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Julia Yellow

The social network:
How everyday interactions shape autism

A new study is the first rigorous test of a controversial idea: that the everyday interactions between caregiver and child can shape the course of autism.

by  /  23 March 2015
illustration by:
Julia Yellow

One afternoon in October 2012, a communication therapist from Manchester, U.K., visited the home of Laura and her three children. Laura sat down at a small white table in a dimly lit room to feed her 10-month-old daughter, Bethany, while the therapist set up a video camera to record the pair’s every movement. (Names of research participants have been changed to protect privacy.)

Bethany sat quietly in her high chair, nibbling on macaroni and cheese. She picked up a slimy noodle with her tiny fingers, looked up at Laura and thrust out her hand. “Oh, Mommy’s going to have some, yum,” Laura said. “Clever girl!”

Bethany beamed a toothy grin at her mother and let out a brief squeal of laughter, and then turned her head to peer out the window as a bus rumbled by. “Oh, you can hear the bus,” Laura said. “Can you say ‘bus?’”

“Bah!” Bethany exclaimed.

“Yeah, bus!” Laura said.

This ordinary domestic moment, immortalized in the video, is part of the first rigorous test of a longstanding idea: that the everyday interactions between caregiver and child can shape the course of autism1.

The dynamic exchanges with a caregiver are a crucial part of any child’s development. As Bethany and her mother chatter away, responding to each other’s glances and comments, for example, the little girl is learning how to combine gestures and words to communicate her thoughts.

In a child with autism, however, this ‘social feedback loop’ might go awry.

Revealing recreation: An infant who doesn’t attend to her parents as they play together gives the parents few opportunities to engage. Birkbeck College, University of London

Revealing recreation: An infant who doesn’t attend to her parents as they play together gives the parents few opportunities to engage.
Birkbeck College, University of London

An infant who avoids making eye contact, pays little attention to faces and doesn’t respond to his or her name gives parents few opportunities to engage. The resulting lack of social interaction may reinforce the baby’s withdrawal, funneling into a negative feedback loop that intensifies mild symptoms into a full-blown disorder.

“It’s not the whole explanation, but it might contribute a bit to the unfolding trajectory,” says Jonathan Green, professor of child and adolescent psychiatry at the University of Manchester in the U.K.

It’s not yet clear whether Bethany has autism, but her older brother was diagnosed with the disorder in 2012. That makes her 20 times more likely than an average child to be diagnosed with it herself. The risk is still small: Only about one in every five so-called ‘baby sibs’ are diagnosed with autism by age 3 or 4. Still, even baby sibs who are not diagnosed often show autism-like signs at an early age.

Green’s team is tracking Bethany and 53 other baby sibs from infancy to document how autism unfolds — including what happens during those crucial months and years before a diagnosis is made.

“One of the misconceptions people have about autism is that autism is just in the child,” says Gordon Ramsay, director of the Spoken Communication Laboratory at the Marcus Autism Center in Atlanta. Ramsay is not involved in Green’s study, but is studying how parent-child interactions influence vocal development. “Autism disrupts the relationship between the child and the caregiver, and that plays out in many ways.”

If the idea that faulty parent-child interactions contribute to autism proves to be correct, it might point to a new way of preventing or treating the disorder — by teaching parents how to adapt and respond to their child’s peculiar way of interacting with the world.

Controversial claim

The notion that a parent’s behavior may exacerbate autism at first seems like a replay of the infamous ‘refrigerator mother theory.’ This shameful episode in the history of psychiatry suggested that cold and uncaring mothers cause autism, and was soundly refuted in the 1980s, but the three decades of its existence cast a long shadow on the field of autism research.

Sound shift: A noninvasive technique called electroencephalography measures brain responses to speech sounds. Birkbeck College, University of London

Sound shift: A noninvasive technique called electroencephalography measures brain responses to speech sounds.
Birkbeck College, University of London

One unfortunate side effect of the theory has been that scientists — and the general public — are wary of any hypothesis that implicates parents in their children’s trajectory.

In the past few decades, research into autism’s origins has focused mostly on genetics. “The traditional view is that it’s very much a biological disorder, and it just unfolds in its own time and there’s nothing that the environment can do,” Green says.

But Green wasn’t satisfied that this view fully accounts for the way autism emerges. It was already clear from research with typically developing children that early interactions are essential for social-skill development and language acquisition — faculties often affected in children with autism.

In fact, in the mid-1970s, child psychologist Arnold Sameroff proposed the ‘transactional’ model of child development. This model posits simply that the relationship between infant and caregiver is shaped by reciprocal feedback. An infant’s sounds and gestures elicit responses from a parent, and those reactions, along with the environment, in turn shape the child’s future behaviors.

