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Journal of Child & Adolescent Mental Health Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/rcmh20
Cradling bias is absent in children with autism spectrum disorders a
a
Lea-Ann Pileggi , Susan Malcolm-Smith , Michelle a
a
Hoogenhout , Kevin GF Thomas & Mark Solms
a
a
Applied Cognitive Science and Experimental Neuropsychology Team Laboratory (ACSENT Laboratory), Department of Psychology , University of Cape Town , Cape Town , South Africa
To cite this article: Lea-Ann Pileggi , Susan Malcolm-Smith , Michelle Hoogenhout , Kevin GF Thomas & Mark Solms (2013): Cradling bias is absent in children with autism spectrum disorders, Journal of Child & Adolescent Mental Health, 25:1, 55-60 To link to this article: http://dx.doi.org/10.2989/17280583.2013.767262
PLEASE SCROLL DOWN FOR ARTICLE Full terms and conditions of use: http://www.tandfonline.com/page/terms-andconditions This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. The publisher does not give any warranty express or implied or make any representation that the contents will be complete or accurate or up to date. The accuracy of any instructions, formulae, and drug doses should be independently verified with primary sources. The publisher shall not be liable for any loss, actions, claims, proceedings, demand, or costs or damages whatsoever or howsoever caused arising directly or indirectly in connection with or arising out of the use of this material.
Journal of Child and Adolescent Mental Health 2013, 25(1): 55–60 Printed in South Africa — All rights reserved
Copyright © NISC Pty Ltd
JOURNAL OF C H I L D & A D O LES C EN T M EN T A L H EA L T H ISSN 1728-0583 EISSN 1728-0591 http://dx.doi.org/10.2989/17280583.2013.767262
Research Paper Cradling bias is absent in children with autism spectrum disorders
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Lea-Ann Pileggi, Susan Malcolm-Smith*, Michelle Hoogenhout, Kevin GF Thomas and Mark Solms Applied Cognitive Science and Experimental Neuropsychology Team Laboratory (ACSENT Laboratory), Department of Psychology, University of Cape Town, Cape Town, South Africa *Corresponding author, email: [email protected] Objective: This study investigated relations among empathy and cradling bias in children diagnosed with autism spectrum disorders (ASDs). Method: Twenty children with ASDs and 20 typically developing (TD) children, aged 5–15 years old, cradled a doll as if it were an infant s/he was putting to sleep on three separate occasions. We recorded side preference on each occasion. Results: Children with ASDs showed no preference for cradling side whereas TD children showed a strong left-sided preference. To the best of our knowledge, children with ASDs are the only population that does not exhibit cradling bias. Conclusion: An absence of cradling bias and empathy deficits in ASD may be related. If so, these data support the hypothesis that leftward cradling is a characteristic of enhanced quality of caregiver-infant interaction and bonding.
Introduction The human preference to cradle an infant to the left of the body midline is a well-documented phenomenon (Salk 1960, Harris 2009). ‘Cradling bias’ can be differentiated from functional cradling: cradling bias is defined as holding an infant in a cradling position to soothe or put the child to sleep; cradling position is defined as “cradling-while-doing-something-else” (Van der Meer and Husby 2006: 263). About three of four human females, regardless of age or prior parenting experience, exhibit leftward cradling bias (Salk 1960, De Château 1983, Manning and Chamberlain 1991). Although cradling bias is less pronounced in males, it is present, and becomes more pronounced with increased parenting experience (Bourne and Todd 2004). Leftward cradling bias also occurs across various primate species, cultures, and historical periods (e.g. Richards and Finger 1975, Saling and Cooke 1984, Manning and Chamberlain 1991, Manning, Heaton and Chamberlain 1994, Hopkins 2004). These facts permit us to infer that there are biological bases for cradling bias, as well as possible adaptive consequences of cradling to the left (Huggenberger et al. 2009). Although several explanations have been proposed for this phenomenon (see Harris 2009), the handedness hypothesis was among the first to emerge (Huheey 1977). The rationale behind this hypothesis is that the evolutionary advantage of handedness could explain the cradling bias. For example, a cradling bias leaves the preferred hand (i.e. the right hand, for most individuals) free to perform tasks. Handedness is, in fact, a determining factor in functional cradling (Van der Meer and Husby 2006). A leftward bias is, however, present in non-functional cradling, irrespective of the Journal of Child & Adolescent Mental Health is co-published by NISC (Pty) Ltd and Routledge, Taylor & Francis Group
