Current Perspectives on Child Development in
the 21st Century
Cognitive conundrums coming our way?
Professor Anne O’Hare
ARICD
15 International Scientific
Meeting
Birmingham 2013
Cognitive Conundrums Coming our Way?
DEFINITIONS
COGNITIVE:
Relating to the mental processes
involved in knowing, learning and
understanding things
As children grow older, their
cognitive processes become sharper
(Collins Cobuild Advanced Dictionary)
CONUNDRUM:
A problem that is difficult to solve
Cognitive Conundrums Coming our Way?
Motor planning and executive function
Language pragmatics
Social cognition
Acute Lymphoblastic Leukaemia
• Prevalence 2-3 per 10,000
• 35% of all childhood malignancies
• Second most common cause of death in 1-15 year olds
Normal Blood
Acute Lymphoblastic Leukaemia
• CNS involved in 5% at
presentation
• Migration of leukaemic
cells along perivascular
and perineural tissues
• CNS relapse ‘inevitable’
without cranial
prophylaxis
Event Free Survival by Trial
Survival
UKALL VIII
Impact of Cranial Irradiation
Animal Model:
• Radiosensitivity of brain decreases with age
• Inhibition of differentiation of myelin
• Less myelin and immature fatty acid composition
Children:
• Intellectual morbidity - ↓ performance IQ and short-term memory but
verbal IQ maintained (Sizer 1980)
• Effect more marked under 3 years
• Arrests normal intellectual growth - gap widens over time (Janoun 1983)
Neurological Morbidity in ALL
CSF biochemical studies:
- Hypoxanthene and Xanthene
- Cyclic adenosine 3’ 5’, monophosphate
- 2’ 3’ -cyclic nucleotide 3’, phosphohydrolase
Cranial CT and CSF Procoagulant activity
10 children
Pre-treatment, induction
and remission, all free of
overt CNS involvement
33 children -5 year
period, 25 controls
undergoing LP to
exclude CNS infection
Neurological Morbidity - Visual evoked
responses and computerised psychometry
Long term survivors
– no CNS involvement, mainstream
school 29 (20 girls, 9 boys)
Matched controls
– age, gender and socio-economic status
O'Hare A E, Eden O B, Aitken K. Computerised psychometry screening in long-term survivors of
childhood acute lymphoblastic leukaemia. Paediatric Haematology and Oncology,1988; 5: 197-208
Computerised Psychometry
•
•
•
•
•
•
Visual spatial ability
Symbol coding
Visual perceptual analysis
Visual spatial recognition memory
Verbal recognition memory
Abstract problem solving
Neurological Morbidity in ALL
1. CSF hypoxanthene raised at diagnosis and induction(p>0.001, p>0.005, p>0.001): ischaemic
brain parenchyma from perivascular infiltration of the arachnoid vessels.
2. Cranial radiotherapy breaches the blood/brain barrier, myelin maturation disturbed during
subsequent 2 years of treatment (p>0.001 procoagulant activity).
3. Cranial CT abnormal at diagnosis in 20% but only 6% at 4-5 years from treatment.
4. Subtle Neurological Morbidity:
•  verbal recognition short term memory (p>0.02)
•  abstract problem solving
– Errors after positive feedback p>0.005
– Number of sorts p>0.005
– Overall performance p>0.01
O'Hare A,Clarke M, McInnes A, Eden O B. The latency of the visual evoked response as an index of myelin disturbance in children
treated for acute lymphoblastic leukaemia. Clinical Electroencephalography, 1987; Vol 18 (2): 68-73).
O'Hare A E, Eden O B, Simpson R McD, Donaldson A, Sainsbury C P Q. Cranial computerised tomography and CSF procoagulant
activity in childhood acute lymphoblastic leukaemia. Haematology and Oncology 1987; Vol 5: 103-113.
Development of an instrument to measure
manual praxis
 Establish typical development of manual praxis – ability to
gesture, use tools and sequence movement.
 Design standardised assessment of ‘hidden’ difficulty for
children who struggle to learn everyday hand skills.
 Explain the role of ‘communication’ in the learning of
manual praxis.
O’Hare A E, Gorzkowska J, Elton R. Development of an instrument to measure manual praxis. Developmental Medicine and Child Neurology, 1999; 41:
597-607
O’Hare A E, Khans S, Hailey J. Delayed development of manual praxis in the presumed normal pre-term survivor. European Journal of Paediatric
Neurology, 1999; 3(6): A137.