Green suspected that these cycles sometimes falter or even come to a halt in autism. To find out, he examined a group of 6- to 10-month-old infants who had a family history of the disorder, hypothesizing that the high-risk babies might interact with their caregivers differently than babies in the general population do.

He found that as the baby sibs played and interacted with their parents, they tended to be less lively than low-risk babies2. The parents of the baby sibs were, in turn, less responsive to their infants’ subtle bids for attention and more intrusive in their attempts to engage — for example, touching their babies more frequently to try to elicit responses.

Other differences between the two groups emerged by the time the children were between 12 and 15 months old3. Children with a family history of autism tended to not show interest in their parents and they smiled and laughed less than low-risk toddlers. The children who were later diagnosed with autism at age 3 were among the least attentive. In this preliminary study, only the infants’ behaviors, not parental reactions, tracked with later diagnosis.

Cracking circuits

Around the same time, other teams were making similar discoveries. Jana Iverson’s group at the University of Pittsburgh explored how mothers respond verbally to their baby-sib toddlers’ social gestures, such as pointing at or sharing a toy. The mothers’ behaviors were no different from those of mothers in the general population4. However, the team found that these children tended to make fewer gestures overall than children in the general population, giving their mothers fewer opportunities to respond.

“Basically, parents have to work with what the child brings to the table,” says Iverson, professor of psychology at the university.

Attention analysis: Eye-tracking tasks assess how long a child takes to shift his gaze from picture to picture. Birkbeck College, University of London

Attention analysis: Eye-tracking tasks assess how long a child takes to shift his gaze from picture to picture.
Birkbeck College, University of London

In this way, a behavioral peculiarity that begins with the children ends up depriving them of guidance from their mothers. “They’re not getting the kind of rich linguistic input that would be really beneficial for them,” Iverson says.

Her observation was borne out by a much larger study last year that recorded an entire day’s worth of verbal sounds made by 183 children — 77 of whom have autism — and their adult caregivers5. The children ranged from 8 months to 4 years of age. Here, too, children with autism made fewer sounds overall than did children without the disorder.

In this study, the caregivers’ patterns of responses to their children in each group also differed. Caregivers of children without autism responded more frequently to speech-related sounds, such as speaking or babbling, than to sounds unrelated to speech, such as grunting or laughing. By contrast, the caregivers of children with autism responded whether the child’s sounds were speech-related or not.

It may be that the parents of children with autism mistook non-speech sounds for speech, or just that children with autism make unusual sounds, says study leader Anne Warlaumont, assistant professor of cognitive and information sciences at the University of California, Merced.

In either case, the findings suggest that autism disrupts the feedback loop that supports speech development. Because they produce fewer sounds, children with autism go through fewer iterations of this loop.

Taken together, the three studies established that there is indeed something amiss in the exchanges between parents and children at risk of autism. But whether this can contribute to autism severity is a much bigger — and more controversial — question. “It’s kind of a hard thing to prove,” says Robert Schultz, director of the Center for Autism Research at the Children’s Hospital of Philadelphia.

The proof would require researchers to alter the behavior of the parents and document its effects on the child, or vice versa. “To assess causality, you need an experiment,” says Daniel Messinger, professor of psychology at the University of Miami in Florida.

Social networks

In the loop: Jonathan Green says cycles of social feedback falter when interacting with a child who has autism. J. Green

In the loop: Jonathan Green says cycles of social feedback falter when interacting with a child who has autism.
J. Green

Green’s study is that experiment.

By changing the dynamic between parents and children at high risk of autism, Green says, his team is trying to change the trajectory of the children’s development.

When Bethany was between 9 and 14 months old, a therapist visited Laura’s home once every two weeks and recorded them engaging in ordinary activities such as mealtime or play. The therapist then analyzed each video, picking out segments to replay for Laura during the next visit.

The goal was to help Laura better recognize and interpret Bethany’s attempts to communicate, whether through gestures, glances, grunts or other sounds. The therapist pointed out moments when Laura did particularly well at noticing and responding to her daughter’s cues.

For instance, when Bethany turned to look at the bus, she was communicating the focus of her attention; by translating this gesture into words, Laura gave her daughter an opportunity to expand her vocabulary.

The therapist also helped Laura spot small signs she had missed — for example, that Bethany had lost interest in a particular toy or game, or that she had not yet finished playing with something Laura was bored with. “Parents don’t always notice these subtle things,” Laura says.

