Families of Autistic and I.
Family Life
Dysphasic Children
and Interaction Patterns
Dennis P. Cantwell, MD; Lorian Baker, PhD; Michael Rutter, MD
\s=b\ Patterns of parent-child interaction and family functioning systematically examined in well-matched groups of 15 autistic and 14 dysphasic children. The measures used included were
the Douglas 24-hour standard day analysis, the Brown and Rutter interview measure of positive interaction, the lttleson scales (based on a four- to six-hour period of home observation, specially developed time-sampled measures of observed mother-child interaction at home), and the Eysenck Personality Inventory. The findings from all measures agreed in showing that family life and interaction patterns were closely similar in the two groups. The results were compared with those of previous investigations; we concluded that autism is most unlikely to be due to abnormal psychogenic influences in the family. (Arch Gen Psychiatry 36:682-687, 1979)
Kanner1 first described the syndrome of infantile autism in 1943, there has been a continuing controver¬ sy over the role of environmental influences, particularly family factors, in the etiology and pathogenesis of the condition. There is now good evidence that autistic children have a basic cognitive defect2 that is often associated with evidence of hereditary origin·1 or organic brain dysfunc¬ tion, as indicated, for example, by epileptic fits.4 Neverthe¬ less, it remains possible that certain pathogenic psychoso¬ cial influences may interact with a biological defect to produce the syndrome of autism. This article is one of a series"'"7 reporting a set of studies designed to investigate that possibility. The present report is primarily concerned with patterns of family life and parent-child interaction. A number of writers have proposed that there may be deviant patterns of interaction between psychotic children and their parents. Too much stimulation, too little stimula¬ tion, inadequate structuring of the environment, lack of family roles and identities, and lack of shared family pleasure have all been postulated'" as figuring in the patho¬ genesis of childhood psychosis.8 Various uncontrolled observations have been used to suggest abnormalities in the families of "schizophrenic" children."'1' Others have failed to confirm these find¬ ings."'" However, little weight can be attached to either positive or negative findings in the absence of con¬ trols.16"'22 A detailed review of previous studies in this area can be found in a previous publication.'" The findings as a whole are both contradictory and difficult to interpret. First, the groups studied have been diagnostically heterogeneous and often poorly defined. Few have been specifically concerned with infantile autism. Second, many of the measures have
Since
Accepted
for publication June 8, 1978. From the Neuropsychiatric Institute, Center for the Health Sciences, University of California, Los Angeles (Drs Cantwell and Baker), and the Institute of Psychiatry, London (Dr Rutter). Reprint requests to Neuropsychiatric Institute, Center for the Health Sciences, University of California, Los Angeles, 760 Westwood Plaza, Los Angeles, CA 90024 (Dr Cantwell).
Downloaded From: by a Uppsala University User on 05/25/2018
been of uncertain reliability and validity. Third, the control quite varied and frequently poorly matched. Parental functioning is likely to be influenced by the characteristics of the children as well as by the personalities and experiences of the parents. If the comparison groups of parents have children who differ greatly in either mental level or language skills, family functioning may well differ simply as a consequence of having markedly different children. The fact that one group has been labeled as "patients" whereas the other has not may also influence how parents and children interact. Fourth, most studies have failed to control for the sex of the children, but there are indications that family interac¬ tion may be affected by the sex of mentally ill off¬
groups have been
spring.23'24
need for a controlled study of a rigorously group of autistic children with measures that were well designed to tap the aspects of parental function¬ ing thought to be abnormal in autism. Because overt brain damage is most frequent in the case of mentally retarded autistic children, it appeared that psychosocial determi¬ nants should be most readily found in the case of autistic children of normal nonverbal intelligence. Goldfarb's2" findings support this supposition. Accordingly, a series of investigations were planned to compare such a group of autistic boys with an age-, sex-, IQ-, and language levelmatched group of children with a specific developmental disorder of receptive language.2827 Although the groups There
was a
diagnosed
closely comparable on the items used in matching, differed very greatly in terms of the social and they behavioral features characteristic of autism.2"-2s A previous article reported an interview and question¬ naire study of parental characteristics in these two groups of families '; a comparison article reports a detailed analy¬ sis of mother-child linguistic interaction"; while this article reports a detailed interview and home observation assess¬ ment of family life and interaction patterns. were
METHODS
Sample subjects of the present study consist of the families of 29 boys, aged 6 years and 6 months to 11 years and 6 months, with a nonverbal IQ of at least 70 and a disorder of language comprehen¬ sion that had been present since infancy and that was not due to overt neurological disorder or peripheral deafness (fuller details of sample selection are given elsewhere2"27)· Fifteen boys met the diagnostic criteria' for infantile autism: a profound and general failure to develop social relationships, ritualistic and compulsive phenomena, and a serious disorder of language. The other 14 boys showed an uncomplicated receptive developmental language disor¬ der; they are referred to as the "dysphasic" group. The two groups of boys were closely similar in age, nonverbal IQ, and level of speech.27 The original sample of children studied by Bartak and his colleagues'" consisted of 19 autistic and 23 dysphasic children. The
However, the dysphasic children tended' to improve more in language and so, to better match the groups at the time of study, the six dysphasic children with least receptive language retarda¬ tion were dropped from the investigation. Two autistic and two dysphasic children had moved overseas or were untraceable and could not be included. The families of two autistic children were unwilling or unable to participate in this part of the study. This left 15 autistic children and 15 dysphasic children for the follow-up study of families of which the present investigation forms a part."27 At the last moment, one of the families of dysphasic children was unable to participate due to illness in the family, leaving a final subject population of 15 families of autistic boys and 14 families of dysphasic boys. The parents and children were of closely comparable age in the two groups, but the autistic group contained a higher proportion of professional and managerial families (80% vs 46%).