Development of an instrument to measure manual
praxis – some interesting outcomes
1. Developmental dyspraxia
2. Deprivation in childhood
Mis-sequence, spatial errors
and few perseverations
Learning to use tools
No disadvantage
Imitation of motor sequences
Mis-locations
Omissions
Disadvantage
Ability to imitate complex gesture and
to undertake more ‘novel’ motor tasks
to verbal instructions (p>0.01)
Aquired dyspraxia
ASSOCIATED FEATURES OF ASPERGER’S
SYNDROME AND THEIR RELATIONSHIP TO
PARENTING STRESS
Epstein T, Saltzman-Benaiah J, O’Hare A, Goll J, Tuck S.
Child: Care, Health & Development, 2008; 34 (4) 503–511.
AIMS OF THE STUDY
• Explore the relationship between some of the associated
features of AS and levels of reported parenting stress in
families of children affected
• Determine whether children with AS show impairment in
executive function and heightened sensory sensitivity
• Determine whether parent report of their child’s demanding
characteristics would be positively associated with their
self-reported levels of parenting stress
ASSOCIATED FEATURES OF ASPERGER’S
SYNDROME AND THEIR RELATIONSHIP TO
PARENTING STRESS
RESULTS – EXECUTIVE DYSFUNCTION
• 92.1% of mothers and 81.8% of fathers rated
their children as having clinically elevated levels of
executive dysfunction
• Correlation between mother’s and father’s overall
score on the BRIEF approached significance
(r=0.49; p>0.05)
RELATIONSHIP BETWEEN MOTHERS’ (M) AND FATHERS’
(F) SCORES ON EACH VARIABLE AS WELL AS
RELATIONSHIP BETWEEN CHILDREN'S DIFFICULTIES
AND PARENTING STRESS
Variables
Correlation
Confidence
interval
P-value
•*P < 0.01.
•Note that the total raw scores for each measure are used for the
correlations.
PSI/SF-M
PSI/SF-F
0.62
0.29 to 0.82
0.001458*
0.67
0.34 to 0.86
0.0007974*
0.73
0.35 to 0.91
0.001890*
0.60
0.34 to 0.77
0.000099*
BRIEF-M
BRIEF-F
SSP-M
SSP-F
BRIEF-M
PSI/SF-M
SSP-M
PSI/SF-M
−0.56
−0.80 to −0.18
0.006478*
0.30
−0.15 to 0.65
0.1793
0.06
−0.46 to 0.56
0.8195
BRIEF-F
PSI/SF-F
SSP-F
PSI/SF-F
*P < 0.01
Epstein T, SaltzmanBenaiah J, O’Hare A,
Goll JC, Tuck S.
Associated features of
Asperger Syndrome
and their relationship
to parenting stress.
Child: care, health and
development 2008
ASPERGER’S SYNDROME AND
PARENTING STRESS
RESULTS – STRESS LEVELS OF PARENTS
OF A.S. CHILDREN
• 75.7% of mothers and 75% of fathers reported clinically
elevated stress levels
• No significant difference between mothers and fathers for
overall levels of parenting stress or on any of the sub-scales
• Mothers’ and fathers’ scores were significantly correlated on
total stress (r=0.62; p>0.01), parenting distress (r=0.71;
p>0.01) and parent-child dysfunctional interaction (r=0.57;
p>0.01)
• However mothers’ and fathers’ scores on the difficult child
index were not significantly correlated
Vision and proprioception in ASD, DCD and
typical development
Does the use of vision and proprioception
differentiate ASD and DCD?
British Psychological Society, September 2013
Louisa Miller, Rob McIntosh, Anne O’Hare
University of Edinburgh
Task 1: MABC results
Percent
Fail: <15th percentile
on MABC
71%
67%
14%
ASD
DCD
TD
(n=31)
(n=9)
(n=28)
Findings confirm
movement deficits in
majority of ASD
Task 2: Visual-proprioceptive
matching task
ASD ‘pure’ vs clumsy ASD/DCD
Mean visual weighting
0.8
ASD with spared
motor skills tend
to weight vision
less
0.4
ASD ‘pure’
0
(n=9)
Clinical
motor deficit
(n=28)
t(35)=2.168, p=0.037,
d=0.73
Clinical assessment in ASD
Disorders of sensory processing
Second order mentalising abilities
Pettigrew L M, O’Hare A E, Bremner L, Nash M, Happe
F, Rutherford M. Journal of Autism and
Developmental Disorder (in press).
O’Hare A E, Adamson A, Graham C. British Journal of
Occupational Therapy, 2006;
Executive function and parental stress
Epstein T, Saltzman-Benaiah J, O’Hare A, Goll J, Tuck S.
Child: Care, Health & Development, 2008.
Prosody and pragmatic ability
Peppé S, McCann J, Gibbon F, O'Hare A, Rutherford M.
Journal Speech Language Hearing Research, 2007.
McCann J, Peppe S, Gibbon F, O’Hare A, Rutherford M.
International Journal of Language and Communication
Disorders 2007.