Laura also learned strategies she could use to respond to Bethany’s bids for attention, practicing them for at least 30 minutes a day to help Laura’s behaviors become habit. “It was loads of fun,” Laura says. “None of this study has been hard work.”

The intervention starts in infancy in the hopes of changing the feedback loops before they become fixed, says Teodora Gliga, a neuroscientist at Birkbeck College, University of London, who helps to assess the infants’ behaviors. “Once they become the usual way in which the parent and child interact, it becomes more difficult to modify them.”

Half of the families in the study are getting this intensive hands-on coaching, and the other half make up a control group. To make sure that they’re seeing an effect of change in the parent’s behavior, the researchers are careful to interact only with the parents.

In Green’s study, “Any effect on the baby comes through a change in the parental behavior,” he says. “There’s no other route through which the baby could be affected.”

The study is still underway, but early results, reported 21 January in Lancet Psychiatry, indicate that the intervention makes a difference for both parents and children. Parents who received the training became less controlling in their interactions, instead waiting for their child to make the first move. What’s more, the children in those families became more attentive to and engaged with their parents. They also showed fewer autism-like behaviors when they were 14 months old, compared with children whose parents did not receive training.

It is not yet possible to determine whether the intervention in Green’s study prevents autism or lessens its symptoms because most of the children are still too young to be accurately diagnosed. Bethany turned 3 in January, and her mother says she showed no signs of autism at her last checkup at Green’s lab in February. “She’s incredibly bright,” Laura says. “She’s the most sociable, most interactive child.”

At the very least, the study’s results suggest that therapists can teach parents strategies to boost the social attention of a child who is biologically predisposed to autism.

“That is pretty exciting,” says Aubyn Stahmer, associate professor of psychiatry at the University of California, San Diego, who was not involved in the study. “What that means for them long-term, I don’t think we know yet, but certainly it suggests that very early intervention with kids who might be at risk is a good idea.”

An added benefit is that the treatment is easy for parents to do and doesn’t require a diagnosis. “The more that we work towards some type of intervention that’s non-stigmatizing, that becomes more normalized, then parents will be able to do it in the privacy of their own homes and maybe make a difference for their babies,” says Connie Kasari, professor of human development and psychology at the University of California, Los Angeles. Kasari was not involved in the study, but has led interventions in preschoolers with autism.

The study’s final evaluations will take place later this year. But already, Green sees these preliminary findings as support of his theory that parent-child interactions play a role in autism’s trajectory.

“I don’t want to say that one can ‘cure’ autism like this, that’s not true,” Green says. “But I hope we’ll be able to make a difference.”

This article was republished on TheGuardian.com.


References:
  1. Green J. et al. Lancet Psychiatry Epub ahead of print (2015) Abstract
  2. Wan M.W. et al. Res. Dev. Disabil. 33, 924-932 (2012) PubMed
  3. Wan M.W. et al. J. Child Psychol. Psychiatry 54, 763-771 (2013) PubMed
  4. Leezenbaum N.B. et al. Autism 18, 694-703 (2013) PubMed
  5. Warlaumont A.S. et al. Psychol. Sci. 25, 1314-1324 (2014) PubMed
  • Seth Bittker

    “If the idea that faulty parent-child interactions contribute to autism proves to be correct, it might point to a new way of preventing or treating the disorder — by teaching parents how to adapt and respond to their child’s peculiar way of interacting with the world.”

    Seriously? Are we still thinking it is the parents’ fault that their kids have autism? Is this what the best minds in science are doing to try to treat this disease? What I take from this is that there are way too many psychologists doing autism research and since they don’t understand the biochemistry and they don’t understand the genetics, they need to find some way of being relevant. So they theorize about parent-child interactions or misinteractions having life long effects.

    My son is affected. He grew up in a very enriching environment. My wife and I interacted with him constantly from birth. We smiled, we played, we read books, he spent quality time with his cousins, and he had play dates too. His development was slower than normal until about age 2.5 when he regressed. Changing his diet and selective supplementation made a huge difference in the ultimate outcome for him. Believe it or not, an antibiotic also helped in his case as well. Yes, ABA probably helped too. However, without some improvements in biochemistry due to non-behavioral interventions, I think the incremental improvement from ABA would have been marginal and he probably would have continued regressing.

    If you look at these kids they are different biochemically from normal. Typically they have markers for dysbiosis, oxidative stess, and unusual cytokine profiles. There are markers in blood, urine, and saliva that could be used to identify most that have this disease. Do we really think that more interactions with caregivers will have a significant affect upon these markers? Unless these interactions convince the parents to adjust the child’s diet or make other non-behavioral changes to the environment, I don’t think they would.

