Assessing aspects of early social communication in non-speaking children with bilateral cerebral palsy.

PURPOSE: Research suggests that rates for autism may be higher in cerebral palsy than in the general population. For those with severe bilateral physical impairment (GMFCS level IV and V) and little or no speech, describing a profile of social communication skills has been difficult because there are currently no assessments for early social communication specifically tailored for these children. Our aim was to explore the assessment of aspects of joint attention and social reciprocity in this group of children with CP. METHODS: We compared the performance of children with bilateral CP on carefully designed assessments of joint attention and social responsiveness with groups of children with Down syndrome and autism. All three groups were matched for chronological age and mental age. RESULTS: Approximately 30% of the children with bilateral CP had early social communication scores similar to the autistic children. The remaining 70% of children with CP had a range of early social communication scores similar to the children with Down syndrome. CONCLUSION: It is possible to assess key early social communication skills in non-speaking children with bilateral motor disability. This could provide insights to help clinicians and caregivers as they discuss abilities and explore potential areas for intervention.

With carefully designed activities, which do not rely on motor skills or verbal exchanges, it was possible to assess joint attention and social responsiveness skills in a group of non-speaking children with bilateral motor disability.We were able to identify a subgroup of non-speaking children with severe motor disability (approximately 30% of our cohort) whose scores on our assessments were similar to a group of autistic children.The ability to describe key early social communication skills should provide insights to help clinicians and caregivers as they discuss abilities and explore potential areas for intervention.

The Functional Vision for Communication Questionnaire (FVC-Q): Exploring Parental Report of Non-Speaking Children's Fixation Skills Using a Structured History-Taking Approach.

This paper explores whether a structured history-taking tool yields useful descriptions of children's looking skills. Parents of 32 children referred to a specialist communication clinic reported their child's looking skills using the Functional Vision for Communication Questionnaire (FVC-Q), providing descriptions of single object fixation, fixation shifts between objects and fixation shifts from object to person. Descriptions were compared with clinical assessment. 24/32 children were reported to have some limitation in fixation. Limitation was subsequently seen in 30/32 children. Parental report and assessment agreed fully in 23/32 (72%). The largest area of discrepancy was object-person fixation shifts, with five children not observed to show this behavior despite its being reported. Findings indicate a structured questionnaire yields description of fixations, which correspond well with clinical assessment. Descriptions supported discussion between parents and clinicians. It is proposed that the FVC-Q is a valuable tool in supporting clinicians in eliciting information about fixation skills.

Use of eye-pointing by children with cerebral palsy: what are we looking at?

BACKGROUND: Children with cerebral palsy often show significant communication impairment due to limited or absent speech. Further, motor impairment can restrict the use of movement, including pointing, to signal interest and intent. For some children, controlled gaze can be an effective 'point-substitute': such 'eye-pointing' can be used to request items, establish mutual interest in an event, or select vocabulary within an alternative or augmentative communication (ACC) system. However, in clinical practice there is a lack of clarity about how the term 'eye-pointing' is used, how 'eye-pointing' is recognized or how it relates to social development. AIMS: To present a clinical description of the term 'eye-pointing' with reference to children with severe cerebral palsy who cannot speak or finger-point. To consider this description within a wider discussion of the importance of gaze in communication development. METHODS & PROCEDURES: Cumulative clinical observations during assessment of children referred to a specialist multidisciplinary communication clinic have provoked discussion between the authors on what factors precipitate use of the term 'eye-pointing' in young children with severe cerebral palsy. In particular, discussion has centred on whether use of the term is appropriate in individual cases and whether guidance is available about how gaze should be observed in this developmentally vulnerable group of children. A literature search was also conducted in order to explore whether the use and meaning of the term is established. CONCLUSIONS & IMPLICATIONS: In interactions with non-speaking children, determining whether a child is using eye-gaze communicatively requires observation and interpretation of several factors. These processes will be informed by reflection on what is known about other aspects of the child's communication and interaction skills. Within the literature, the term 'eye-pointing' is sometimes used when describing the communication functions of individuals using augmentative and alternative communication (AAC) systems, and is occasionally qualified by a definition. No papers have been found that set out a clinical description universally applicable to children with severe motor impairment. Moreover, guidance is lacking on how possible episodes of 'eye-pointing' might be confidently distinguished from other episodes of directed gaze in young, developing communicators. The discussion of the term makes reference to the importance of gaze in early communication development, and explores factors that might influence gaze and its interpretation in young children with cerebral palsy. A description of eye-pointing for this group is offered. The authors suggest that this will bring practical benefits to those supporting the communication development of children with severe cerebral palsy.

