||Identifying cognitive correlates of social interactions in children with Autistic disorder and Asperger syndrome
||Department of Occupational Therapy
autism spectrum disorder
社交互動(social interaction)缺損是自閉症類群障礙症(autism spectrum disorder, ASD)孩童的核心特徵。ASD孩童社交互動當中亦缺乏適當的交互行為(reciprocity)。交互行為是產生合作行為的重要過程，讓人與人間可以一起進行活動並達成共同的目標。兒童社交互動及交互行為的發展仰賴日漸成熟的認知及情緒功能。過去研究指出與交互行為相關的腦部區域為控制心智理論(theory of mind)和執行功能(executive function)的腦區。但迄今未有行為研究同時考量二者探討ASD孩童交互行為。再加上在實驗室情境中，以結構化評估工具無法反應孩童交互行為缺損。若使用和日常生活的情境較相似的非結構化評估工具，可能可較精確評估與日常生活中較相似的交互行為。此外，目前探討ASD孩童社交互動的研究，大多僅使用心智理論和冷執行功能來解釋ASD孩童的社交缺損，未考量熱執行功能，即忽略情緒及動機對於社交互動重要性。
本研究從台南、高雄、台北的醫院及診所招募59位4至12歲依據精神疾病診斷與統計手冊第四版(The Diagnostic and Statistical Manual of Mental Disorders- fourth edition, DSM-IV)的自閉症(autistic disorder)及亞斯伯格症(Asperger’s syndrome)孩童。分別以心智理論測驗(Theory of Mind Task battery)、孩童賭博作業(Children’s gambling task)、卡片向度改變分類作業(Dimensional card change sort task , DCCS)、互動式繪畫作業(Interactive Drawing Task , IDT)、社交反應量表學齡版(Social Responsiveness Scale-second edition school aged form, SRS-2)、自閉症兒童行為檢核表(Childhood Autism Rating Scale, CARS)、魏氏兒童智力量表第四版/魏氏幼兒智力量表第四版(Wechsler Intelligence Scale for Children - Fourth Edition, WISC-IV/Wechsler Preschool and Primary Scale of Intelligence - Fourth Edition, WPPSI - IV)、文蘭適應行為量表(Vinland Adaptive Behavior Scale , VABS)評估兒童的心智理論、冷執行功能、熱執行功能、交互行為、自閉症症狀嚴重程度、語言能力、日常生活中的社交互動。統計分析包含（一）以描述性統計分析孩童的基本資料；（二）使用皮爾森相關係數(Pearson’s correlations coefficient)分析冷執行功能、熱執行功能、心智理論三個因子與交互行為及社交互動的相關性；（三）以冷執行功能、熱執行功能、心智理論為獨變項，使用逐步線性迴歸(stepwise linear regression analysis)分析三因子對於交互行為與社交互動之影響。
研究結果顯示自閉症及亞斯伯格症的孩童（一）冷執行功能中的單向度正確率(r =.482, p <.01 )、雙向度正確率(r =.501, p <.01)及熱執行功能(r =.396, p <.05)與交互行為有顯著的相關；在迴歸分析中，雙向度正確率與熱執行功能為顯著的預測因子，對交互行為有31.2%的解釋性；（二） 冷執行功能中的雙向度正確率(r =.348, p <.01)、單向度正確率(r = -.339, p <.01)、雙向度反應時間(r =-.296, p <.05)、轉換時間差(r =.382, p <.01) 與心智理論(r =.471, p <.01)與社交互動有顯著的相關性；在迴歸分析中，語言能力、症狀嚴重程度、執行功能中的轉換時間差為顯著的預測因子，對社交互動有47%的解釋性；（三）實驗室情境中交互行為(r =.290, p <.05)與日常生活情境中社交互動有顯著的相關。
本研究對於自閉症及亞斯伯格症之孩童的心智理論能力、冷執行功能、熱執行功能、交互行為與社交互動的相關性提供進一步的瞭解。研究結果顯示若自閉症及亞斯伯格症孩童有較佳的冷執行功能與熱執行功能可能會有較佳的交互行為、有較佳的心智理論與執行功能可能會有較佳的社交互動表現，以及有較佳的交互行為能力則可能會有較好的社交互動表現。然而，本研究有四限制，包含(一) 結果無法類化至低功能且無口語的ASD及未分類廣泛性發展障礙(pervasive developmental disorder not otherwise specified, PDD-NOS)診斷之孩童；(二) 心智理論能力可能因為測驗需要較好的語言能力而被低估；(三) 本研究並未考量孩童的交互行為可能受到社交互動風格(social interaction style)影響; (四) 本研究VABS教室版由家長填答，但應由老師填答。因此，建議未來研究可招募低功能且無口語的ASD、未分類廣泛性發展障礙診斷之孩童、使用較不需口語的心智理論評估工具、增加評估社交互動風格的工具、採納老師填答之學校社交互動表現，以更進一步闡明社交互動中所需的認知相關因子。此研究的結果協助我們找出影響自閉症及亞斯伯格症孩童日常生活社交互動及交互行為的認知因子，進而作為臨床依據改善自閉症及亞斯伯格症孩童的社交缺損，並進一步提升其日常生活的社交參與。
Social interaction deficits are core symptoms of children with autism spectrum disorder (ASD). Reciprocity deficit, one of the social interaction deficits in children with ASD, is the process of collaborative behavior between individuals who perform activities to reach shared goals. The reciprocity and social interaction deficits of children with ASD lead to difficulties in social participation in real-life contexts. Reciprocal behaviors and social interactions depend on the child’s developing cognitive skills and emotional functioning. In previous studies, the brain regions controlling theory of mind (ToM) and executive function (EF) were found to be the neural correlates of reciprocity. However, to date, no behavioral studies have investigated the relations among ToM, EF, and reciprocity in children with ASD. Moreover, the structured computer games used in past studies could not reflect the performance of children with ASD in real life contexts. In addition, ToM and cool EF have been examined to explain the social interaction deficit in children with ASD. However, based on current evidence these two abilities cannot fully explain the social deficits in children with ASD, possibly because the influences of motivation- and emotion-related factors, such as hot EF, were not examined in past studies
To resolve the above gaps, this study aimed to investigate in children with autistic disorder and Asperger’s syndrome (1) the correlates of reciprocity by considering cool EF, hot EF, and ToM; (2) the correlates of social interactions in daily life by considering cool EF, hot EF, and ToM; and (3) the correlation between reciprocity in a laboratory context and social interactions in a real-life context by using a relatively unstructured measure to assess reciprocity.
