Assessing Theory of Mind in Children: A Tablet-Based Adaptation of a Classic Picture Sequencing Task.

Correctly assessing children's theory of mind (TOM) is essential to clinical practice. Yet, most tasks heavily rely on language, which is an obstacle for several populations. Langdon and Coltheart's (Cognition 71(1):43-71, 1999) Picture Sequencing Task (PST), developed for research purposes, avoids this limitation through a minimally-verbal procedure. We thus developed a tablet adaptation of this task for individual application, engaging children's motivation and allowing response times collection. To assess this tablet-PST, we first tested a large sample of neurotypical children (6-11 years-old, N = 248), whose results confirmed the task's structural and content validity, and permitted the construction of three standardized clinical indices. In a second experiment, we applied those to previously diagnosed autistic children (N = 23), who were expected to show atypical TOM performance. Children's outcomes were consistent with what was hypothesized and confirmed the task's external validity and moderate clinical sensitivity. The tablet-PST thus appears as a suitable tool, providing detailed profiles to inform clinical decisions.

Clinical predictors of psychotropic medication prescription in children with ASD of the ELENA cohort.

Psychotropic drugs are often used to treat behavior problems in ASD with some evidence supporting efficacity (e.g.: risperidone and irritability) but also significant side effects at the short and longer-term. It is then essential to know better the factors associated with the prescription of these medications and potentially implement early behavioral and psychosocial intervention or cognitive remediation before to use medication. We designed a case-control study based on the population of the ELENA cohort to assess the factors associated with early psychotropic drugs use in children with ASD. Externalized behavior symptoms (measured by the Child Behavior Checklist) is the leading risk factor during the first years of follow-up (aOR = 2.8; CI [1.04; 7.67]; p = 0.04). Age, gender, autism severity, adaptive behaviors, or internalized behaviors were not associated with psychotropic medication prescription. Low IQ and parents who had received training tended to increase the risk of psychotropic medication prescription during follow-up but were not statistically significant. These findings underscore the need for early identification of symptoms of externalizing behaviour, early appropriate information for parents about treatment with and without medication, early analysis of externalising behaviour and targeted treatments.

A 1-Day Training Course to Disseminate the BREF Psychoeducational Program to Caregivers and Promote Network Establishment between Psychiatry Departments and Family Associations.

OBJECTIVE: Although international guidelines state that psychoeducation to caregivers should be provided systematically, it remains insufficiently available in psychiatry. This study reports the development and evaluation of an original training course aimed to provide participants with the knowledge and skills to implement "BREF," a psychoeducational program for caregivers. METHODS: The BREF program training course, a free, 1-day course incorporating peer role-play was developed. In addition to psychiatrists, nurses, and psychologists, caregivers were involved as preceptors. Participants were mental health professionals and volunteer caregivers. Participants to the first 28 sessions of the course (n=467) completed a post-course questionnaire (n=341) and a cross-sectional questionnaire (n=56). Quantitative data on satisfaction, learning, and behavior changes following the course were collected equating to levels 1, 2, and 3 of Kirkpatrick's model. RESULTS: After the course, high levels of satisfaction and commitment were observed with 100% of responders recommending the course and 81% intending to implement the BREF program. Confidence mean score to implement BREF was 7.9/10 (±1.4) with no significant effect of course session. At cross-sectional evaluation, 73% of responders reported improvements in skills related to providing psychoeducation to caregivers, 64% stated that the BREF program was implemented/under implementation, and 66% stated that their department had connected with a family association. CONCLUSIONS: Training course sessions alone can increase psychoeducational programs for caregivers and network establishment. The BREF program training course demonstrates a high level of participant satisfaction and is a promising method to disseminate psychoeducation to caregivers, thus addressing a major shortage in mental health organization.

Response (minimum clinically relevant change) in ASD symptoms after an intervention according to CARS-2: consensus from an expert elicitation procedure.

The lack of consensual measures to monitor core change in Autism Spectrum Disorder (ASD) or response to interventions leads to difficulty to prove intervention efficacy on ASD core symptoms. There are no universally accepted outcome measures developed for measuring changes in core symptoms. However, the CARS (Childhood Autism Rating Scale) is one of the outcomes recommended in the EMA Guideline on the clinical development of medicinal products for the treatment of ASD. Unfortunately, there is currently no consensus on the response definition for CARS among individuals with ASD. The aim of this elicitation process was to determine an appropriate definition of a response on the CARS2 scale for interventions in patients with Autism Spectrum Disorder (ASD). An elicitation process was conducted following the Sheffield Elicitation Framework (SHELF). Five experts in the field of ASD and two experts in expert knowledge elicitation participated in an 1-day elicitation workshop. Experts in ASD were previously trained in the SHELF elicitation process and received a dossier of scientific evidence concerning the topic. The response definition was set as the mean clinically relevant improvement averaged over all patients, levels of functioning, age groups and clinicians. Based on the scientific evidence and expert judgment, a normal probability distribution was agreed to represent the state of knowledge of this response with expected value 4.03 and standard deviation 0.664. Considering the remaining uncertainty of the estimation and the available literature, a CARS-2 improvement of 4.5 points has been defined as a threshold to conclude to a response after an intervention. A CARS-2 improvement of 4.5 points could be used to evaluate interventions' meaningfulness in indivudals. This initial finding represents an important new benchmark and may aid decision makers in evaluating the efficacy of interventions in ASD.