The ability of typically developing 2-3 year olds to infer the control mechanism for eye-gaze technology and the impact of causal language instruction.

PURPOSE: Little is known about how children learn to control eye-gaze technology, and clinicians lack information to guide decision-making. This paper examines whether typically developing 2-3 year olds can infer for themselves the causal mechanisms by which eye-gaze technology is controlled, whether a teaching intervention based on causal language improves performance and how their performance compares to the same task accessed via a touchscreen.Methods and materials: Typically developing children's (n = 9, Mean Age 28.7 months) performance on a cause and effect game presented on eye-gaze and touchscreen devices was compared. The game was presented first with no specific instruction on how to control the devices. This was followed by a subsequent presentation with explicit instruction about how the access methods worked, using a causal language approach. A final presentation examined whether children had retained any learning. RESULTS: Performance in the eye-gaze condition without instruction (42.5% successful trials) was significantly below performance in the corresponding touchscreen condition (75%). However, when causal language instruction was added, performance with both access methods rose to comparable levels (90.7% eye-gaze and 94.6% touchscreen success). Performance gains were not retained post-intervention. CONCLUSIONS: Although 2-3 years in the study could make use of eye-gaze technology with support, this study found no evidence that these children could infer the causal mechanisms of control independently or intuitively. The lack of spatial contiguity and the comparative lack of feedback from eye-gaze devices are discussed as possible contributory factors.

There are challenges in young children inferring for themselves the causal link between eye movements and control of an eye-gaze device.Explicit instruction may improve children's performance in a specific task, but it is debatable whether this translates to the establishment of causal mechanisms for control of the device.Clinicians should be cautious of making assumptions about what children are learning from activities claiming to teach cause and effect or other foundational eye-gaze control skills.

Development and testing of the eye-pointing classification scale for children with cerebral palsy.

PURPOSE: The aim of this study was to develop and test a new classification scale to describe looking behaviours (gaze fixations and gaze shifts) in relation to eye-pointing. METHODS: The Eye-pointing Classification Scale (EpCS) was developed and tested following established procedures for the construction and evaluation of equivalent scales, and involved 2 phases: Drawing on research literature, Phase 1 involved initial drafting of the scale through a series of multi-disciplinary group discussions; evaluation of the scale through a survey procedure, and subsequent expert group evaluation. Phase 2, was an examination of scale reliability and relationships between child characteristics and level of EpCS classification. RESULTS: In Phase 1, an initial draft of the scale was developed and then evaluated by 52 participants in 10 countries, leading to its refinement. Subsequent expert evaluation of content, style and structure indicated that no further refinement was required. In Phase 2, the scale achieved excellent levels of reliability in clinical testing. A significant relationship was identified between level of child motor ability and EpCS classification, and level of child language understanding and EpCS classification.Implications for rehabilitationNon-speaking children with severe bilateral cerebral palsy who have limited upper limb movement may communicate by using controlled looking behaviours to point to objects and people, referred to as eye-pointing.However, there is little consensus as to which looking behaviours represent eye-pointing and which do not.The Eye-pointing Classification Scale (EpCS) was developed to describe looking behaviours related to eye-pointing in this population of childrenThe EpCS provides a new robust tool for clinical management and research with children with cerebral palsy.

The Effect of Visual Perceptual Load on Auditory Awareness of Social vs. Non-social Stimuli in Individuals with Autism.

This study examined the effect of increasing visual perceptual load on auditory awareness for social and non-social stimuli in adolescents with autism spectrum disorder (ASD, n = 63) and typically developing (TD, n = 62) adolescents. Using an inattentional deafness paradigm, a socially meaningful ('Hi') or a non-social (neutral tone) critical stimulus (CS) was unexpectedly presented under high and low load. For the social CS both groups continued to show high awareness rates as load increased. Awareness rates for the non-social stimulus were reduced when load increased for the TD, but not the ASD group. The findings indicate enhanced capacity for non-social stimuli in ASD compared to TD, and a special attentional status for social stimuli in the TD group.

Development of motion processing in children with autism.