To fulfill these aims, 59 children with diagnoses of autistic disorder or Asperger’s syndrome according to the Diagnostic and Statistical Manual of Mental Disorders-fourth edition (DSM-IV) and aged from 4 to 12 years were recruited from clinics and hospitals in Tainan, Kaohsiung, and Taipei. Their ToM, hot and cool EF, reciprocity, social interactions, autistic symptom severity, and verbal abilities were examined with the Theory of Mind Task Battery (TOMB), Dimensional Card Change Sort Task (DCCS), Children’s Gambling Task, Interactive Drawing Task (IDT), Vinland Adaptive Behavior Scale (VABS), Social Responsiveness Scale (SRS), Childhood Autism Rating Scale (CARS), and Wechsler Intelligence Scale for Children-Fourth Edition (WISC-IV) or Wechsler Preschool and Primary Scale of Intelligence-Fourth Edition (WPPSI-IV). For the data analysis, (1) descriptive analysis was used to analyze the demographic data of the children; (2) Pearson’s correlation coefficients were used to analyze the correlations among cool EF, hot EF, and ToM to reciprocity and social interaction, respectively; and (3) stepwise regression and hierarchical regression models with a stepwise method were used to examine the predictors of reciprocity in the laboratory context and social interactions in real-life contexts, respectively.
The results of the present study showed the following: (1) Cool EF-single block accuracy (r =.482, p <.01), mixed block accuracy (r =.501, p <.01), and hot EF (r =.396, p <.05) were significantly correlated with reciprocity; in the stepwise regression and hierarchical regression models with a stepwise method, cool EF-mixed block accuracy and hot EF were significant predictors, jointly explaining 31.2% of the variance in reciprocity. (2) Cool EF-mixed block accuracy (r =.348, p <.01), single block reaction time (r = -.339, p <.01), mixed block reaction time (r =-.296, p <.05), shifting cost (r =.382, p <.01), and ToM (r =.471, p <.01) were significantly correlated with social interaction; in the stepwise regression and hierarchical regression models with a stepwise method, verbal ability, autistic symptom severity, and cool EF-shifting cost were the significant predictors, jointly explaining 47% of the variance in social interaction. (3) Reciprocity in the laboratory context (r =.290, p <.05) was significantly correlated with social interaction in daily life.
The present study provides further understanding of the relationships among ToM, cool EF, hot EF, reciprocity, and social interaction. The results indicate that children with autistic disorder and Asperger’s syndrome who have better cool and hot EF capacity tend to have better reciprocity capacity, that those who have better ToM and cool EF ability tend to have better social interaction performance, and that better reciprocity capacity has a positive correlation with social interaction. However, the limitations of the present study include the following: (1) The findings cannot be generalized to lower-functioning and non-verbal ASD and children diagnosed with PDD-NOS; (2) ToM ability may have been underestimated due to the verbal demands of the ToM tasks ; (3) social interaction style was not examined, and (4) the VABS-classroom version was reported by caregivers. Therefore, further study is warranted to (1) recruit lower-functioning children with less verbal ability and children diagnosed with PDD-NOS; (2) apply a ToM measurement which is less verbally demanding; (3) add a measure for assessing social interaction styles, and (4) collect VABS-classroom version reports from teachers to better illustrate the cognitive correlates in social interactions. The results of the present study should help clinicians to identify the cognitive correlates of reciprocity and social interactions in children with autistic disorder and Asperger’s syndrome, which can be the basis of clinical interventions for reducing children’s social interactions deficits and improving their social participations in daily life. In addition, the results may also serve as a foundation for further studies to identify the correlates of social interactions in children with ASD.