Peppe S, McCann J, Gibbon F, O’Hare A, Rutherford M.
Journal of Pragmatics, 2006.
Identifying need and service requirements
O’Hare A E, Quew R, Aitken K. Autism, 1998;
Harrison M J, O’Hare A E, Campbell H, Adamson A,
McNeillage J. Developmental Mental Medicine Child
Neurology, 2004
Prevalence of ASD
The prevalence rate of ASD in children in the UK is 1 in
86 children (Baird et al 2006)
The prevalence rate of ASD in adults in the UK is 1 in 100
adults (Brugha et al 2009)
The USA Center for Disease Control (2012) reports a
prevalence of 1 in 88 children in the USA
Brugha et al (2012) report a prevalence of 1 in 90 adults
in the UK
4.11 Evidence statements: conditions with an increased
prevalence of ASD
ASD is observed more frequently in children with the
following coexisting conditions than in the general
population:
•
•
•
•
•
•
•
•
Intellectual disability (prevalence of ASD: 8-27.9%)
Fragile X (prevalence of ASD: 24–60%)
Tuberous sclerosis (prevalence of ASD: 36–79%)
Neonatal encephalopathy/epileptic/encephalopathy/infantile
spasms
(prevalence of ASD: 4–14%)
Cerebral palsy (prevalence of ASD: 15%)
Down‟s syndrome (prevalence of ASD: 6–15%)
Muscular dystrophy (prevalence of ASD: 3–37%)
Neurofibromatosis (prevalence of ASD: 4–8%).
The quality of the evidence was very low in all studies.
24
Child characteristics (n=258)
Child characteristic
Gender
Male: Female
% (n=)
84.16 (216:42)
4:1)
Age at survey completion
< 2 years 11 months
3 years – 5 years 11 months
6 – 11 years
2 (5)
31(81)
67 (172)
ASD diagnosis
Autism
Asperger’s Syndrome
Autism Spectrum Disorder
PDD-NOS/ atypical autism
27 (70)
20 (52)
49 (127)
4 (9)
Age at diagnosis
< 2 years 11 months
3 years – 5 years 11 months
6 – 11 years
27 (70)
57 (146)
16 (42)
Language level
No meaningful speech
Single words and phrases
Sentences with good grammar
Other( no details)
19 (50)
28 (70)
51 (132)
1 (5)
Learning disability
Type of educational establishment attended
Mainstream (school, nursery, unit attached)
Specialist provision
Home ed.
Educational support
*Individual Education Plan
**Statement of Special Educational Needs
(ratio
* An Individual Education Plan
(IEP) is a teaching and learning
plan devised to identify the
targets, provision and
outcomes for a child identified
with special educational
needs. ** Statement of Special
Educational Needs is a legal
document issued by the Local
Authority responsible for
education, following an indepth multidisciplinary
assessment of the child’s
needs.
31 (81)
71 (179)
28 (70)
2 (4)
57 (150)
55 (144)
Adams S J, Burton N, Cutress A, Adamson A J, McColl E, O’Hare A E, Baird G, Le Couteur A. Parents’ and Child Health Professionals’
Attitudes Towards Dietary Interventions for Children with Autism Spectrum Disorders. JADD. Accepted August 2013
em pathos : ‘feeling into’
Empathy is understanding a person’s
subjective experience by sharing it
vicariously but maintaining an observant
stance
Casebook MPS January 2011
Descriptions of empathy difficulties by a man
affected with Asperger’s syndrome and
diagnosed at the age of 50
The Guardian Weekend: 15 Jan 2011
“How can they interact with each other so
unselfconsciously …”
“I like people, I long to have friends and most of
all to be in a relationship…”
“The bottom line is, human beings were not
meant to have to live like this. Social
interaction is a basic human need”
How do we measure empathy in young
children?






Self report
Observer report eg ASD screening instruments
Direct measurement eg theory of mind
assessments
Indirect measurement eg perception of facial
expression
Response to intervention
Neuroscience modalities eg electrophysiology,
neuroimaging, genetics and animal models
Total Social Communication Questionnaire (SCQ) scores for extremely preterm
children with (n=11) and without (n=162) an autism spectrum disorder (ASD)
diagnosis at 11 years of age
Clinical diagnoses were assigned using
the Development and Well Being
Assessment (DAWBA) diagnostic
interview. Horizontal bars indicate the
mean SCQ score. Dashed lines indicate
published SCQ cut-offs for positive
screening.