Recent findings suggest that children with autism may be impaired in the perception of biological motion from moving point-light displays. Some children with autism also have abnormally high motion coherence thresholds. In the current study we tested a group of children with autism and a group of typically developing children aged 5 to 12 years of age on several motion perception tasks, in order to establish the specificity of the biological motion deficit in relation to other visual discrimination skills. The first task required the recognition of biological from scrambled motion. Three quasi-psychophysical tasks then established individual thresholds for the detection of biological motion in dynamic noise, of motion coherence and of form-from-motion. Lastly, individual thresholds for a task of static perception--contour integration (Gabor displays)--were also obtained. Compared to controls, children with autism were particularly impaired in processing biological motion in relation to any developmental measure (chronological or mental age). In contrast, there was some developmental overlap in ability to process other types of visual motion between typically developing children and the children with autism, and evidence of developmental change in both groups. Finally, Gabor display thresholds appeared to develop typically in children with autism.

Selective attention and perceptual load in autism spectrum disorder.

It has been suggested that the locus of selective attention (early vs. late in processing) is dependent on the perceptual load of the task. When perceptual load is low, irrelevant distractors are processed (late selection), whereas when perceptual load is high, distractor interference disappears (early selection). Attentional abnormalities have long been reported within autism spectrum disorder (ASD), and this study is the first to examine the effect of perceptual load on selective attention in this population. Fourteen adults with ASD and 23 adults without ASD performed a selective attention task with varying perceptual loads. Compared with the non-ASD group, the ASD group required higher levels of perceptual load to successfully ignore irrelevant distractors; moreover, the ASD group did not show any general reduction in performance speed or accuracy. These results suggest enhanced perceptual capacity in the ASD group and are consistent with previous observations regarding superior visual search abilities among individuals with ASD.

Contrasting the Effects of Task Difficulty and Perceptual Load on Auditory Detection Sensitivity in Individuals with Autism.

To test a central assumption of the increased perceptual capacity account in individuals with Autism Spectrum Disorder (ASD), the effects of perceptual load and target-stimulus degradation on auditory detection sensitivity were contrasted. Fourteen adolescents with ASD and 16 neurotypical controls performed a visual letter search task under three conditions: low perceptual load, high perceptual load and low perceptual load with a degraded target while simultaneously detecting an auditory tone in noise. For both participants with ASD and neurotypical controls, increasing perceptual load and target degradation increased task difficulty as indexed by reaction times and accuracy. However, only increasing perceptual load reduced subsequent auditory detection sensitivity. The study confirms that perceptual load, and not task difficulty, modulates selective attention in ASD.

Signing with the Face: Emotional Expression in Narrative Production in Deaf Children with Autism Spectrum Disorder.

This study examined facial expressions produced during a British Sign Language (BSL) narrative task (Herman et al., International Journal of Language and Communication Disorders 49(3):343-353, 2014) by typically developing deaf children and deaf children with autism spectrum disorder. The children produced BSL versions of a video story in which two children are seen to enact a language-free scenario where one tricks the other. This task encourages elicitation of facial acts signalling intention and emotion, since the protagonists showed a range of such expressions during the events portrayed. Results showed that typically developing deaf children produced facial expressions which closely aligned with native adult signers' BSL narrative versions of the task. Children with ASD produced fewer targeted expressions and showed qualitative differences in the facial actions that they produced.

Implications of capacity in the classroom: Simplifying tasks for autistic children may not be the answer.

BACKGROUND: Research has demonstrated evidence for increased perceptual capacity in autism: autistic people can process more information at any given time than neurotypical individuals. The implications of this for educating autistic pupils have not been investigated. For example, this ability to process more information at any given time may explain why autistic children sometimes process more peripheral task-irrelevant information than neurotypical individuals (e.g. in background classroom wall-displays). AIMS: The current study assessed the impact of different types of background information on autistic and non-autistic children's ability to perform a learning task. METHODS AND PROCEDURES: Autistic (N = 23) and non-autistic (N = 50) children took part in a computer-based task designed to simulate a lesson. They watched three videos of a teacher telling a story, each with a different background condition: blank, relevant images, or irrelevant images. OUTCOMES AND RESULTS: When the visual display contained story-relevant information, both groups recalled background information in addition to the central story. When the background displays were irrelevant to the story, autistic children recalled more background information than their neurotypical peers, yet maintained their ability to recall information from the central story. CONCLUSION AND IMPLICATIONS: The current study suggests that pupils' perceptual capacity- including those on the autistic spectrum - can indeed be capitalised on to support learning in the classroom. To do so, however, we must ensure that the child can use their capacity for task-relevant processing, rather than irrelevant distractions.

Visual perceptual load reduces auditory detection in typically developing individuals but not in individuals with autism spectrum disorders.