Downloaded by [University Library Utrecht] at 11:08 10 June 2013
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Pileggi, Malcolm-Smith, Hoogenhout, Thomas and Solms
individual’s dominant hand (Manning and Chamberlain 1991, Bourne and Todd 2004). Recent research has linked cradling bias with quality of the caregiver–infant interaction and bonding (Sieratzki and Woll 2002, Suter, Huggenberger and Schächinger 2007). This reasoning is based on hemispheric asymmetry for emotional communication and right hemisphere dominance for social attachment and communication behaviour (Schore 2005, Rueckert and Naybar 2008). The results of several studies have documented overall poorer quality of caregiver–infant interaction with rightward cradling (e.g. De Château, Holmberg and Winberg 1978, Bogren 1984). Turnbull and Collins (2000), for example, found that normal healthy adults who cradle to the right are more detached from and less responsive to their infants than those who cradle to the left. Rightward cradlers thus have difficulty relating to their infants. Findings such as these suggest that the leftward cradling bias relies on the ability to interact and form relationships with others, i.e. to relate to others. This leads us to argue that the leftward cradling bias is facilitated by a capacity for empathy. As Decety and Lamm (2006: 1146) explain, a “crucial aspect of empathy” is that it concerns the ability to relate to others. The ability to relate facilitates empathic behaviour, which in turn leads to forming social and emotional relationships. More specifically, because leftward cradling bias arises without conscious effort and occurs in various primates without the demonstrable higher-order mental capacities of humans, it is plausible to argue that innate, basic empathic processes involved in relating facilitate leftward cradling. The availability of a population of children with ASDs presents a unique opportunity to examine this idea using quasi-experimental designs. Although much controversy surrounds the validity of ASD subcategories, ineffective social skills and deficits in empathy characterise all varieties of the diagnosis (De Bildt et al. 2005, Hermans et al. 2009, Minio-Paluello et al. 2009). More specifically, these are disorders of emotional relatedness; the capacity of people with ASDs to bond with and relate to others is impaired. As current literature concerning the underlying mechanisms and function of cradling bias seems to implicate basic empathic processes (e.g. Manning et al. 1994, Sieratzki and Woll 2002, Hopkins 2004), the leftward cradling bias should be absent in ASD individuals. To the best of our knowledge, no published study has investigated cradling bias in the ASD population. Our aim was to investigate if the leftward cradling bias, arguably facilitated by a capacity for empathy, exists in a population (viz., ASD individuals) with known deficits in emotional relatedness. We hypothesised that, because of these deficits, cradling bias is absent in ASD individuals. Method Participants Twenty children diagnosed with ASDs participated in this study. A qualified independent clinician diagnosed the children using the DSM-IV-TR (American Psychiatric Association 2000) criteria. Twenty typically developing (TD) children within the same age range constituted the control group. The groups were matched on age, sex, home language, and socio-economic status (see Table 1). A minimum requirement for participation was ability to understand instructions to hold a doll in either English or Afrikaans. Exclusion criteria for both groups included a history of head injury, infantile meningitis or both. TD participants diagnosed with any neurological condition(s), and participants with ASD diagnosed with any additional neurological condition(s), were excluded from the study. Additionally, a diagnosis or history of behavioural disorders, attention disorders, developmental disorders, affective disorders, psychotic disorders, and/or substance abuse disorders, resulted in exclusion from the TD group. Procedures General The Research Ethics Committee of the University of Cape Town’s Department of Psychology granted approval for the study. Parents/guardians provided written informed consent for their children’s participation; on the day of assessment, the children provided assent. We used a quiet room, free of distractions, as the test setting. The session lasted approximately 15 minutes.
