resonance imaging study (fMRI) involving two rather different tasks both designed to tap theory of mind. Brain activation during the theory of mind condition of a story task and a cartoon task showed considerable overlap, specifically in the medial prefrontal cortex (paracingulate cortex). These results are discussed in relation to the cognitive mechanisms underpinning our everyday ability to 'mind-read'.

The neuroanatomy of autism: a voxel-based whole brain analysis of structural scans

Autism is a biological disorder which affects social cognition, and understanding brain abnormalities of the former will elucidate the brain basis of the latter. We report structural MRI data on 15 high-functioning individuals with autistic disorder. A voxel-based whole brain analysis identified grey matter differences in an amygdala centered system relative to 15 age- and IQ-matched controls. Decreases of grey matter were found in anterior parts of this system (right paracingulate sulcus, left inferior frontal gyrus). Increases were found in posterior parts (amygdala/peri-amygdaloid cortex, middle temporal gyrus, inferior temporal gyrus), and in regions of the cerebellum. These structures are implicated in social cognition by animal, imaging and histopathological studies. This study therefore provides converging evidence of the physiological basis of social cognition.

Acquired 'theory of mind' impairments following stroke

The ability to attribute thoughts and feelings to self and others ('theory of mind') has been hypothesised to have an innate neural basis and a dedicated cognitive mechanism. Evidence in favour of this proposal has come from autism; a brain-based developmental disorder which appears to be characterised by impaired theory of mind, despite sometimes good general reasoning skills/IQ. To date no case of specific acquired theory of mind impairment has been reported. The present study examined theory of mind in adults who had suffered right hemisphere stroke, a group known to show pragmatic and social difficulties. In one study using story materials and two using cartoons, patients' understanding of materials requiring attribution of mental states (e.g. ignorance, false belief) was significantly worse than their understanding of non-mental control materials. Data from healthy elderly subjects, and a small group of left hemisphere patients (who received the tasks in modified form), suggest that this impairment on mental state tasks is not a function of task difficulty. The findings support the notion of a dedicated cognitive system for theory of mind, and suggest a role for the healthy right hemisphere in the attribution of mental states.

Distinguishing lies from jokes: theory of mind deficits and discourse interpretation in right hemisphere brain-damaged patients

Right-hemisphere brain damaged (RHD) patients and a normal control group were tested for their ability to infer first- and second-order mental states and to understand the communicative intentions underlying ironic jokes and lies. Subjects listened to stories involving a character who had either a true or a false belief about another character's knowledge. Stories ended either with an ironic joke or a lie by this character. In the joke stories, the speaker knew that the listener knew the truth (a true second-order belief) and did not expect the listener to believe what was said; in the lie stories, the speaker did not know that the listener actually knew the truth (a false second-order belief) and thus did expect the listener to believe what was said. RHD patients performed significantly worse than control subjects on one of two measures of second-order belief, which suggests that the ability to make second-order mental state attributions is fragile and unreliable following right-hemisphere damage. RHD patients in addition performed worse than controls when asked to distinguish lies from jokes, confirming their known difficulties with discourse interpretation. For both groups, the ability to distinguish lies from jokes was strongly correlated with two measures of the ability to attribute correctly second-order beliefs. These results suggest that the fragility of RHD patients' understanding of second-order mental states underlies a portion of their difficulties in discourse comprehension, but that the underlying impairment is not restricted to right hemisphere dysfunction.

'Theory of mind' in the brain. Evidence from a PET scan study of Asperger syndrome

The ability to attribute mental states to others ('theory of mind') pervades normal social interaction and is impaired in autistic individuals. In a previous positron emission tomography scan study of normal volunteers, performing a 'theory of mind' task was associated with activity in left medial prefrontal cortex. We used the same paradigm in five patients with Asperger syndrome, a mild variant of autism with normal intellectual functioning. No task-related activity was found in this region, but normal activity was observed in immediately adjacent areas. This result suggests that a highly circumscribed region of left medial prefrontal cortex is a crucial component of the brain system that underlies the normal understanding of other minds.