OBJECTIVE: Previous studies examining selective attention in individuals with autism spectrum disorder (ASD) have yielded conflicting results, some suggesting superior focused attention (e.g., on visual search tasks), others demonstrating greater distractibility. This pattern could be accounted for by the proposal (derived by applying the Load theory of attention, e.g., Lavie, 2005) that ASD is characterized by an increased perceptual capacity (Remington, Swettenham, Campbell, & Coleman, 2009). Recent studies in the visual domain support this proposal. Here we hypothesize that ASD involves an enhanced perceptual capacity that also operates across sensory modalities, and test this prediction, for the first time using a signal detection paradigm. METHOD: Seventeen neurotypical (NT) and 15 ASD adolescents performed a visual search task under varying levels of visual perceptual load while simultaneously detecting presence/absence of an auditory tone embedded in noise. RESULTS: Detection sensitivity (d') for the auditory stimulus was similarly high for both groups in the low visual perceptual load condition (e.g., 2 items: p = .391, d = 0.31, 95% confidence interval [CI] [-0.39, 1.00]). However, at a higher level of visual load, auditory d' reduced for the NT group but not the ASD group, leading to a group difference (p = .002, d = 1.2, 95% CI [0.44, 1.96]). As predicted, when visual perceptual load was highest, both groups then showed a similarly low auditory d' (p = .9, d = 0.05, 95% CI [-0.65, 0.74]). CONCLUSIONS: These findings demonstrate that increased perceptual capacity in ASD operates across modalities. (PsycINFO Database Record

Motion and form coherence detection in autistic spectrum disorder: Relationship to motor control and 2:4 digit ratio.

Children with autistic spectrum disorder and controls performed tasks of coherent motion and form detection, and motor control. Additionally, the ratio of the 2nd and 4th digits of these children, which is thought to be an indicator of foetal testosterone, was measured. Children in the experimental group were impaired at tasks of motor control, and had lower 2D:4D than controls. There were no group differences in motion or form detection. However a sub-group of children with autism were selectively impaired at motion detection. There were significant relationships between motion coherence detection and motor control in both groups of children, and also between motion detection, fine motor control and 2D:4D in the group of children with autistic spectrum disorder.

The effect of visual perceptual load on auditory awareness in autism spectrum disorder.

Recent work on visual selective attention has shown that individuals with Autism Spectrum Disorder (ASD) demonstrate an increased perceptual capacity. The current study examined whether increasing visual perceptual load also has less of an effect on auditory awareness in children with ASD. Participants performed either a high- or low load version of a line discrimination task. On a critical trial, an unexpected, task-irrelevant auditory stimulus was played concurrently with the visual stimulus. In contrast to typically developing (TD) children, children with ASD demonstrated similar detection rates across perceptual load conditions, and reported greater awareness than TD children in the high perceptual load condition. These findings suggest an increased perceptual capacity in children with ASD that operates across sensory modalities.

Interpreting gaze in Turner syndrome: impaired sensitivity to intention and emotion, but preservation of social cueing.

Women with Turner's syndrome (TS), who lack a complete X-chromosome, show an impairment in remembering faces and in classifying "fear" in face images. Could their difficulties extend to the processing of gaze? Three tasks, all of which rely on the ability to make use of the eye-region of a pictured face, are reported. Women with TS were impaired at judging mental state from images of the upper face ("reading the mind in the eyes"). They were also specifically impaired at interpreting "fear" from displays of the eye-region of the face. However, they showed normal susceptibility to direction of gaze as an attentional cue (social cueing), since they were as sensitive as controls to the validity of the cue, under conditions where it should be ignored. In this task, unlike those of reading the upper face for intention or expression, PIQ accounted for a significant amount of individual variance in task performance. The processing of displays of the eye region affording social and affective information is specifically affected in TS. We speculate that amygdala dysfunction is likely to be implicated in this anomalous behaviour. The presence in the female karyotype of two complete X-chromosomes is protective for some socio-cognitive abilities related to the modulation of behaviour by the interpretation of gaze.

Thought-bubbles help children with autism acquire an alternative to a theory of mind.

Children with autism have specific difficulties understanding complex mental states like thought, belief, and false belief and their effects on behaviour. Such children benefit from focused teaching, where beliefs are likened to photographs-in-the-head. Here two studies, one with seven participants and one with 10, tested a picturein-the-head strategy for dealing with thoughts and behaviour by teaching children with autism about cartoon thought-bubbles as a device for representing such mental states. This prosthetic device led children with autism to pass not only false belief tests, but also related theory of mind tests. These results confirm earlier findings of the efficacy of picture-in-the-head teaching about mental states, but go further in showing that thought-bubble training more easily extends to children's understanding of thoughts (not just behaviour) and to enhanced performance on several transfer tasks. Thought-bubbles provide a theoretically interesting as well as an especially easy and effective teaching technique.