Measures
Day Interview.-The standard day interview developed by Douglas and his colleagues29'3" was used to obtain a detailed account of the children's daily activities together with measures of the frequency, nature, and intensity of the children's interactions Standard
with other family members. With this technique, the interviewer takes the parents step by step chronologically through the events of the previous 24 hours (having previously ensured that the day was not atypical due to visitors, illness, etc). Detailed information is obtained on a minute-by-minute basis with respect to what the child was doing, how long the activity lasted, who was with the child, the nature of any personal interactions, and whether any interruptions or additional events had occurred. A tape recording of the interview was made and transcribed for coding. Four major groups of behaviors were used: activities (playing games, reading, etc), basic care (eating, toileting, etc), outings (shopping, visiting, etc), and other (tantrums, nothing particular, etc). All persons who had contact with the child were coded. Five different levels of interaction were coded: (1) concentrated, (2) continuous, (3) available, (4) available, but not used, and (5)
separate.
Concentrated interactions were those in which at least two of the following three conditions applied: (1) there was close physical contact between the child and the person concerned; (2) the child and the person concerned were sharing the activity; and (3) the child and person concerned were giving the activity and each other their full attention. Continuous interactions were those that fell short of the criteria for "concentrated" but that involved the person giving the child a good deal of attention. This category was usually used for playing with other children, going out visiting, being visited, going out shopping, going for walks, and some mealtimes. Available interactions were those that met one of the following criteria: (1) the child was being supervised, someone was around and easily reached, and contacts were possible such as through a doorway; (2) another child or adult was in the room and awake and was being talked to or approached, if only occasionally; or (3) there was a high intensity of interaction with someone else, but a third person was still around and available for interaction. Available, but not. used interactions were defined as the child and another adult or child being in situations where contact was possible (as for available) but, despite an attempt by the other person, no interaction occurred. Separate was scored if the child was alone and communication was only possible by shouting or crying or by the mother coming to the child or vice versa. If the child was inside, doors must have been shut. A weighted qualitative interaction score for persons interacting with the child was obtained by giving a weighting of 4 for concentrated, 3 for continuous, 2 for available and available not used, and 1 for separate. The interaction score was then the sum of
Downloaded From: by a Uppsala University User on 05/25/2018
the products of these weights and the minutes of each type of interaction with the child. A weighted interaction score for the child was obtained similarly by using the child's minutes of interaction with the same weights, except that available not used was weighted 1 rather than 2. The reason for this is that available not used is equivalent to available from the perspective of the person giving the attention, but equivalent to separate from the perspective of the child receiving the attention. In these various ways, the type, quantity, and quality of interaction could all be assessed. Douglas et al2" have shown the measures to have a high interrater reliability and to agree well with similar measures obtained from direct observation. Positive Interaction as Reported by Parents.—A more global view of parent-child interaction that included less frequent, as well as everyday, activities was obtained by systematically asking the parent about all parent-child interactions that might be pleasura¬ ble to the child that had occurred over the previous week. The scale used was a slightly modified version of that developed by Brown and Rutter." It has been shown to have a high interrater reliability (over + .90). Also, it has been found that there is good agreement (r .72 to .78) between independent accounts from the mother and father. Specific enquiry was made about playing games, reading to the child, roughhousing, doing things with the child, helping the child, the child helping mother or father, and outings with mother or father. An interaction was given a score of one point if it lasted an hour or less, and two points if it lasted an hour or more. Separate scores for these activities were obtained for mother and father together with a total score for all positive interactions over the course of a week. Ittleson Scales.