Journal of Child and Adolescent Mental Health 2013, 25(1): 55–60
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Table 1: Demographic characteristics of the ASD and TD groups
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Demographic information Age range (Years:Months) Age (years) Mean (SD) Gender Male:Female Home language English:Afrikaans Socio-economic status High:Medium:Low Handedness Left:Ambidextrous:Right
ASD (n = 20)
TD (n = 20)
6:3–14:8
5:10–14:6
10.52 (2.56)
10.70 (2.62)
14:6
14:6
14:6
14:6
13:7:0
13:7:0
1:1:18
0:0:20
Pretend play task These tasks test an ability to use a doll as an independent agent in a pretend situation. We modified it from tasks used by Kavanaugh, Eizenmand and Harris (1997) and Steele, Joseph and Tager-Flusberg (2003) because the original appeared inappropriately female stereotyped. Stories used here depicted sex-neutral events. Participants were asked to complete four stories by acting out simple scenarios (e.g. watering a plant) using the dolls provided. Cradling bias task This task consisted of three separate trials. We used independent trials to ensure that our measure of cradling side preference was a stable and reliable source of data. In the first trial, the researcher introduced the participant to the doll saying, “This is Suzie. Suzie is very tired. Will you hold Suzie, like you are putting her to sleep?” The researcher then presented the doll in an upright position at the participant’s midline. In each of the second and third trials, the researcher reintroduced the child to Suzie, told him/her that Suzie was tired again, and asked him/ her to put Suzie to sleep once again. If the child did not hold the doll in the cradling position, the researcher demonstrated the cradling position, being careful not to demonstrate a particular side, and said, “hold Suzie in this way” (see Figure 1). The researcher distracted the participant for about 1 minute between trials by making conversation about the participant’s daily activities (e.g. what he/ she was currently doing at school). Cradling bias was determined by the preferred side of cradling observed across the three trials (i.e. the side preferred on two or all of the trials). The cradling side was determined by the visual field of the child in which the doll’s face lay.
Figure 1: Demonstration of cradling position
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Pileggi, Malcolm-Smith, Hoogenhout, Thomas and Solms
Cradling bias Whereas 18 of the 20 TD children cradled to the left, only 10 of the 20 children with ASD cradled to the left. Side of cradling was contingent on group membership (χ2(1) = 7.62, p = 0.007, R = 9.00, Fisher’s Exact Test (FET)). TD children were 9 times more likely than ASD children to show a preference for cradling to the left. A significant chi-squared test of contingency (p = 0.003, FET), indicated an inconsistent preference for one side across the three trials, with TD children 11 times more likely than children with ASD to cradle to one side consistently (R = 11.00). Figure 2 illustrates the difference between the ASD and TD groups. The result of a chi-squared analysis indicated that, in our sample, gender did not influence cradling preference (p = 1.000, FET). Discussion This study is the first to document the absence of leftward cradling bias in children with ASD. When cradling a doll, TD children showed a strong leftward bias whereas children with ASD did not. Moreover, children with ASDs showed no consistent side preference across the three trials. Overall, then, these data demonstrate that children diagnosed with ASDs chose cradling side at a level no greater than chance and showed no fixed preference for side cradled. These data are consistent with predictions derived from the idea that leftward cradling is a characteristic of enhanced quality of caregiver–infant interaction and bonding; that basic empathic processes facilitate the leftward cradling bias. Given that the cradling task included an element of pretence—children pretended the doll was a tired infant that needed to be put to sleep—and given that children with ASDs often have deficits in pretend play, we carefully checked that all of our participants could successfully engage in basic pretend play. We thus affirmed that deficits in pretend-play ability cannot account for the lack of 20 18
NUMBER OF PARTICIPANTS
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Results Pretend play All children with ASD and TD children used the dolls to perform the pretend play scenarios successfully, demonstrating adequate abilities in this domain and confirming their readiness to attempt the cradling bias task.