How do typically developing deaf children and deaf children with autism spectrum disorder use the face when comprehending emotional facial expressions in British sign language?

Facial expressions in sign language carry a variety of communicative features. While emotion can modulate a spoken utterance through changes in intonation, duration and intensity, in sign language specific facial expressions presented concurrently with a manual sign perform this function. When deaf adult signers cannot see facial features, their ability to judge emotion in a signed utterance is impaired (Reilly et al. in Sign Lang Stud 75:113-118, 1992). We examined the role of the face in the comprehension of emotion in sign language in a group of typically developing (TD) deaf children and in a group of deaf children with autism spectrum disorder (ASD). We replicated Reilly et al.'s (Sign Lang Stud 75:113-118, 1992) adult results in the TD deaf signing children, confirming the importance of the face in understanding emotion in sign language. The ASD group performed more poorly on the emotion recognition task than the TD children. The deaf children with ASD showed a deficit in emotion recognition during sign language processing analogous to the deficit in vocal emotion recognition that has been observed in hearing children with ASD.

Seeing the unseen: autism involves reduced susceptibility to inattentional blindness.

OBJECTIVE: Attention research in individuals with autism spectrum disorder (ASD) has produced conflicting results. Some findings demonstrate greater distractibility while others suggest superior focused attention. Applying Lavie's load theory of attention to account for this discrepancy led us to hypothesize increased perceptual capacity in ASD. Preliminary support for our hypothesis has so far been found for adults with ASD with reaction time (RT) and signal detection sensitivity measures. Here we test the novel prediction we derived from this hypothesis that children with ASD should have lower rates of inattentional blindness than controls. METHOD: Twenty-four children with ASD (mean age = 10 years 10 months) and 39 typically developing children (age and IQ matched) took part in the study. We assessed the effects of perceptual load on the rates of inattentional blindness in each group. Participants performing a line discrimination task in either a high load or low load condition were presented with an unexpected extra stimulus on a critical trial. Performance on the line judgment task and rates of detection and stimulus identification were recorded. RESULTS: Overall rates of detection and identification were higher in the ASD group than in the controls. Moreover, whereas both detection and identification rates were significantly lower in the high (compared with low) load conditions for the controls, these were unaffected by load in the ASD group. CONCLUSION: Reduced inattentional blindness rates under load in ASD suggests higher perceptual capacity is a core feature, present from childhood and leading to superior performance in various measures of perception and attention.

Perception of pointing from biological motion point-light displays in typically developing children and children with autism spectrum disorder.

We examined whether the movement involved in a pointing gesture, depicted using point-light displays, is sufficient to cue attention in typically developing children (TD) and children with autism spectrum disorder (ASD) (aged 8-11 years). Using a Posner-type paradigm, a centrally located display indicated the location of a forthcoming target on 80% of trials and the opposite location on 20% of trials. TD children, but not children with ASD, were faster to identify a validly cued target than an invalidly cued target. A scrambled version of the point-light pointing gesture, retaining individual dot speed and direction of movement but not the configuration, produced no validity effect in either group. A video of a pointing gesture produced validity effects in both groups.

Assessing true and false belief in young children with cerebral palsy through anticipatory gaze behaviours: a pilot study.

Children with a clinical description of cerebral palsy (CP) commonly experience cognitive and sensory difficulties that co-occur with motor impairment, and for some children this can include impairments in social communication. While research has begun to examine theory of mind abilities in children with CP, relatively little is known about social communication difficulties in this population. Assessing theory of mind abilities in children with CP using traditional procedures such as the classic Sally-Anne task can be problematic if performance is affected by physical difficulties in signalling responses and/or by cognitive and language demands inherent to the task itself. The central aim of this study therefore was to examine the potential of using a new action anticipation task and eye-tracking technique to assess implicit true and false belief understanding in four developmentally young children with quadriplegic cerebral palsy who had little or no functional speech, and one language age matched child with Down syndrome who did not have severe motor impairment. All children in this study consistently demonstrated anticipatory gaze behaviours in the context of the true belief task. One child with CP and the child with Down syndrome demonstrated anticipatory gaze behaviours indicative of an ability to attribute false belief. The findings are discussed in relation to the application of action anticipation and eye-tracking paradigms in research and clinical practice.