The neuropsychology of autism

In this review, we aim to bring together major trends in autism research at three levels: biology, behaviour and cognition. We propose that cognitive theories are vital in neuropsychology, which seeks to make connections between brain abnormality and behavioural symptoms. Research at each of the three levels is incomplete, but important advances have been made. At the biological level, there is strong evidence for genetic factors, although the mechanism is, as yet, unknown. At the behavioural level, diagnosis and education are becoming more coherent and less controversial, although the possibility of autism subtypes has provoked new debate. At the cognitive level, three major theories are proving fruitful (mentalizing impairment, executive dysfunction and weak central coherence), although the relation and overlap between these is uncertain. Rapidly advancing technology and methodology (e.g. brain imaging, gene mapping), as tools of cognitive theory, may help to make autism one of the first developmental disorders to be understood at the neuropsychological level.

Other minds in the brain: a functional imaging study of "theory of mind" in story comprehension

The ability of normal children and adults to attribute independent mental states to self and others in order to explain and predict behaviour ("theory of mind") has been a focus of much recent research. Autism is a biologically based disorder which appears to be characterised by a specific impairment in this "mentalising" process. The present paper reports a functional neuroimaging study with positron emission tomography in which we studied brain activity in normal volunteers while they performed story comprehension tasks necessitating the attribution of mental states. The resultant brain activity was compared with that measured in two control tasks: "physical" stories which did not require this mental attribution, and passages of unlinked sentences. Both story conditions, when compared to the unlinked sentences, showed significantly increased regional cerebral blood flow in the following regions: the temporal poles bilaterally, the left superior temporal gyrus and the posterior cingulate cortex. Comparison of the "theory of mind" stories with "physical" stores revealed a specific pattern of activation associated with mental state attribution: it was only this task which produced activation in the medial frontal gyrus on the left (Brodmann's area 8). This comparison also showed significant activation in the posterior cingulate cortex. These surprisingly clear-cut findings are discussed in relation to previous studies of brain activation during story comprehension. The localisation of brain regions involved in normal attribution of mental states and contextual problem solving is feasible and may have implication for the neural basis of autism.

Language and communication in autistic disorders

Communication problems form one of the key diagnostic criteria for autism, but there is a wide variety of manifestations. The theory that autistic individuals are unable to represent mental states can shed light on both the nature and range of communication impairments. This theory predicts that the specific communication deficit lies in the use of language to affect other minds. Language is not special in this respect, and is important only in so far as it may be used to give evidence of a speaker's thoughts and intentions. Thus, in autism, language level would be expected to relate strongly to performance on standard tests of theory of mind. Normal language acquisition appears to build upon the ability to recognize and orient towards ostensive behaviour. For this reason, it may not be necessary to postulate additional language impairments in order to explain the almost universal prevalence of language delay in children with autism. Autism, then, provides a model for studying the important distinction between language and communication, and demonstrates the vital part which mind-reading plays in normal human verbal and non-verbal interaction.

Sampling the form of inner experience in three adults with Asperger syndrome

Three adults with Asperger syndrome were invited to talk about their inner experiences, using an experience sampling and interview technique. They reported thoughts primarily or solely in the form of images. By contrast, normal adults previously tested with this technique reported inner experiences of a variety of forms. The present report suggests the feasibility and potential interest of the experience sampling method with high-functioning individuals with autistic disorder.

Autism: beyond "theory of mind"

The theory of mind account of autism has been remarkably successful in making specific predictions about the impairments in socialization, imagination and communication shown by people with autism. It cannot, however, explain either the non-triad features of autism, or earlier experimental findings of abnormal assets and deficits on non-social tasks. These unexplained aspects of autism, and the existence of autistic individuals who consistently pass false belief tasks, suggest that it may be necessary to postulate an additional cognitive abnormality. One possible abnormality-weak central coherence--is discussed, and preliminary evidence for this theory is presented.