TABLE OF CONTENTS
TABLE OF CONTENTS X
LIST OF TABLES XIV
LIST OF FIGURES XV
LIST OF APPENDICES XVI
CHAPTER 1 Introduction 1
CHAPTER 2 Literature Review 6
2.1. Autism Spectrum Disorder 6
2.1.1. Diagnosis 6
2.1.2. Prevalence 9
2.1.3. Prognosis 10
2.2. Social interaction in children with Autism Spectrum Disorder 10
2.3. Reciprocity 11
2.3.1. Definition and importance of reciprocity 11
2.3.2. Neural correlates of reciprocity 12
2.3.3. Development of reciprocity 12
2.3.4. Reciprocity in children with Autism Spectrum Disorder 13
2.4. Theory of mind 14
2.4.1. Definition and importance 14
2.4.2. Development of theory of mind 15
2.4.3. Theory of mind in children with Autism Spectrum Disorder 16
2.5. Executive Function 17
2.5.1. Definition and importance 17
2.5.2. Cool executive function and hot executive function and their respective importance 17
2.5.3. Cool executive function in children with Autism Spectrum Disorder 19
2.5.4. Hot executive function in children with Autism Spectrum Disorder 20
2.6. The relationships between theory of mind and reciprocity in children with Autism Spectrum Disorder 21
2.7. The relationships between executive function and reciprocity in children with Autism Spectrum Disorder 21
2.8. The relationships between theory of mind and social interactions in children with Autism Spectrum Disorder 22
2.9. The relationships between executive function and social interactions in children with Autism Spectrum Disorder 22
2.10. Summary of the literature review 23
2.11. Schematic representation of human reciprocity in social interactions 24
CHAPTER 3 Methods 26
3.1. Purposes and hypotheses 26
3.2. Participants 26
3.3. Measures 27
3.3.1. Interactive Drawing Test (IDT) 28
3.3.2. Vineland Adaptive Behavior Scale (VABS) 29
3.3.3. Dimensional Card Change Sort Task (DCCS) 30
3.3.4. Children’s Gambling Task 32
3.3.5. Theory of Mind Task Battery 33
3.3.6. Wechsler Intelligence Scale for Children® - Fourth Edition (WISC®-IV) or Wechsler Preschool and Primary Scale of Intelligence™ - Fourth Edition (WPPSI™ - IV) 34
3.3.7. Social Responsiveness Scale (SRS) 35
3.3.8. Child Autism Rating Scale 36
3.4. Procedures 37
3.4.1. Measurement preparation 37
3.4.2. Study procedure 38
3.5. Data analysis 39
CHAPTER 4 Results 41
4.1. Demographic characteristics of the participants 41
4.2. Descriptive analysis of ToM, cool EF, hot EF, reciprocity and social interaction 42
4.3. The relationships among ToM, cool EF, hot EF, reciprocity and social interaction 43
4.4. The predictors of reciprocity 44
4.5. The predictors of social interaction 45
CHAPTER 5 DISCUSSION 46
5.1. The relationships between ToM, cool EF, hot EF and reciprocity 46
5.2. The relationships between ToM, cool EF, hot EF and social interaction 50
5.3. The relationship between reciprocity and social interaction 53
5.4. Limitations 54
5.5. Contributions and Implications 55
5.6. Conclusions 56
LIST OF TABLES
Table 1. Outcomes of each card in the advantageous and disadvantageous decks. 72
Table 2. Demographic characteristics of the participants 73
Table 3. Descriptive analysis of ToM, cool EF, hot EF, reciprocity and social
Table 4. Correlations on measurements of interest in children with ASD 75
Table 5. Stepwise linear regression analysis of reciprocity in children with ASD (N=59) 76
Table 6. Hierarchical regression analysis with stepwise method of reciprocity in children with ASD (N=59) 77
Table 7. Stepwise linear regression analysis of social interaction in children with ASD (N=59) 78
Table 8. Hierarchical regression analysis with stepwise method of social interaction in children with ASD (N=59) 79
LIST OF FIGURES
Figure 1. Schematic representation of human reciprocity in social interactions 80
Figure 2. Measurements corresponding to the measured abilities 81
Figure 3. Schematic illustration of two sample trials from a single task block of the
Dimensional Change Card Sort Task 82
Figure 4. Sample card face from the disadvantageous deck (Gain= 2, Loss= -4) 83
Figure 5. Procedure of the study 84
Figure 6. Overview of the number of participants for recruitment and the reason for exclusion 85
LIST OF APPENDICES
Appendix A. Diagnostic criteria for Autism Spectrum Disorder in DSM-5 86
Appendix B. Diagnostic criteria for Autism Spectrum Disorder in DSM-IV-TR 88
Appendix C. The inputs of IDT 92
Appendix D. The human study appoval 93
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