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“Showing” Gesture in Children with Autism Spectrum Disorder

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“Showing” Gesture in Children with Autism Spectrum Disorder Beyond Pointing: Development of the “Showing” Gesture in Children with Autism Spectrum Disorder Caitlin Clements & Katarzyna Chawarska YALE UNIVERSITY While research on early indicators of autism spectrum disorder (ASD) has focused predominantly on infants’ inability to point, other social gestures such as showing may also help to distinguish ASD from non- autistic language delays in high-risk populations. Parents of infants at high-risk (HR) for ASD ( n = 28) and typically developing infants at low-risk (TD-LR; n = 12) reported their child’s gesture use at nine and twelve months. Infants were followed until 24 months, at which time 8 high-risk children showed symptoms of ASD (ASD-HR), 14 showed symptoms of language delay (LD-HR), and 6 were developing typically (TD-HR). Results indicate a lack of pointing in both ASD-HR and LD- HR groups at twelve months, but decreased frequency of showing on- ly in the ASD-HR group. These results suggest that the showing ges- ture might be a better indicator of ASD than pointing among infant siblings of children with ASD. Implications for early identification are discussed. 46 INTRODUCTION early recognition and diagnosis must rely on indicators of nonverbal communication Autism Spectrum Disorder skills that typically emerge before twelve Autism Spectrum Disorder (ASD) is a group months of age. of neurodevelopmental disorders character- ized by profound deficits in communication, Nonverbal communication social functioning, and the presence of re- Nonverbal communication skills develop petitive and stereotyped behaviors or inter- before verbal language and therefore can ests (American Psychiatric Association, play an important role in identification of 2004). It affects 1 in 110 children in the US ASD during the first year of life (Baron- (CDC, 2009) and in most cases impairs the Cohen, Cox, Baird, Sweettenham, & Night- child’s ability to function independently ingale, 1996; Chawarska et al., 2007; Lord, (Howlin, 2005). Because there is currently 1995; Mundy, Sigman, Ungerer, & Sherman, no known cure, to date the best means of 1986; Paul, 2007; Stone, Ousley, Yoder, Ho- mitigating the negative effects of ASD are gan, & Hepburn, 1997; Wetherby, 1986). early identification. This way, children can Nonverbal communication behaviors such begin an early behavioral intervention pro- as pointing, waving goodbye, and smiling gram (Klin, Chawarska, Rubin, & Volkmar, convey a message to another person without 2004). language (Tager-Flusberg et al., 2005). Nonverbal communication is particularly ASD and nonverbal communication relevant to early ASD diagnosis because Parents and clinicians use early indicators, children use hand gestures such as reach- such as delayed speech and language, to ing, pointing, and giving to express their recognize ASD during the second year of life desires before they can do so with verbal (Chawarska et al., 2007). Though commu- language. In typical development, gestures nication is often impaired in ASD (American emerge around eight to ten months and are Psychiatric Association [ DSM-IV-TR ], 2004), used frequently until around 18 months, identification during the first year of life when their use begins to fade as verbal lan- cannot depend on verbal language alone. guage develops to replace them (Bates & Even in typical development, children do not Dick, 2002; Capone & McGregor, 2004). speak their first words until around twelve months of age and do not combine words Pointing into phrases until around 18 months (Tager- The vast majority of studies on nonverbal Flusberg, Paul, & Lord, 2005). Therefore, communication in ASD have focused on The authors would like to give special thanks to Jessie Bradshaw, Suzanne Macari, and Fred Shic. The first author can be reached at [email protected] or at Massachusetts General Hospital, Simches Research Bldg., 6th floor, 185 Cambridge St., Boston, MA 02114. 47 THE YALE REVIEW OF UNDERGRADUATE RESEARCH IN PSYCHOLOGY pointing gestures. Pointing emerges around 3.5 years, Baron-Cohen et al. (1996) found eight to ten months in typically developing that a deficit in protodeclarative pointing children (Bates & Dick 2004; Capone & was one of the three best predictors of au- McGregor, 2004), and accounts for the ma- tism. (Gaze monitoring and pretend play jority (60%) of gestures by twelve months also predicted autism.) An early deficit in (Kita, 2003). There are two types of point- protodeclarative pointing is consistent with ing: protodeclarative and protoimperative the social impairments that characterize au- (Paul, 2007; Tomasello, 2007). Protoimpera- tism, and other highly social gestures are tive points represent desire for an