May 24, 2011 (Honolulu, Hawaii) — Virtual reality training may help improve complex social attention in school-aged children with higher-functioning autism (HFA), suggests new research presented here at the American Psychiatric Association (APA) 2011 Annual Meeting.
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| Head-mounted virtual reality apparatus |
In the pilot program, 18 children with HFA and 20 healthy controls wore head-mounted displays showing a virtual classroom with 9 "virtual avatar peers." As the participants gave short speeches about themselves, each peer was programmed to start fading and become transparent if ignored.
Although results showed no difference in the preadolescent HFA and control children in number of looks to the avatars, the adolescent HFA children made significantly fewer looks than did their age-matched controls, signifying evidence of impairment that emerges later in life.
In addition, "the social attention of all children was malleable," meaning the looks improved dramatically for all groups during the fade conditioning session, report the investigators.
"The preadolescent to adolescent period may represent an important window of opportunity to affect the course of autism," Peter Clive Mundy, PhD, professor of neurodevelopmental disorders and education at the University of California at Davis in Sacramento, told Medscape Medical News.
During his presentation, he noted that this effect may be due in part to adolescent changes in frontal connectivity and synaptic density during both executive functioning and social information processing.
"Research and intervention with school-aged HFA children should also carefully consider the impact of moderating factors, such as low average IQ or ADHD [attention-deficit/hyperactivity disorder] symptom expression," said Dr. Mundy.
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| Dr. Peter Clive Mundy |
Few Studies of HFA, Older Kids
According to the study, those with autism have impairments in the domains of joint attention (the capacity to readily coordinate visual, auditory, or mental attention with a social partner), social orienting (the tendency to prioritize and deploy attention to people vs objects), and face perception (the capacity to process facial expressions of affect and nonverbal communication). Together, these domains make up social attention.
"Complex social attention refers to school-aged development in these domains that involve enhanced effort because of number of possible attention options, such as difference in attention load and/or the dual task nature of the social interaction, such as attending to multiple social partners while also expressing one's own thoughts," write the researchers.
"The identification of impairments in these abilities and the examination of their malleability may be pivotal to advancing the treatment and prevention of impediments to positive outcome for these individuals," added Dr. Mundy.
However, he noted that there have been few studies of children with autism beyond the age of 9 and few concerning those with HFA.
"There has been a wholesale shift in the proportion of children with autism who function without intellectual development disability. And that has a huge impact on conceptualization of autism and its treatment," said Dr. Mundy.
The investigators enrolled 18 children with HFA and 20 children with typical development. The participants were further split into preadolescent (8-11 years old, n = 19) and adolescent (12-16 years old, n = 19) subgroups to measure age group effect.
All children, who had to have an IQ above 75 at entry, completed 2 sessions where they answered autobiographical questions for 3 minutes. In 1 session, the 3-dimensional virtual peers started fading if ignored and became solid again after fixation. In the other session, the peers did not change throughout the speech.
"The beauty of virtual reality is that with these head-mounted displays, the child actually controls a lot of what goes on in the interactive medium with their own visual attention," said Dr. Mundy.
In addition, the researchers examined effects associated with IQ and ADHD. For this study, lower IQ was defined as 80 to 105 and higher IQ was 106 to 136.
Measurements used included the Wechsler Abbreviated Scale of Intelligence, Autism Spectrum Screening Questionnaire, Social Communication Questionnaire, Social Responsiveness Scale, and Conner's 3 Parent Report (for Attention Deficit Standard Score and 9-item Learning Problems Scale Score).
Important Markers for Social Learning
Results showed that the number of looks to the avatars did not differ significantly between the preadolescent HFA and control groups (106.8 vs 98.3, respectively).
However, the number was significantly different between the adolescent HFA and control groups (105.4 vs 144.5, respectively).
"Interestingly, we didn't see a significant change between the preadolescent and the adolescent high-functioning children. They didn't show development in the capacity to look at people while talking," said Dr. Mundy.
The number of looks increased significantly for all groups during the fade cue conditioning session.
Twelve of the HFA children were in either or both of the lower IQ or higher ADHD (scores > 75) subgroups. The mean score for the higher ADHD group was 83.8.
The adolescent HFA children with higher ADHD scores "had the lowest rates of social attention compared to all other subgroups (82.93 looks to avatars)," report the investigators.
There was also a 76.6 group difference in looks between the HFA children with high ADHD and those with low ADHD scores, compared with a group difference of just 49.4 for the typical developing children with high and low ADHD scores (P < .001).
Although the number of looks did improve during fade cue conditioning for the HFA children with higher ADHD scores, it was not as strong as for the other groups.
The effect was similar for the HFA children with low IQ vs high IQ.
"Finally, regardless of ADHD symptoms, poorer social orienting was strongly associated with parent reports of School Learning Problems on the Conner's scale in both groups (P < .002)," report the researchers.
"This means that more looks equalled less learning problems and less looking meant more learning problems. And this was found in both those with HFA and in the controls," explained Dr. Mundy.
For those with autism, these learning problems were specifically related to poor spelling, a need for extra explanation, and poor math concepts, he said.
"This is very early and I'm not completely sure I trust these data. But they are in line with what we think is the case in social attention — that these are markers that are very important to the social learning that happens in school."
He reported that the next step is to replicate the study while determining social attention vs nonsocial attention effects and to evaluate "whether an intervention effect translates to an in vivo learning and social interaction test."
"Potentially Cool" Treatment Option
During the Q&A session after the presentation, Thomas Insel, MD, director of the National Institute of Mental Health, asked whether the findings are generalizable to a real-world setting. Dr. Mundy said this hasn't been investigated yet.
"It would be great if we could emulate social interactions in a way that virtual reality allows, but I'm not sure that's necessary. The important thing in changing executive function is allowing someone to practice often enough that it becomes effortless."
"So will it translate? Not sure, but I think that's the line of logic. It's important to have a place for them to practice these skills without errors in a variety of situations that mimic the real world."
Session discussant James McCracken, MD, professor and director of the Child and Adolescent Psychiatry Division at the University of California, Los Angeles, told Medscape Medical News that the study raised 2 important points.
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| Dr. James McCracken |
"One is the important developmental changes that occur after age 5 and 8 and 10. The other is the notion that while we may have a single gene disorder, there may be secondary problems that do not reflect the underlying pathophysiology of the disability. And we should be careful of that," said Dr. McCracken.
He also noted that using virtual reality could be "a very cool potential treatment option."
"Virtual reality allows us to create a replica of a social environment and then assess an individual's behavior in that paradigm. While we would like to believe that we can characterize a child's social adjustment by the standard questions to parents or teachers or person themselves, in actual fact our measures of social behavior and social functioning aren't very good. And they really fail us in measuring change in a treatment trial."
Dr. McCracken said that overall, he was impressed with the finding that although HFA children "start off looking very similar" to typically developing children in the age 8-10 range, "you really only start to see them falling down in their social development" when they get into the older range.
"There's something about social functioning during adolescence that is proving much more difficult for them to adapt to. And I think Dr. Mundy's work is really helping us to see that in a much more sensitive way than we have before."
The study was funded by grants from the National Institute of Mental Health and from the University of California, Davis, Department of Psychiatry Lisa Capps Endowment for Research on Neurodevelopmental Disorders and Education. Dr. Mundy has reported no relevant financial relationships. Dr. McCracken reported being a consultant for BioMarin and PharmaNet and receiving grant/research support from Seaside Therapeutics and BMS.
American Psychiatric Association (APA) 2011 Annual Meeting: Symposium 19, No. 4. Presented May 15, 2011.
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