Johnson S et al. Arch Dis Child 2011;96:73-77
29
Performance of children with transposition of the great
arteries (TGA) and of comparison individuals on theory of
mind tasks (Calderon 2010)
a
First-order
false belief
task
(level 1)
b
Secondorder false
belief task
(level 2)
INDIRECT MEASUREMENT
• Reversible autism among congenitally
blind children – a controlled follow-up
study (Hobson & Lee 2010)
• Cognitive processing of social cues and in
particular facial expression in high risk
girls of a major depressive disorder
(Joorman 2009)
ADOS
Module 1
Preverbal/single words eg
spontaneous initiation of joint
attention.
This rating codes the child’s
attempts to draw another
person’s attention to objects that
neither of them is touching.
Module 4
Fluent speech.
Adolescent/adult.
Empathy/comments on other’s emotions.
The focus of this item is on the
participants communication of his/her
understanding and empathy for the
feelings of other people, real or conveyed
in stories or other tasks.
A Clinical Assessment Tool for Advanced Theory of Mind Performance in 5 to 12 Year Olds
J Autism Dev Disord. 2009; 39(6): 916-928
White lie (Hat)
One day Aunt Jane came to visit
Peter. Now Peter loves his aunt
very much, but today she is wearing
a new hat; a new hat which Peter
thinks is very ugly indeed. Peter
thinks his aunt looks silly in it, and
much nicer in her old hat. But when
Aunt Jane asks Peter, “How do you
like my new hat?” Peter says, “Oh,
it’s very nice”.
Was it true what Peter said?
Why did he say it?
Incorrect
PHYSICAL
It’s got a(u)nts on it
It looked nice
PSYCHOLOGICAL
He liked the hat
He wanted one
He liked the old hat
Physical State (2P)
The lady asked him
It looked horrible
Partial Psychological State
(2M)
He didn’t want to get a row
He didn’t want to get into
trouble
He didn’t like the hat
He loved his aunt
Psychological State Full and
Accurate Answer (2M)
To make his auntie feel that he
likes it
He didn’t want his auntie to think
that he didn’t like it
He didn’t want her to get sad/to
make his auntie sad
He didn’t want to hurt her feelings
He didn’t want to upset his auntie
So his auntie wouldn’t be offended
He didn’t want to tell her he hated it
He didn’t want to be rude
He didn’t want to be nasty to her
He wanted to make his auntie feel
good
He wanted to make his auntie
happy
Mean scores for individual stories and the total according to age for Question
2M. P-value is for significance of association with age
Story
5;0-5;11
6;0-6;11
7;0-7;11
8;0-8;11
9;0-9;11
10;010;11
11;011;11
12;012;11
P-value
1 Lie (Dentist)
0.75
0.83
1.44
1.43
1.33
1.57
1.45
1.29
0.004
2 White Lie (Hat)
0.50
1.00
1.31
1.40
1.83
1.71
1.73
1.86
<0.001
3 Misunderstanding (Glove)
0.00
0.43
0.69
1.00
1.17
1.57
1.23
1.43
<0.001
4 Sarcasm (Picnic)
0.00
0.09
0.62
0.62
0.78
0.90
1.14
1.71
<0.001
5 Persuasion (Kittens)
0.00
0.30
0.44
0.67
1.39
1.43
1.36
1.71
<0.001
6 Contrary Emotion (Swings)
0.67
0.48
0.75
0.52
1.56
1.19
0.95
1.43
0.002
7 Pretend (Bananas)
1.00
0.61
1.50
1.05
1.56
1.52
1.59
1.86
<0.001
8 Joke (Haircut)
0.25
0.17
0.69
0.95
1.06
0.67
1.05
1.71
<0.001
9 Figure of Speech (Cough)
0.00
0.13
0.31
0.62
1.17
0.81
1.05
1.57
<0.001
10 Double Bluff (Ping-Pong)
0.00
0.48
0.56
0.62
0.67
1.14
0.55
0.86
0.006
11 Appearance/Reality
(Santa Claus)
1.00
1.00
1.19
1.24
1.39
1.48
1.50
1.57
0.001
12 Forget (Doll)
0.50
0.83
1.38
1.24
1.17
1.57
1.09
2.00
0.001
Total
4.67
6.35
10.88
11.65
15.06
15.57
14.68
19.00
<0.001
Question 2M (psychological/mental state) : Age specific lower limits
calculated by subtracting twice the residual standard deviation from
the linear regression line
Lower limit: Total = -13.76 + 1.96 x age
Autism and Reactive Attachment Disorder:
some research evidence
Social relationship difficulties in autism and reactive
attachment disorder; improving diagnostic validity
through structured assessment.
Davidson C, Minnis H, O'Hare A, MacTaggart F, Green J,
Gillberg C, Young D
Submitted to Journal of Child Psychology and Psychiatry
Disorders of social
interaction
“…the clearest early sign [of autism], is when a
child seems to lose interest in social interaction”
Cathy Lord, NYU Child Study Centre
RAD “is a syndrome characterised by relative
failure to develop committed intimate social
relationships”
Michael Rutter JCPP 2009
Autism spectrum
disorders
Deficits in social
communication and
social interaction
Restricted, repetitive
behaviours,
interests and
activities
Autism spectrum
disorders
Highly heritable
Usually life-long
NOT related to
abuse, neglect or
“refrigerator
parenting”!