object, likely to be impaired early as well. e.g., pointing to a cookie. Protodeclarative points indicate the desire to share an experi- Other protodeclarative gestures: giving and ence with another person, e.g., a child showing pointing to an airplane overhead. Protode- Though pointing is a crucial indicator of so- clarative pointing requires joint attention, or cial functioning, other gestures such as the ability to share experiences with others showing and giving also reflect social skills by attracting or following their attention by and interest. Showing refers to a person’s looking or pointing (Paul, 2007; Tomasello, arm extending toward another person’s face 2007; Loveland & Landry, 1986). Joint atten- while holding an object (Wetherby, Yonclas, tion is an early emerging social cognitive & Btyan, 1989; Stone et al., 1997). Giving re- skill and is impaired in autism (Dawson et fers to placing an object in another person’s al., 2004; Loveland & Landry, 1986). hand or pushing an object at least halfway toward another person (Wetherby et al., Pointing in Autism Spectrum Disorders 1989; Stone et al., 1997). While many in- In autism, protodeclarative pointing is im- stances of giving serve protodeclarative pur- paired while protoimperative pointing re- poses (e.g., giving an interesting object to a mains relatively intact, especially in older parent), others serve protoimperative pur- children (Baron-Cohen, 1989; Camaioni, poses (e.g., handing a jar to a parent to get it Perucchini, Muratori, & Milone, 1997; Ca- opened) or occur in the context of sharing maioni, Perucchini, Muratori, Parrinini, & (e.g., giving a cracker or a toy to another Cesari, 2003; Itoh, 2000). Because protode- person). Both showing and giving emerge clarative pointing requires social interest, its around eight to ten months in typically de- deficit is considered one of the critical ASD veloping children, concurrently with point- risk indicators on a number of screening ing (Capone & McGregor, 2004; Bates & instruments, including the Checklist for Au- Dick, 2004). tism in Toddlers (CHAT; Baron -Cohen, Al- len, & Gillberg, 1992) and Modified Check- Giving and showing in Autism Spectrum list for Autism in Toddlers (M-CHAT; Rob- Disorder ins, Fein, Barton, & Green, 2001). Pointing Little is known about the early development deficits have proven to be an effective flag of giving and showing in children with ASD, for autism as measured by the longitudinal but studies of older children with ASD have stability of CHAT results. In a study that fol- found deficits in both types of gestures. lowed 16,000 children from 18 months to Children with autism at 52 months were less BEYOND POINTING CLEMENTS & CHAWARSKA 48 likely to give, take, and show objects in re- found that of 469 Danish people diagnosed sponse to adult cues compared to develop- with a developmental language delay as mentally delayed children (Leekam & Rams- children, 10 later carried a diagnosis of ASD den, 2006). At 49 months, children with in adulthood (Mouridsen & Hauschild, ASD showed similar differences in frequen- 2009). Deficits in social gestures may pro- cy of giving (DiLavore, Lord, & Rutter, vide an extra indicator in these ambiguous 1995). Children with ASD demonstrated situations. Wetherby and Prizant (2002) fewer “gestural joint attention skills” (de- found that a deficit in showing differentiat- fined as pointing and showing) at 45 ed children with ASD from both develop- months when compared to children with mentally delayed and typically developing mental retardation matched on language, children. Protodeclarative pointing, howev- mental age, or IQ (Mundy, Sigman, & Kasa- er, did not distinguish children with ASD ri, 1990). Wetherby, Watt, Morgan, and from developmentally delayed children. A Shumway (2007) found that a strong predic- similar problem was also noted in the Bar- tor of ASD between 24 and 36 months was on-Cohen et al. (1996) study on 18-month “inventory of gesture,” which assessed the olds. These results suggest that other signs children’s use of eight gestures and includ- beyond pointing are necessary for distin- ed showing, pointing and giving. In an ear- guishing between these groups. Showing lier prospective study, the authors found and giving, which depend heavily on social that limited showing was a red flag that dif- skills, may serve this purpose. ferentiated children with ASD from both de- velopmentally delayed and typically develop- Diagnosis in high-risk populations ing children. Frequency of pointing, howev- Distinguishing ASD from similar non- er, did not differ between children with ASD autistic disorders is of particular concern and those with developmental delays. When when diagnosing children at high risk for Stone et al. (1997) measured giving and ASD. Children with an older sibling with showing within the same age
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