16
ASD group TD group
14 12 10 8 6 4 2
Left
Right
CRADLING SIDE Figure 2: Preferences of left cradling and right cradling across the two groups
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cradling bias demonstrated here. Moreover, we propose that a leftward cradling bias is a product of enhanced quality of interactions between a caregiver and infant, and thereby concerns how the caregiver relates to the infant. The facts of hemispheric asymmetry for emotional communication and right hemisphere dominance for social attachment and communication behaviour suggest that placing an infant in a caregiver’s left visual field allows higher quality interactions, which in turn facilitates bonding. Where this bias is disrupted, caregivers seem to be less responsive (Turnbull and Collins 2000). Greater responsiveness is evidenced, for example, by the observations that, when asked to hold the doll and put it to sleep, our TD participants immediately placed the doll in the cradling position, and looked at its face. In contrast, our participants with ASDs sometimes held the doll at arm’s length, were often hesitant to hold it, and occasionally refused to hold it. Furthermore, they frequently held the doll against their chests and did not look at it. These behaviours are likely to reflect their deficits in relating to others, both socially and emotionally. While TD participants naturally assumed a caregiver role, ASD participants seemed to engage with the doll in the same way they would engage with an inanimate object. Summary and future directions We asked if the well-established leftward cradling bias present in various primate species, including humans across cultures and time, is also present in a population with deficits in empathy (i.e. relating to others). Our data demonstrated that children with ASDs do not show a cradling bias, providing tentative evidence that a basic, innate empathic or relational capacity may be impaired in ASD individuals. As Kanner (1943: 250) suggested, these individuals have “…come into the world with an innate inability to form the usually biologically provided affective contact with other people”. Our study has several limitations that could be addressed in future investigations. One such limitation is the small sample size: A larger sample permitting investigation of this phenomenon in separate age bands could delineate and compare developmental trajectories in both ASD and TD individuals. Whether or not higher order abilities such as intelligence, executive function, or social cognition have an impact on cradling bias in ASD should be explored. The fact that the leftward cradling bias is present in non-human primates suggests that higher-order social and cognitive abilities may not influence cradling bias, but studies investigating the relations among such abilities and cradling bias are required to confirm this hypothesis. Our findings provide evidence for the absence of the otherwise universal leftward cradling bias in children diagnosed with ASDs. To our knowledge, children with ASDs are the only population studied to date that does not exhibit this bias. The absence of the leftward cradling bias in a population known to have deficits in empathy suggests a link between this phenomenon and empathic processes. Further investigation is required to confirm this link. Acknowledgements — Our thanks to Professor W Jake Jacobs for his comments on the manuscript.
References American Psychiatric Association. 2000. Diagnostic and statistical manual of mental disorders (4th edn, Text Revision). Washington, DC: American Psychiatric Association. Bogren LY. 1984. Side preference in women and men when holding their newborn child: Psychological background. Acta Psychiatrica Scandanavia 69: 13–23. Bourne VJ, Todd BK. 2004. When left means right: an explanation of the left cradling bias in terms of right hemisphere specializations. Developmental Science 7: 19–24. De Bildt A, Serra M, Luteijn E, Kraijer D, Sytema S, Minderaa R. 2005. Social skills in children with intellectual disability with and without autism. Journal of Intellectual Disability Research 49: 317–328. Decety J, Lamm C. 2006. Human empathy through the lens of social neuroscience. The Scientific World Journal 6: 1146–1163. De Château P. 1983. Left-side preference for holding and carrying newborn infants: Parental holding and carrying during the first week of life. Journal of Nervous and Mental Disease 171: 241–245. De Château P, Holmberg H, Winberg, J. 1978. Left side preference in holding and carrying newborn infants I:
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Mothers’ holding and carrying during the first week of life. Acta Paediatrica Scandanavia 67: 169–175. Harris LJ. 2009. Side bias for holding and carrying infants: Reports from the past and possible lessons for today. Laterality: Assymetries of Body, Brain and Cognition 15: 56–135. Hermans EJ, Van Wingen G, Bos PA, Putman P, Van Honk J. 2009. Reduced spontaneous facial mimicry in women with autistic traits. Biological Psychology 80: 348–353. Hopkins WD. 2004. Laterality in maternal cradling and infant positional biases: Implications or the development of evolution of hand preferences in nonhuman primates. International Journal of Primatology 25: 1243–1265. Huggenberger HJ, Suter SE, Reijnen E, Schächinger H. 2009. Cradling side preference is associated with lateralized processing of baby facial expressions in females. Brain and Cognition 70: 67–72. Huheey JE. 1977. Concerning the origin of handedness in humans. Behavior Genetics 7: 29–32. Kanner L. 1943. Autistic disturbances of affective contact. Nervous Child 2: 217–250. Kavanaugh R, Eizenman D, Harris P. 1997. Young children’s understanding of pretense expressions of independent agency. Developmental Psychology 33: 764–770. Manning JT, Chamberlain AT. 1991. Left-side cradling and brain lateralisation. Ethology and Sociobiology 12: 237–244. Manning JT, Heaton R, Chamberlain AT. 1994. Left-sided cradling: Similarities and differences between apes and humans. Journal of Human Evolution 26: 77–83. Minio-Paluello I, Baron-Cohen S, Avenanti A, Walsh V, Aglioti SM. 2009. Absence of embodied empathy during pain observation in Asperger Syndrome. Biological Psychiatry 65: 55–62. Richards JL, Finger S. 1975. Mother and child holding patterns: A cross-cultural photographic survey. Child Development 46: 1001–1004. Rueckert L, Naybar N. 2008. Gender differences in empathy: The role of the right hemisphere. Brain and Cognition 67: 162–167. Saling MM, Cooke WL. 1984. Cradling and transport of infants by South African mothers: A cross-cultural survey. Current Anthropology 25: 333–335. Salk L. 1960. The effects of the normal heart-beat sound on the behavior of the newborn infant: Implications for mental health. World Mental Health 12: 168–175. Schore A. 2005. Attachment, affect regulation, and the developing right brain: Linking developmental neuroscience to paediatrics. Paediatrics in Review 26: 204–217. Sieratzki JS, Woll B. 2002. Neuropsychological and neuropsychiatric perspectives on maternal cradling preferences. Epidemiologia e Psichiatria Sociale 11: 170–176. Steele S, Joseph RM, Tager-Flusberg H. 2003. Developmental change in theory of mind abilities in children with autism. Journal of Autism and Developmental Disorders 33: 461–467. Suter SE, Huggenberger HJ, Schächinger H. 2007. Cold pressor stress reduces left cradling preference in nulliparous human females. The International Journal on the Biology of Stress 10: 45–51. Turnbull O, Collins P. 2000. Lateral cradling preferences and the mother-infant interaction: Investigating a group of mothers experiencing difficulties. Masters thesis, University College, London. Van der Meer A, Husby A. 2006. Handedness as a major determinant of functional cradling bias. Laterality: Assymetries of Body, Brain and Cognition 11: 263–276.
Journal of Child & Adolescent Mental Health Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/rcmh20
Cradling bias is absent in children with autism spectrum disorders a
a
Lea-Ann Pileggi , Susan Malcolm-Smith , Michelle a
a
Hoogenhout , Kevin GF Thomas & Mark Solms
a
a
Applied Cognitive Science and Experimental Neuropsychology Team Laboratory (ACSENT Laboratory), Department of Psychology , University of Cape Town , Cape Town , South Africa
To cite this article: Lea-Ann Pileggi , Susan Malcolm-Smith , Michelle Hoogenhout , Kevin GF Thomas & Mark Solms (2013): Cradling bias is absent in children with autism spectrum disorders, Journal of Child & Adolescent Mental Health, 25:1, 55-60 To link to this article: http://dx.doi.org/10.2989/17280583.2013.767262
PLEASE SCROLL DOWN FOR ARTICLE Full terms and conditions of use: http://www.tandfonline.com/page/terms-andconditions This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. The publisher does not give any warranty express or implied or make any representation that the contents will be complete or accurate or up to date. The accuracy of any instructions, formulae, and drug doses should be independently verified with primary sources. The publisher shall not be liable for any loss, actions, claims, proceedings, demand, or costs or damages whatsoever or howsoever caused arising directly or indirectly in connection with or arising out of the use of this material.