    • Katie

      Thank you Seth. Maybe this means nothing but I have two graduate degrees in childhood psychology and worked incredibly hard parenting my (now) ASD son. I resent the implication that “something was amiss in our parent- child interaction.” Almost every ASD parent I know bought half of Toys R Us trying to elicit reactions and communications with their toddlers! Our children are not autistic because we we disinterested or unresponsive parents!

      I am incredulous that the Marcus Institute funded such retrograde, sexist and anti ASD family research.

      • Shane F.

        It’s understandable that parents might feel blamed, and therefore offended. And that’s a shame.

        At the same time, if a potential remedy is out there, everyone deserves to know about it — especially the families trying to deal with autism.

  • usethebrainsgodgiveyou

    The reason why children don’t interact with their parents like most kids is because they aren’t wired like most kids. My son was diagnosed at age 3 w/PDD-NOS by a pediatrician, and Semantic-Pragmatic Disorder by a Neurologist. What I had read of ABA, it included teaching children language visually. So, for a year we worked on a curriculum of words in Catherine Maurice’s book, Behavioral Intervention for Young Children with Autism. For 1-2 hours the list was presented visually, Kinesthetically, Tactilly, as my son only understood nouns…that have a visual representation in the brain.I think that is why ABA can be so successful, having little to do with “behavioral interventions”, which I went out of my way to avoid.

    Even at age 8, he continued to be very visual, not auditory. One of the things that broke my heart at age 3 was I was told he had no imagination, because he didn’t interact via speech, he didn’t “pretend”. This stayed in my heart. However, at age 8, I heard a splashing in the bathroom. “What are you doing?” I asked. “I’m the captain of the Titanic. I’m traveling up and down the Easter Seaboard.” he said. “Can you see it all in your mind?” I asked. “Yes.” he said.That’s an imagination, but it is a visual imagination, which, I guess you could say, is hard to share. We can’t play the movies in our heads to others if we are wired that way. I no longer felt he didn’t have an imagination.

    He is gifted, verbally, with an IQ of 126 now. He is who he is. Bad things happen when we try to make children something they are not. However, would my son have grown up to be so intelligent if I hadn’t given him those words presented visually? I don’t know.Why did I do it? Because 20 years ago, a parent wrote a book, “Sonrise”. Barry Kauffman’s son Raun was considered autistic at the time, and his parents worked on interacting with him, the social context being the only one of meaning. Raun now runs the Son-Rise Treatment Center. The thing is, trying to make this a scientific paradigm is doomed. Children aren’t born to be research cases. They are born to be loved.

  • Payman

    1 in 68 boys suffer from autism. It is in all schools and almost soon in every family. Kids regression into speechless world. And this is the best research they have come up with?

  • RAJensen

    The baby sib studies violate every principle of epidemiology, They are volunteer studies with families recruited by social media and clinical referals. The 20% recurrence risk is vastly inflated. In population based epidemiological studies in Denmark which includes millions of children whose birth records and mental health records are in national registries, the acutal sib recurrence risk is 6.9%, not the inflated 20% in baby sib studies. This was ther first population based research that coverd an entire population :

    http://archpedi.jamanetwork.com/article.aspx?articleid=1728998

  • Autism parent

    My son was the first grandchild in our family. Needless to say, as the first grandbaby, he was showered with attention and interaction by everyone in the family. There was no lack of social engagement from anyone during his first few years. And he thrived from it and his words began coming in. His first word was “boat” and by age 18 months he could look at a book of planets and name all of them. He developed normally his first 2 years then slowly his development started to deteriorate and he regressed. He withdrew, would not respond to his name, he became echolalic, started spinning in circles, spacing out and pressing his ears. I think the elephant in the room is environmental causation, specifically poisoning be it from the effect of the overdosing of vaccines or other toxic exposures (pesticide residue on food). Once thing for sure, Autism is effecting children from every walk of life. It’s time for scientist to stop focusing so intently of parents and look at toxic load that is happening to babies that is pushing them over the edge into autism. Start with doing follow up studies on documented cases of children who have had severe adverse reaction to vaccines and received settlements through the NVICP. What do these children have in common? What happened to them neurologically? Did they all suffer a mitochondrial dysfunction at a critical point in their development due to toxic overload? Let’s put some research dollars into studying this subset of kids. Studying this population could provide needed insight into what is causing autism in so many American children now 1 in 68.