—The Ittleson family interaction scales were developed by Behrens et al32 to measure qualitative aspects of family relationships, parent-child interaction, and style of child care. The data for rating the scales derive from observations made by one of us (D.C.) during a four- to six-hour home visit that included a family mealtime. During the visit, parents were encouraged to adhere to their usual family routines as much as possible. Mothers and fathers were separately evaluated according to eight seven-point scales concerning spontaneity of interactions, decisiveness, consistency of emotional relatedness, mode of relat¬ ing to the child, control of the child, imposition of routines, anticipation of the child's needs, and meeting the demands of the child. Behrens et al32 provide anchoring descriptions for points 1, 3, 5, and 7 on the scales. In each case, 1 represents very poor functioning and 7 is optimal. Interrater reliability is reported as generally good; validity is based on a patient sample using comparisons with the judgments of caseworkers who have treated the families over a prolonged period.32 Time-Sampled Measures of Mother-Child Interaction.—During the four- to six-hour period of home observation, 90 minutes were set aside for the systematic observation of mother-child interaction, using quantitative measures developed by Hemsley et al (unpub¬ lished data, 1978). The 90-minute period was chosen as one in which the mother was free of obligations (such as cooking a meal) and would normally be with her child. No restrictions were placed on activities, and mothers were asked to do whatever they would normally do at that time. The observation schedule included 36 categories of behavior, 17 for the child's activities and 19 for parental behavior. Behavior was rated every ten seconds on specially constructed sheets laid out for minimal hand movement and association of related categories. Each sheet was divided into 12 time periods, giving a total observation time of two minutes' continuous recording per sheet. After each two-minute period, there was a 30-second rest pause. Each observation session lasted for about 90 minutes, including time spent talking with the mother, setting up equipment, and allowing both mother and child to become accustomed to the observer's presence. Forty minutes of actual recorded time was =
Table 1.—Children's Activities as Determined Standard Day Analysis hr
Duration, min/24 Autistic Kinds of Activities
Mean
Games with
books
Playing on own Active playing with toys, riding bikes, etc
Sleeping School Errands and out¬
ings Television Basic care All other activities Total *P
fP %P
< <
Family Life
Dysphasic Children
and Interaction Patterns
Dennis P. Cantwell, MD; Lorian Baker, PhD; Michael Rutter, MD
\s=b\ Patterns of parent-child interaction and family functioning systematically examined in well-matched groups of 15 autistic and 14 dysphasic children. The measures used included were
the Douglas 24-hour standard day analysis, the Brown and Rutter interview measure of positive interaction, the lttleson scales (based on a four- to six-hour period of home observation, specially developed time-sampled measures of observed mother-child interaction at home), and the Eysenck Personality Inventory. The findings from all measures agreed in showing that family life and interaction patterns were closely similar in the two groups. The results were compared with those of previous investigations; we concluded that autism is most unlikely to be due to abnormal psychogenic influences in the family. (Arch Gen Psychiatry 36:682-687, 1979)
Kanner1 first described the syndrome of infantile autism in 1943, there has been a continuing controver¬ sy over the role of environmental influences, particularly family factors, in the etiology and pathogenesis of the condition. There is now good evidence that autistic children have a basic cognitive defect2 that is often associated with evidence of hereditary origin·1 or organic brain dysfunc¬ tion, as indicated, for example, by epileptic fits.4 Neverthe¬ less, it remains possible that certain pathogenic psychoso¬ cial influences may interact with a biological defect to produce the syndrome of autism. This article is one of a series"'"7 reporting a set of studies designed to investigate that possibility. The present report is primarily concerned with patterns of family life and parent-child interaction. A number of writers have proposed that there may be deviant patterns of interaction between psychotic children and their parents. Too much stimulation, too little stimula¬ tion, inadequate structuring of the environment, lack of family roles and identities, and lack of shared family pleasure have all been postulated'" as figuring in the patho¬ genesis of childhood psychosis.8 Various uncontrolled observations have been used to suggest abnormalities in the families of "schizophrenic" children."'1' Others have failed to confirm these find¬ ings."'" However, little weight can be attached to either positive or negative findings in the absence of con¬ trols.16"'22 A detailed review of previous studies in this area can be found in a previous publication.'" The findings as a whole are both contradictory and difficult to interpret. First, the groups studied have been diagnostically heterogeneous and often poorly defined. Few have been specifically concerned with infantile autism. Second, many of the measures have
Since
Accepted
for publication June 8, 1978. From the Neuropsychiatric Institute, Center for the Health Sciences, University of California, Los Angeles (Drs Cantwell and Baker), and the Institute of Psychiatry, London (Dr Rutter). Reprint requests to Neuropsychiatric Institute, Center for the Health Sciences, University of California, Los Angeles, 760 Westwood Plaza, Los Angeles, CA 90024 (Dr Cantwell).