Reactive Attachment
Disorder
Disinhibited type
indiscriminate sociability
with marked inability to
exhibit appropriate
selective attachments
N.B. now called
Disinhibited Social
Engagement Disorder in
DSM V
Reactive Attachment
Disorder
Inhibited type
excessively inhibited,
hypervigilant or highly
ambivalent and contradictory
responses
Emotional, behavioural and developmental features
indicative of neglect or emotional abuse in preschool
children: a systematic review
(Naughton, JAMA Pediatric 2013)
Key features in the child:
 Aggression (11 studies): exhibited as angry, disruptive behaviour, conduct




problems, oppositional behaviour and low ego control
Withdrawal or passivity (12 studies): including negative self esteem,
anxious or avoidant behaviour, poor emotional knowledge and difficulties
in interpreting emotional expressions in others
Developmental delay (17 studies): delayed language, cognitive function
and overall development quotient
Poor peer interaction (5 studies): poor social interactions, unlikely to act to
relieve distress in others
Transition (6 studies): from ambivalent to avoidant insecure attachment
pattern and from passive to increasingly aggressive behaviour and
negative self-representation
Emotional, behavioural and developmental
features indicative of neglect or emotional abuse
in preschool children: a systematic review
(Naughton, JAMA Pediatric 2013)
Children aged 20-30 months:



Less positive social interaction
Toddler spent the least time with adults and
were avoidant even of their mothers
Deficits of memory in neglected children
Emotional, behavioural and developmental
features indicative of neglect or emotional abuse
in preschool children: a systematic review
(Naughton, JAMA Pediatric 2013)
Children aged 3-4 years:
•
Specific delays in receptive language
• In free play and play initiated by a
parent, neglected children
demonstrated significantly more
negative affect
• Ability to discriminate amongst
emotions did not differ between groups
of abused, emotionally neglected and
physically neglected children with IQ as
entered as a co-variate.
Emotional, behavioural and developmental
features indicative of neglect or emotional abuse
in preschool children: a systematic review
(Naughton, JAMA Pediatric 2013)
Children aged 4-5 years:
•
•
•
•
•
•
•
Delay in syntatic development of language
Increasing social difficulties in interaction with other
children
Lower scores on cognitive functioning
Exhibited disruptive behaviour that correlated with
aggression
Neglected children perceive other children as responding
less often to relieve their distress
Neglected children have difficulty recognising angry faces,
preferentially selecting sad faces, more difficulty in
discriminating among emotional expressions
Neglected children are more likely to demonstrate undercontrolled or ambivalent emotional response to simulated
intra-adult aggression
Emotional, behavioural and developmental
features indicative of neglect or emotional abuse
in preschool children: a systematic review
(Naughton, JAMA Pediatric 2013)
Children aged 5-6 years:
•
•
•
•
•
Low self esteem
Insecure avoidant pattern of attachment
Self-rating as angry and oppositional
Rating others as sad, hurt or anxious
Poor peer relationship
The Scottish Index of Multiple Deprivation
(SIMD) quintile for our sample:
Children:
SIMD 1
SIMD 2
SIMD 3
SIMD 4
SIMD 5
Note: According to the Scottish Index of Multiple Deprivation, SIMD 1 is the most
deprived and SIMD 5 is the least deprived.
Total LAC Population in Edinburgh 1998-2012
Citation from Stuart Osborough. Planning and performance, City of
Edinburgh Council. Putting the looked after children population in
context. 2012.