  • Oh, dear

    I am the fun Mom at the park. The one that chases my kids and plays tag. Even when one of them doesn’t necessarily stay with it very long. The one that snuggles her babies even when they are sleeping because they are just so cute. I even, gasp!, did the co-sleeping thing. I am not a deep sleeper, so it didn’t worry me. I nursed. I did the whole skin-to-skin time thing. He was snuggly and interactive. It wasn’t my first baby that had autism. I actually didn’t think I was at risk for autism because my first boy was fine. He’s actually very bright. And, I do give myself some credit because I wouldn’t let him go in the corner by himself and just play there. I insisted on being part of his world. Now, when I am home, and he hears the front door open, he’ll say, “Daddy? Daddy!” And, runs to give his Dad a hug. When I am coming home from work, he runs downstairs to give me a hug before he runs back to what he was doing. This has all come at a very steep cost to me, though. I will be broken backed and rocking in a corner myself after I am done, but BOTH my children will be happy. He also has a heterozygous C677T MTHFR gene mutation, which to me, should have been indicative to not vaccinate him. But, no one wants to test for these things before they vaccinate kids.

  • Amanda

    This type of autism research is so naive and disappointing.
    Autism is not merely behavioral. Many potentially ASD infants are less social than peers because they have reflux, undiagnosed allergies/ colic, ongoing strep infections (approx 25% of toddlers dx with autism had reoccurring strep infections)…Naturally an ASD sib shares many of the same vulnerabilities as the ASD brother/ sister. ASD does not exist in a genetic vacuum however, it is 2015, we know this.
    This research is so dispiriting because most ASD moms work so much harder to communicate with and parent a sib of an ASD child!
    This work is being framed as if benign neglect is a precursor to the onset of ASD.

    Of course parent training and education is beneficial but what is being hypothesized here is much deeper than that. “There is something amiss in the parent child interaction,” is really parent blaming and our families deserve better than this from ASD research $.

  • usethebrainsgodgiveyou

    Please study this carefully: https://www.youtube.com/watch?v=evjbx9_RiMY

    This mama came up with this after her child had been given thousands of hours of the best “therapy” that science and psychology had to offer.

    Yes, opening up the right channels to communication can help a child enormously. But this study is so simplistic. It is much, much harder to actually make a difference. Autistic children are much more complicated (as would be any person whose life was observed under a microscope).

    Please watch it. Autism is neurological, but our children are enormously human.

  • usethebrainsgodgiveyou

    For the sceptics among you, here is a youtube video of Ethan released a couple of days ago. https://www.youtube.com/channel/UCBRjXfiSVr1XzU5ZhAZkLMA

    Now that’s some happy there…a mama did it!

  • Autism MOM

    If the idea that faulty parent-child interactions contribute to autism proves to be correct, it might point to a new way of preventing or treating the disorder — by teaching parents how to adapt and respond to their child’s peculiar way of interacting with the world.” This is unbelievable!!! Autism is not all behavioral…I have two sons -one with autism and one without. My neurotypical son is the most socially advanced child-naturally. I was the most doting social mom with both sons and nothing I did or did not do contributed to autism. How dare an article like this even remotely blame a parent’s interaction. http://www.zigsocial.com-social network for those with autism.

  • Amy Penna

    This article and the so-called research it entails hurts me. I’m a mother of a severely autistic child. Please please please stop eating up research dollars on your pedantic and useless theories.I try day and night to connect with a human who is so entirely disconnected most of the time. He is being provided a 300k /year education and at 9 years old with 5 years of
    ABA at a private school with a great reputation he cannot toilet, feed or dress himself without perpetual verbal and physical prompts. This is my only child. I will be terrified about his vulnerability until the day I die because almost no research being done applies to HELPING HIM NOW.

    Get to work on how to activate low functioning parts of the brain while down regulating uselessly overactive sections of the brain. Please don’t bother with your crummy, non-applicable research. You may be responsible for contributing to increased stress and anxiety of caregivers by doing such research.

  • Ethyl

    >>>At the end of the study, the researchers assessed the behavioral
    development of the infants in both groups. Overall, the babies in the
    treatment group showed greater improvement across a wide range of social
    and communication behaviors including attentiveness to caregivers.
    However, the difference between groups was not clear and significant in
    most areas.,<<<
    https://www.autismspeaks.org/science/science-news/video-feedback-helps-parents-engage-infants-risk-autism

    Study showed no significant difference.

    For twenty years, I've followed autism science. I'm used to it.

  • Teresa

    This sounds like Pivotal Response Treatment. Am I mistaken?

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