Downloaded From: by a Uppsala University User on 05/25/2018
been of uncertain reliability and validity. Third, the control quite varied and frequently poorly matched. Parental functioning is likely to be influenced by the characteristics of the children as well as by the personalities and experiences of the parents. If the comparison groups of parents have children who differ greatly in either mental level or language skills, family functioning may well differ simply as a consequence of having markedly different children. The fact that one group has been labeled as "patients" whereas the other has not may also influence how parents and children interact. Fourth, most studies have failed to control for the sex of the children, but there are indications that family interac¬ tion may be affected by the sex of mentally ill off¬
groups have been
spring.23'24
need for a controlled study of a rigorously group of autistic children with measures that were well designed to tap the aspects of parental function¬ ing thought to be abnormal in autism. Because overt brain damage is most frequent in the case of mentally retarded autistic children, it appeared that psychosocial determi¬ nants should be most readily found in the case of autistic children of normal nonverbal intelligence. Goldfarb's2" findings support this supposition. Accordingly, a series of investigations were planned to compare such a group of autistic boys with an age-, sex-, IQ-, and language levelmatched group of children with a specific developmental disorder of receptive language.2827 Although the groups There
was a
diagnosed
closely comparable on the items used in matching, differed very greatly in terms of the social and they behavioral features characteristic of autism.2"-2s A previous article reported an interview and question¬ naire study of parental characteristics in these two groups of families '; a comparison article reports a detailed analy¬ sis of mother-child linguistic interaction"; while this article reports a detailed interview and home observation assess¬ ment of family life and interaction patterns. were
METHODS
Sample subjects of the present study consist of the families of 29 boys, aged 6 years and 6 months to 11 years and 6 months, with a nonverbal IQ of at least 70 and a disorder of language comprehen¬ sion that had been present since infancy and that was not due to overt neurological disorder or peripheral deafness (fuller details of sample selection are given elsewhere2"27)· Fifteen boys met the diagnostic criteria' for infantile autism: a profound and general failure to develop social relationships, ritualistic and compulsive phenomena, and a serious disorder of language. The other 14 boys showed an uncomplicated receptive developmental language disor¬ der; they are referred to as the "dysphasic" group. The two groups of boys were closely similar in age, nonverbal IQ, and level of speech.27 The original sample of children studied by Bartak and his colleagues'" consisted of 19 autistic and 23 dysphasic children. The
However, the dysphasic children tended' to improve more in language and so, to better match the groups at the time of study, the six dysphasic children with least receptive language retarda¬ tion were dropped from the investigation. Two autistic and two dysphasic children had moved overseas or were untraceable and could not be included. The families of two autistic children were unwilling or unable to participate in this part of the study. This left 15 autistic children and 15 dysphasic children for the follow-up study of families of which the present investigation forms a part."27 At the last moment, one of the families of dysphasic children was unable to participate due to illness in the family, leaving a final subject population of 15 families of autistic boys and 14 families of dysphasic boys. The parents and children were of closely comparable age in the two groups, but the autistic group contained a higher proportion of professional and managerial families (80% vs 46%).
Measures
Day Interview.-The standard day interview developed by Douglas and his colleagues29'3" was used to obtain a detailed account of the children's daily activities together with measures of the frequency, nature, and intensity of the children's interactions Standard
with other family members. With this technique, the interviewer takes the parents step by step chronologically through the events of the previous 24 hours (having previously ensured that the day was not atypical due to visitors, illness, etc). Detailed information is obtained on a minute-by-minute basis with respect to what the child was doing, how long the activity lasted, who was with the child, the nature of any personal interactions, and whether any interruptions or additional events had occurred. A tape recording of the interview was made and transcribed for coding. Four major groups of behaviors were used: activities (playing games, reading, etc), basic care (eating, toileting, etc), outings (shopping, visiting, etc), and other (tantrums, nothing particular, etc). All persons who had contact with the child were coded. Five different levels of interaction were coded: (1) concentrated, (2) continuous, (3) available, (4) available, but not used, and (5)
separate.