The national picture for Looked After
Children (LAC) populations 2011
• LAC 1.5%
• 34% of LAC ‘at home’
• Ratio kinship; residential is 10:1
• 59% under 12 years
• 30% in LAC for over 3 years
Additional Support Needs (Social)
Reasons for being in day care
•
•
Respite/befriending
Share the care
Reasons for being in foster care
•
•
•
•
Neglect
Physical abuse
Behavioural difficulties
Supervise parental visits
Reasons for being in residential
care
•
•
Adolescent inpatient unit
Homeless young person
Reasons for under guardianship
•
Parental abuse
•
•
Parental substance misuse
Under care of grandparents
Reasons for being under child
protection
•
•
•
•
•
Domestic violence
Inappropriate underage sexual activity
Parental substance misuse
Physical violence
Parental psychotic illness
Identified risk factors for ASD
Risk factor
% Child cases
% Adult cases
% Overall
Neurological disorder associated with ASD
4
3
3
Intellectual disability
21
37
29
Speech delay
55
47
51
Speech regression
9
3
6
Premature (born 35 weeks or below)
11
3
7
Additional support needs (education)
84
23
55
Involved in supported social care (adults only)
n/a
23
n/a
Family history of ASD
14
9
11
Family history of related condition
44
14
30
Parental history of psychosis/affective disorder
34
7
21
Identified risk factors for ASD
Risk factor
% Child cases
% Adult cases
% Overall
Neurological disorder associated with ASD
4
3
3
Intellectual disability
21
37
29
Speech delay
55
47
51
Speech regression
9
3
6
Premature (born 35 weeks or below)
11
3
7
Additional support needs (education)
84
23
55
Involved in supported social care (adults only)
n/a
23
n/a
Family history of ASD
14
9
11
Family history of related condition
44
14
30
Parental history of psychosis/affective disorder
34
7
21
Identified risk factors for ASD
Risk factor
% Child cases
% Adult cases
% Overall
Neurological disorder associated with ASD
4
3
3
Intellectual disability
21
37
29
Speech delay
55
47
51
Speech regression
9
3
6
Premature (born 35 weeks or below)
11
3
7
Additional support needs (education)
84
23
55
Involved in supported social care (adults only)
n/a
23
n/a
Family history of ASD
14
9
11
Family history of related condition
44
14
30
Parental history of psychosis/affective disorder
34
7
21
Antenatal risk factors : ASD
• Maternal folic acid supplements associated with reduced
autism risk in the child (Suren et al, JAMA 2013 309 570-7)
• Schmidt 2013 Evidence for gestational nutrition influences
on autism risk: renewed findings for iron (IMFAR abstract
2013)
• Offspring with a prenatal history of maternal depression
were at higher risk of autism spectrum disorder, particularly
autism without intellectual disability (Rai D, BMJ 2013 343)
• High maternally derived intrauterine androgen
concentrations eg gestational diabetes, obstetric
suboptimality may be a major environmental cause of
autism (James, DMCN 2012)
Adjusted odds ratios (95% confidence intervals) for relation between maternal depression
and autism spectrum disorder overall and autism with and without intellectual disability in
main and supplementary analyses (tables S3-S7).
Rai D et al. BMJ 2013;346:bmj.f2059
©2013 by British Medical Journal Publishing Group
Select findings after controlling for race, ethnicity, and mother’s education.
Close H A et al. Pediatrics 2012;129:e305-e316
©2012 by American Academy of Pediatrics
What do children with ASD
look like on measures of
RAD?
Three groups (RAD, ASD, GP comparison) matched
on age and verbal IQ
58 children
with ASD
recruited
through
Lothian and
Lanarkshire
67 children
with RAD
from
previous
studies
61 typically
developing
children from
previous
studies
• Parent-report semistructured interview
on RAD symptoms
• Teacher questionnaire
• Videotaped
observation for
interaction with
strangers
• Cognitive assessment
What do children with ASD
look like on measures of
RAD?
Assessment of children with ASD:
• Parent-report semi-structured interview on
RAD symptoms (CAPA-RAD)
• Parent-report semi-structured interview for
other diagnoses (DAWBA)
• Teacher questionnaire (RPQ)
• Cognitive assessment in school with
videotaped observation for interaction with
strangers
What do children with ASD
look like on measures of
RAD?
Table 1: group characteristics
RAD
Gender
Mean Age
&
Standard
Deviation
Mean
full
Scale
IQ
(FIQ)
Mean
Verbal
IQ (VIQ)
Mean
performance
IQ (PIQ)
Difference
between
VIQ & PIQ
45 Males
(67%)
7.08,
96.37
97.69
95.38
1.32
88.783
83.92
98.31
14.39
109.06
110.95
105.74
5.21
1
1.42 std
22 (33%)
ASD 46 (79%)
males
7.97
1.96 std
12 (21%)
girls
Typically 38 (62%)
developing males
23 (38%)
girls
7.00
1.56 std
5
What do children with ASD
look like on measures of
RAD?
Differences between disinhibited symptom rates in RAD and ASD group
RAD
ASD
Significance level
Cuddliness with
strangers
29 (45%)
8 (14 %)
<0.001
Indiscriminate Adult
Relationships (is a
problem)
36 (55%)
5 (10%)
<0.001
Comfort seeking from
strangers
13 (20%)
0
<0.001
Personal Questions
34 (52%)
9 (16%)
<0.001
Minimal Checking (is a
problem)
31 (48%)
16 (28%)
<0.001
What do children with ASD
look like on measures of
RAD?