Journal of Child and Adolescent Mental Health 2013, 25(1): 55–60 Printed in South Africa — All rights reserved
Copyright © NISC Pty Ltd
JOURNAL OF C H I L D & A D O LES C EN T M EN T A L H EA L T H ISSN 1728-0583 EISSN 1728-0591 http://dx.doi.org/10.2989/17280583.2013.767262
Research Paper Cradling bias is absent in children with autism spectrum disorders
Downloaded by [University Library Utrecht] at 11:08 10 June 2013
Lea-Ann Pileggi, Susan Malcolm-Smith*, Michelle Hoogenhout, Kevin GF Thomas and Mark Solms Applied Cognitive Science and Experimental Neuropsychology Team Laboratory (ACSENT Laboratory), Department of Psychology, University of Cape Town, Cape Town, South Africa *Corresponding author, email: [email protected] Objective: This study investigated relations among empathy and cradling bias in children diagnosed with autism spectrum disorders (ASDs). Method: Twenty children with ASDs and 20 typically developing (TD) children, aged 5–15 years old, cradled a doll as if it were an infant s/he was putting to sleep on three separate occasions. We recorded side preference on each occasion. Results: Children with ASDs showed no preference for cradling side whereas TD children showed a strong left-sided preference. To the best of our knowledge, children with ASDs are the only population that does not exhibit cradling bias. Conclusion: An absence of cradling bias and empathy deficits in ASD may be related. If so, these data support the hypothesis that leftward cradling is a characteristic of enhanced quality of caregiver-infant interaction and bonding.
Introduction The human preference to cradle an infant to the left of the body midline is a well-documented phenomenon (Salk 1960, Harris 2009). ‘Cradling bias’ can be differentiated from functional cradling: cradling bias is defined as holding an infant in a cradling position to soothe or put the child to sleep; cradling position is defined as “cradling-while-doing-something-else” (Van der Meer and Husby 2006: 263). About three of four human females, regardless of age or prior parenting experience, exhibit leftward cradling bias (Salk 1960, De Château 1983, Manning and Chamberlain 1991). Although cradling bias is less pronounced in males, it is present, and becomes more pronounced with increased parenting experience (Bourne and Todd 2004). Leftward cradling bias also occurs across various primate species, cultures, and historical periods (e.g. Richards and Finger 1975, Saling and Cooke 1984, Manning and Chamberlain 1991, Manning, Heaton and Chamberlain 1994, Hopkins 2004). These facts permit us to infer that there are biological bases for cradling bias, as well as possible adaptive consequences of cradling to the left (Huggenberger et al. 2009). Although several explanations have been proposed for this phenomenon (see Harris 2009), the handedness hypothesis was among the first to emerge (Huheey 1977). The rationale behind this hypothesis is that the evolutionary advantage of handedness could explain the cradling bias. For example, a cradling bias leaves the preferred hand (i.e. the right hand, for most individuals) free to perform tasks. Handedness is, in fact, a determining factor in functional cradling (Van der Meer and Husby 2006). A leftward bias is, however, present in non-functional cradling, irrespective of the Journal of Child & Adolescent Mental Health is co-published by NISC (Pty) Ltd and Routledge, Taylor & Francis Group
Downloaded by [University Library Utrecht] at 11:08 10 June 2013
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Pileggi, Malcolm-Smith, Hoogenhout, Thomas and Solms
individual’s dominant hand (Manning and Chamberlain 1991, Bourne and Todd 2004). Recent research has linked cradling bias with quality of the caregiver–infant interaction and bonding (Sieratzki and Woll 2002, Suter, Huggenberger and Schächinger 2007). This reasoning is based on hemispheric asymmetry for emotional communication and right hemisphere dominance for social attachment and communication behaviour (Schore 2005, Rueckert and Naybar 2008). The results of several studies have documented overall poorer quality of caregiver–infant interaction with rightward cradling (e.g. De Château, Holmberg and Winberg 1978, Bogren 1984). Turnbull and Collins (2000), for example, found that normal healthy adults who cradle to the right are more detached from and less responsive to their infants than those who cradle to the left. Rightward cradlers thus have difficulty relating to their infants. Findings such as these suggest that the leftward cradling bias relies on the ability to interact and form relationships with others, i.e. to relate to others. This leads us to argue that the leftward cradling bias is facilitated by a capacity for empathy. As Decety and Lamm (2006: 1146) explain, a “crucial aspect of empathy” is that it concerns the ability to relate to others. The ability to relate facilitates empathic behaviour, which in turn leads to forming social and emotional relationships. More specifically, because leftward cradling bias arises without conscious effort and occurs in