Neural correlates of interoceptive accuracy: Beyond cardioception.

Interoceptive accuracy (IAc), the precision with which one assesses the signals arising from one's own body, is receiving increasing attention in the literature. IAc has mainly been approached as an individual trait and has been investigated through the cardiac modality using mostly non-ecological methods. Such studies consensually designate the anterior insular cortex as the main brain correlate of IAc. However, there is a lack of brain imaging studies investigating IAc in a broader and more ecological way. Here, we used a novel ecological task in which participants monitored their general bodily reactions to external events and investigated brain regions subtending intraindividual (i.e. trial-by-trial) variations of IAc. At each trial, participants had to rate the intensity of their bodily reactions to an emotional picture. We recorded participants' skin conductance response (SCR) to the picture as an indicator of actual physiological response intensity. We fitted a functional magnetic resonance imaging (fMRI) model using, as regressors, the SCR value, the rating and the product of the two (as a proxy of participants' IAc) obtained trial per trial. We observed that activity in the dorsomedial prefrontal cortex (dmPFC) increased when individuals' IAc decreased. This result reveals general mechanism of error processing in intraindividual variations of IAc, which are unspecific to interoception. Our result has a practical impact in the clinical domain. Namely, it supports the predictive coding framework whereby IAc deficits may reflect impairments in processing a mismatch between actual interoceptive signals and predictions.

"Reading the Mind in the Eyes" in Autistic Adults is Modulated by Valence and Difficulty: An InFoR Study.

Autism spectrum disorders (ASD) are heterogeneous and complex neurodevelopmental conditions that urgently need reliable and sensitive measures to inform diagnosis properly. The Reading the Mind in the Eyes Task (or Eyes Test from now on) is widely used for this purpose. A recent study showed that subcategories of items of the children version of the Eyes Test could be especially discriminative to distinguish ASD and control children. Here, we analyzed the performance on the Eyes Test of 30 high functioning (IQ > 70) adults with ASD and 29 controls from the InFoR cohort multicentric study, using a Generalized Linear Mixed Model. We found that valence and difficulty modulate the performance on the Eyes Test, with easy and positive items being the most discriminative to distinguish ASD and controls. In particular, we suggest this result might be actionable to discriminate ASD patients from controls in subgroups where their overall scores show less difference with controls. We propose for future research the computation of two additional indexes when using the Eyes Test: the first focusing on the easy and positive items (applying a threshold of 70% of correct responses for these items, above which people are at very low risk of having ASD) and the second focusing on the performance gain from difficult to easy items (with a progression of less than 15% showing high risk of having ASD). Our findings open the possibility for a major change in how the Eyes Test is used to inform diagnosis in ASD. LAY SUMMARY: The Eyes Test is used worldwide to inform autism spectrum disorders (ASD) diagnosis. We show here that ASD and neurotypical adults show the most difference in performance on subgroups of items: ASD adults do not improve as expected when comparing easy and difficult items, and they do not show an improvement for items displaying a positive feeling. We advise clinicians to focus on these comparisons to increase the property of the test to distinguish people with ASD from neurotypical adults.

How did I get so late so soon? A review of time processing and management in autism.

While the definition of Autism Spectrum Disorder (ASD) does not include any explicit criteria concerning difficulties of time perception or management, there is growing evidence of atypical temporal perception in individuals with ASD. This review synthesizes the evidence and gaps of the current literature on time processing in ASD. After a brief overview of clinical findings and available assessment tools, we synthetize outcomes of studies evaluating time perception at second and infra-second level, and then, recent literature on the circadian timing system. Findings point that all levels of time processing are atypical in autism (i.e. millisecond, interval and circadian timing). We discuss how time perception abnormalities and ASD core symptoms might intertwine and offer a new perspective for future research on this topic. We advocate the need to systematically assess temporal perception in ASD, and to include these aspects in global functional assessments before intervention. Implementing early intervention techniques to remediate time perception alterations in children with ASD may substantially improve their developmental trajectory.

I know you can see me: Social attention influences bodily self-awareness.

It has recently been demonstrated that eye contact influences bodily self-awareness. Here, we investigated if the belief of being the target of another person's attention may also induce such influence. We created videos of an individual wearing two different pairs of sunglasses. We manipulated the participants to believe that they were in on-line connection with the individual and that one of the pairs of sunglasses was obstructed so that the individual could not see them through it. We demonstrated that the perception of an individual wearing see-through sunglasses, as compared to obstructed sunglasses or a low-level baseline condition, led to a greater correlation between the participants' rating of the intensity of their bodily reactions and their skin conductance response to emotional pictures. This shows that the belief to be watched by another social agent increases bodily self-awareness and further suggests that such belief is embedded in direct gaze perception.

Eye contact elicits bodily self-awareness in human adults.

Eye contact is a typical human behaviour known to impact concurrent or subsequent cognitive processing. In particular, it has been suggested that eye contact induces self-awareness, though this has never been formally proven. Here, we show that the perception of a face with a direct gaze (that establishes eye contact), as compared to either a face with averted gaze or a mere fixation cross, led adult participants to rate more accurately the intensity of their physiological reactions induced by emotional pictures. Our data support the view that bodily self-awareness becomes more acute when one is subjected to another's gaze. Importantly, this effect was not related to a particular arousal state induced by eye contact perception. Rejecting the arousal hypothesis, we suggest that eye contact elicits a self-awareness process by enhancing self-focused attention in humans. We further discuss the implications of this proposal.