Differences between inhibited symptom rates in RAD and ASD group
Unpredictable Reunion
response
12 (18%)
7 (12%)
0.327
Frozen watchfulness
8 (18%)
7 (12%)
0.388
Hypervigilance
19 (39%)
11 (19%)
< 0.05
Avoids eye contact
38 (58%)
38 (66%)
0.421
What do children with ASD
look like on measures of
RAD?
Prosody and its relationship to language in school
aged children with high functioning autism (HFA)
•
Disordered expressive prosody characteristic of the speech in
people with autism.
•
“Not what you say but how you say it” - attitude and emotion,
emphasis, conversational turns.
•
Impacts on socialising and making friends.
•
All children with HFA had a difficulty with prosody
•
This correlates with receptive and expressive language
•
Prosody (PEPS-C) and theory of mind impairment correlate
•
Abnormal prosody persists over time
McCann J, Peppe S, Gibbon F, O’Hare A, Rutherford M. International Journal of Language and Communication
Disorders 2007; 42 (6) 682-702
Carroll L. Language development and its relationship to theory of mind in children with high functioning autism. 2007
Receptive and expressive prosodic ability in
children with high-functioning autism
Total
Prosody
Output
Intonation
Output
Prosody
Input
Intonation
Input
Focus
Output
Focus Input
Chunking
Input
Affect
Output
p=0.0001
Chunking
Output
TD
Affect Input
HFA
Turnend
Output
100
90
80
70
60
50
40
30
20
10
0
Turnend
Input
% Correct
p=0.001 p=0.003
HFA
TD
PEPS-C Subtest
Peppé S, McCann J, Gibbon F, O'Hare A, Rutherford M. Receptive and expressive
prosodic ability in children with high-functioning autism. Journal Speech Language Hearing
Research, 2007; 50: 1015 - 1028
Accuracy of signs and symptoms to predict ASD
Diagnostic Tool
Quality assessment
Studies
Summary of Findings
Number
Diagnostic accuracy
Design
Limitations
Inconsistency
Indirect
-ness
Quality
ASD
Controls
Sensitivity
(95%CI)
Specificity
(95%CI)
PRE-SCHOOL CHILDREN (0-5 years)
Failure to perform
protodeclarative pointing, gaze
monitoring and pretend play
1
Con
obs
Some
NA
None
Very low
10
23
100
(100,100)
100
(100,100)
Failure to perform
protodeclarative pointing or
protodeclarative pointing and
pretend play
1
Con
obs
Some
NA
None
Very low
10
23
100
(100,100)
70 (51,88)
No pretend play
1
Con
obs
Some
NA
None
Very low
10
19
90
(71,100)
63 (41,85)
No functional play
1
Con
obs
Some
NA
None
Very low
10
19
40 (10,70)
84 (68,100)
No facial concern in response
to others distress
1
Con
obs
Some
NA
None
Very low
10
19
100
(100,100)
68 (48,89)
No attention to distress
1
Con
obs
Some
NA
None
Very low
72
39
21 (11,30)
100
(100,100)
Atypical use of object
1
Con
obs
Some
NA
None
Very low
9
47
78
(51,100)
77 (64,88)
Lack of orienting to name
2
Con
obs
Some
NA
None
Very low
25
76
64 (43,82)
88 (79,94)
65
Accuracy of signs and symptoms to predict ASD
Diagnostic Tool
Quality assessment
Studies
Summary of Findings
Number
Diagnostic accuracy
Design
Limitations
Inconsistency
Indirect
-ness
Quality
ASD
Controls
Sensitivity
(95%CI)
Specificity
(95%CI)
PRIMARY SCHOOL CHILDREN (6-11 years)
No social play
1
Con
obs
Serious
NA
None
Very low
20
37
90
(77,100)
100
(100,100)
Social isolation
1
Con
obs
Serious
NA
None
Very low
20
37
80 (62,98)
70 (51,88)
No respect for personal
boundaries
1
Con
obs
Serious
NA
None
Very low
20
37
90 (28,72)
63 (41,85)
Socially inappropriate
behaviour
1
Con
obs
Serious
NA
None
Very low
20
37
40 (19,61)
84 (68,100)
Unable to follow rules of a
game
1
Con
obs
Serious
NA
None
Very low
20
37
100
(100,100)
68 (48,89)
Doesn’t respond to
winning/losing a game
1
Con
obs
Serious
NA
None
Very low
20
37
100
(100,100)
100
(100,100)
Doesn’t initiate
communication with peers
1
Con
obs
Serious
NA
None
Very low
20
37
80 (62,98)
77 (64,88)
Doesn’t sustain conversation
with peers
1
Con
obs
Serious
NA
None
Very low
20
37
100
(100,100)
88 (79,94)
Gross motor inco-ordination
1
Con
obs
Serious
NA
None
Very low
20
37
65 (44,86)
100
(100,100)
No functional use of
playground equipment
1
Con
obs
Serious
NA
None
Very low
20
37
50 (28,72)
68 (52,83)
66
Neuroscience modalities for measuring empathy
Discrimination maps for the five
different morphometric features in the
left and right hemispheres
EEG in 5 year old girl with LKS
• Mundy (2003): PET scanning of children
undergoing hemispherectomy showed that left
frontal hemisphere was predictive of being able to
initiate joint attention
• Herber (2006): the implicit matching of emotions
subserved by the subcortical limbic system, explicit
by the prefrontal cortex
• Ecker (2010): the neuroanatomy of autism is
inherently difficulty to describe. A multi-parametric
classification showed that the neuroanatomy of
autism is truly multidimensional and affects
multiple and most likely independent cortical
features
• Lombardo (2010): atypical neural self
representation in autism
Using eye tracking as an early assessment of
cognitive and social functioning in at-risk infant
groups
Karri Gillespie-Smith, Sue Fletcher-Watson, James Boardman,
Ian Murray, Jane Norman, Anne O’Hare
INTRODUCTION
• Recent studies have identified that eye-tracking gaze behaviours in
at-risk infants are predictive of later ASD diagnosis.