various primates without the demonstrable higher-order mental capacities of humans, it is plausible to argue that innate, basic empathic processes involved in relating facilitate leftward cradling. The availability of a population of children with ASDs presents a unique opportunity to examine this idea using quasi-experimental designs. Although much controversy surrounds the validity of ASD subcategories, ineffective social skills and deficits in empathy characterise all varieties of the diagnosis (De Bildt et al. 2005, Hermans et al. 2009, Minio-Paluello et al. 2009). More specifically, these are disorders of emotional relatedness; the capacity of people with ASDs to bond with and relate to others is impaired. As current literature concerning the underlying mechanisms and function of cradling bias seems to implicate basic empathic processes (e.g. Manning et al. 1994, Sieratzki and Woll 2002, Hopkins 2004), the leftward cradling bias should be absent in ASD individuals. To the best of our knowledge, no published study has investigated cradling bias in the ASD population. Our aim was to investigate if the leftward cradling bias, arguably facilitated by a capacity for empathy, exists in a population (viz., ASD individuals) with known deficits in emotional relatedness. We hypothesised that, because of these deficits, cradling bias is absent in ASD individuals. Method Participants Twenty children diagnosed with ASDs participated in this study. A qualified independent clinician diagnosed the children using the DSM-IV-TR (American Psychiatric Association 2000) criteria. Twenty typically developing (TD) children within the same age range constituted the control group. The groups were matched on age, sex, home language, and socio-economic status (see Table 1). A minimum requirement for participation was ability to understand instructions to hold a doll in either English or Afrikaans. Exclusion criteria for both groups included a history of head injury, infantile meningitis or both. TD participants diagnosed with any neurological condition(s), and participants with ASD diagnosed with any additional neurological condition(s), were excluded from the study. Additionally, a diagnosis or history of behavioural disorders, attention disorders, developmental disorders, affective disorders, psychotic disorders, and/or substance abuse disorders, resulted in exclusion from the TD group. Procedures General The Research Ethics Committee of the University of Cape Town’s Department of Psychology granted approval for the study. Parents/guardians provided written informed consent for their children’s participation; on the day of assessment, the children provided assent. We used a quiet room, free of distractions, as the test setting. The session lasted approximately 15 minutes.
Journal of Child and Adolescent Mental Health 2013, 25(1): 55–60
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Table 1: Demographic characteristics of the ASD and TD groups
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Demographic information Age range (Years:Months) Age (years) Mean (SD) Gender Male:Female Home language English:Afrikaans Socio-economic status High:Medium:Low Handedness Left:Ambidextrous:Right
ASD (n = 20)
TD (n = 20)
6:3–14:8
5:10–14:6
10.52 (2.56)
10.70 (2.62)
14:6
14:6
14:6
14:6
13:7:0
13:7:0
1:1:18
0:0:20
Pretend play task These tasks test an ability to use a doll as an independent agent in a pretend situation. We modified it from tasks used by Kavanaugh, Eizenmand and Harris (1997) and Steele, Joseph and Tager-Flusberg (2003) because the original appeared inappropriately female stereotyped. Stories used here depicted sex-neutral events. Participants were asked to complete four stories by acting out simple scenarios (e.g. watering a plant) using the dolls provided. Cradling bias task This task consisted of three separate trials. We used independent trials to ensure that our measure of cradling side preference was a stable and reliable source of data. In the first trial, the researcher introduced the participant to the doll saying, “This is Suzie. Suzie is very tired. Will you hold Suzie, like you are putting her to sleep?” The researcher then presented the doll in an upright position at the participant’s midline. In each of the second and third trials, the researcher reintroduced the child to Suzie, told him/her that Suzie was tired again, and asked him/ her to put Suzie to sleep once again. If the child did not hold the doll in the cradling position, the researcher demonstrated the cradling position, being careful not to demonstrate a particular side, and said, “hold Suzie in this way” (see Figure 1). The researcher distracted the participant for about 1 minute between trials by making conversation about the participant’s daily activities (e.g. what he/ she was currently doing at school). Cradling bias was determined by the preferred side of cradling observed across the three trials (i.e. the side preferred on two or all of the trials). The cradling side was determined by the visual field of the child in which the doll’s face lay.