• Edinburgh Perinatal Injury Research Group are interested in exploring
these same effects in babies born premature.
• We have developed novel eye-tracking assessments measuring
social and cognitive constructs in typically developing infants aged
6-12 months.
• We explore if we can create valid cognitive assessments for the 1st
year of life and relate these to clinically relevant variables.
METHODOLOGY
PARTICIPANTS
• 30 typically developing infants (16 female; 14 male)
• Age = 182–366 days old
PROCEDURE
• An eye-tracking battery was presented in three 8 minute
blocks combining both novel visual tasks with previously tested
tasks provided by British Autism Study of Infant Siblings (BASIS)
• Additional measures were also collected to investigate the
relationship between eye tracking tasks, maternal mental
health and stress
METHODOLOGY
A
B
C
D
(A) Memory (B) Gap-Overlap Task (C) Face Scanning
(D) Pop-Out Task (E) Social Scene Preference
E
Results: Validation of Tasks
Significant age effect
with performance in
memory task which
indicated older infants
showed a novelty
effect and younger
infants showed a
familiarity effect
(p<0.05)
Significant correlation between age and
novelty effect during the memory task with
2000 (ms) gap only
Results: Links to Clinical Markers
Significant correlation
between Daily Hassles
Score and Social Score
showing that mothers
who view tasks as less
stressful show more prosocial gaze (p<0.05)
Significant correlation between hassle scores
and standardized social scores
DISCUSSION
 Infants show high social preferences. Social tasks
correlated with each other (validating new cognitive
tasks); standardized social score was created.
 Eye gaze data correlated with with clinical markers ie
social standardized score and maternal stress/hassle;
novel or familiarity preferences during memory task
with age.
 Future research directions will involve developing more
visual tasks and exploring eye-tracking further as a
clinical marker in at-risk infant groups ie babies born
pre-term.
Grateful thanks to …
Prosody: Fiona Gibbon, Joanne McCann J, Sue Peppe,
Leanne Carroll, Queen Margaret University, Edinburgh;
Marion Rutherford, Royal Hospital for Sick Children,
Edinburgh.
Dyspraxia/Sensory: Amanda Adamson, Kirsty Forsyth, Jill
Gorzkowska, Queen Margaret University; Rob Elton,
University of Edinburgh.
Mentalising Assessment: Lynne Bremner, Marysia Nash,
Royal Hospital for Sick Children, Edinburgh.
Prevalence ASD: Harry Campbell, Mark Harrison,
Edinburgh University.
Leukaemia and CNS: Tim Eden, Midge Clarke, Keith Brown,
University of Edinburgh.
Autism Achieve Alliance: Iain McClure, Karen McKenzie,
University of Edinburgh; Kirsty Forsyth, Marion Rutherford,
Ciara Catchpole, Tess Johnson, Ashley Peter, Deborah
McCartney, Queen Margaret University
ISS: Eye tracking: Karri Gillespie-Smith, Sue FletcherWatson, James Boardman, Ian Murray, Jane Norman,
University of Edinburgh
Autism & Reactive Attachment Disorder: Fiona Minnis,
Claire Davidson, Glasgow University; Fiona MacTaggart,
NHS Lothian.
Funders:
CSO  Action Medical Research  ESRC
 MRC  Autism Speaks  NHS QIS  RHSC
Friends Foundation (Autism Research and
Development Fund)  Scottish Executive
Surestart Programme and Innovation Fund 
NHS HTA  Research and Development Fund,
Western Hospital, Toronto  LUHTR&D 
Action Against Autism  Wellcome ISSF