Figure 1: Demonstration of cradling position
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Cradling bias Whereas 18 of the 20 TD children cradled to the left, only 10 of the 20 children with ASD cradled to the left. Side of cradling was contingent on group membership (χ2(1) = 7.62, p = 0.007, R = 9.00, Fisher’s Exact Test (FET)). TD children were 9 times more likely than ASD children to show a preference for cradling to the left. A significant chi-squared test of contingency (p = 0.003, FET), indicated an inconsistent preference for one side across the three trials, with TD children 11 times more likely than children with ASD to cradle to one side consistently (R = 11.00). Figure 2 illustrates the difference between the ASD and TD groups. The result of a chi-squared analysis indicated that, in our sample, gender did not influence cradling preference (p = 1.000, FET). Discussion This study is the first to document the absence of leftward cradling bias in children with ASD. When cradling a doll, TD children showed a strong leftward bias whereas children with ASD did not. Moreover, children with ASDs showed no consistent side preference across the three trials. Overall, then, these data demonstrate that children diagnosed with ASDs chose cradling side at a level no greater than chance and showed no fixed preference for side cradled. These data are consistent with predictions derived from the idea that leftward cradling is a characteristic of enhanced quality of caregiver–infant interaction and bonding; that basic empathic processes facilitate the leftward cradling bias. Given that the cradling task included an element of pretence—children pretended the doll was a tired infant that needed to be put to sleep—and given that children with ASDs often have deficits in pretend play, we carefully checked that all of our participants could successfully engage in basic pretend play. We thus affirmed that deficits in pretend-play ability cannot account for the lack of 20 18
NUMBER OF PARTICIPANTS
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Results Pretend play All children with ASD and TD children used the dolls to perform the pretend play scenarios successfully, demonstrating adequate abilities in this domain and confirming their readiness to attempt the cradling bias task.
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ASD group TD group
14 12 10 8 6 4 2
Left
Right
CRADLING SIDE Figure 2: Preferences of left cradling and right cradling across the two groups
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Journal of Child and Adolescent Mental Health 2013, 25(1): 55–60
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cradling bias demonstrated here. Moreover, we propose that a leftward cradling bias is a product of enhanced quality of interactions between a caregiver and infant, and thereby concerns how the caregiver relates to the infant. The facts of hemispheric asymmetry for emotional communication and right hemisphere dominance for social attachment and communication behaviour suggest that placing an infant in a caregiver’s left visual field allows higher quality interactions, which in turn facilitates bonding. Where this bias is disrupted, caregivers seem to be less responsive (Turnbull and Collins 2000). Greater responsiveness is evidenced, for example, by the observations that, when asked to hold the doll and put it to sleep, our TD participants immediately placed the doll in the cradling position, and looked at its face. In contrast, our participants with ASDs sometimes held the doll at arm’s length, were often hesitant to hold it, and occasionally refused to hold it. Furthermore, they frequently held the doll against their chests and did not look at it. These behaviours are likely to reflect their deficits in relating to others, both socially and emotionally. While TD participants naturally assumed a caregiver role, ASD participants seemed to engage with the doll in the same way they would engage with an inanimate object. Summary and future directions We asked if the well-established leftward cradling bias present in various primate species, including humans across cultures and time, is also present in a population with deficits in empathy (i.e. relating to others). Our data demonstrated that children with ASDs do not show a cradling bias, providing tentative evidence that a basic, innate empathic or relational capacity may be impaired in ASD individuals. As Kanner (1943: 250) suggested, these individuals have “…come into the world with an innate inability to form the usually biologically provided affective contact with other people”. Our study has several limitations that could be addressed in future investigations. One such limitation is the small sample size: A larger sample permitting investigation of this phenomenon in separate age bands could delineate and compare developmental trajectories in both ASD and TD individuals. Whether or not higher order abilities such as intelligence, executive function, or social cognition have an impact on cradling bias in ASD should be explored. The fact that the leftward cradling bias is present in non-human primates suggests that higher-order social and cognitive abilities may not influence cradling bias, but studies investigating the relations among such abilities and cradling bias are required to confirm this hypothesis. Our findings provide evidence for the absence of the otherwise universal leftward cradling bias in children diagnosed with ASDs. To our knowledge, children with ASDs are the only population studied to date that does not exhibit this bias. The absence of the leftward cradling bias in a population known to have deficits in empathy suggests a link between this phenomenon and empathic processes. Further investigation is required to confirm this link. Acknowledgements — Our thanks to Professor W Jake Jacobs for his comments on the manuscript.
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