Concentrated interactions were those in which at least two of the following three conditions applied: (1) there was close physical contact between the child and the person concerned; (2) the child and the person concerned were sharing the activity; and (3) the child and person concerned were giving the activity and each other their full attention. Continuous interactions were those that fell short of the criteria for "concentrated" but that involved the person giving the child a good deal of attention. This category was usually used for playing with other children, going out visiting, being visited, going out shopping, going for walks, and some mealtimes. Available interactions were those that met one of the following criteria: (1) the child was being supervised, someone was around and easily reached, and contacts were possible such as through a doorway; (2) another child or adult was in the room and awake and was being talked to or approached, if only occasionally; or (3) there was a high intensity of interaction with someone else, but a third person was still around and available for interaction. Available, but not. used interactions were defined as the child and another adult or child being in situations where contact was possible (as for available) but, despite an attempt by the other person, no interaction occurred. Separate was scored if the child was alone and communication was only possible by shouting or crying or by the mother coming to the child or vice versa. If the child was inside, doors must have been shut. A weighted qualitative interaction score for persons interacting with the child was obtained by giving a weighting of 4 for concentrated, 3 for continuous, 2 for available and available not used, and 1 for separate. The interaction score was then the sum of
Downloaded From: by a Uppsala University User on 05/25/2018
the products of these weights and the minutes of each type of interaction with the child. A weighted interaction score for the child was obtained similarly by using the child's minutes of interaction with the same weights, except that available not used was weighted 1 rather than 2. The reason for this is that available not used is equivalent to available from the perspective of the person giving the attention, but equivalent to separate from the perspective of the child receiving the attention. In these various ways, the type, quantity, and quality of interaction could all be assessed. Douglas et al2" have shown the measures to have a high interrater reliability and to agree well with similar measures obtained from direct observation. Positive Interaction as Reported by Parents.—A more global view of parent-child interaction that included less frequent, as well as everyday, activities was obtained by systematically asking the parent about all parent-child interactions that might be pleasura¬ ble to the child that had occurred over the previous week. The scale used was a slightly modified version of that developed by Brown and Rutter." It has been shown to have a high interrater reliability (over + .90). Also, it has been found that there is good agreement (r .72 to .78) between independent accounts from the mother and father. Specific enquiry was made about playing games, reading to the child, roughhousing, doing things with the child, helping the child, the child helping mother or father, and outings with mother or father. An interaction was given a score of one point if it lasted an hour or less, and two points if it lasted an hour or more. Separate scores for these activities were obtained for mother and father together with a total score for all positive interactions over the course of a week. Ittleson Scales.—The Ittleson family interaction scales were developed by Behrens et al32 to measure qualitative aspects of family relationships, parent-child interaction, and style of child care. The data for rating the scales derive from observations made by one of us (D.C.) during a four- to six-hour home visit that included a family mealtime. During the visit, parents were encouraged to adhere to their usual family routines as much as possible. Mothers and fathers were separately evaluated according to eight seven-point scales concerning spontaneity of interactions, decisiveness, consistency of emotional relatedness, mode of relat¬ ing to the child, control of the child, imposition of routines, anticipation of the child's needs, and meeting the demands of the child. Behrens et al32 provide anchoring descriptions for points 1, 3, 5, and 7 on the scales. In each case, 1 represents very poor functioning and 7 is optimal. Interrater reliability is reported as generally good; validity is based on a patient sample using comparisons with the judgments of caseworkers who have treated the families over a prolonged period.32 Time-Sampled Measures of Mother-Child Interaction.—During the four- to six-hour period of home observation, 90 minutes were set aside for the systematic observation of mother-child interaction, using quantitative measures developed by Hemsley et al (unpub¬ lished data, 1978). The 90-minute period was chosen as one in which the mother was free of obligations (such as cooking a meal) and would normally be with her child. No restrictions were placed on activities, and mothers were asked to do whatever they would normally do at that time. The observation schedule included 36 categories of behavior, 17 for the child's activities and 19 for parental behavior. Behavior was rated every ten seconds on specially constructed sheets laid out for minimal hand movement and association of related categories. Each sheet was divided into 12 time periods, giving a total observation time of two minutes' continuous recording per sheet. After each two-minute period, there was a 30-second rest pause. Each observation session lasted for about 90 minutes, including time spent talking with the mother, setting up equipment, and allowing both mother and child to become accustomed to the observer's presence. Forty minutes of actual recorded time was =
Table 1.—Children's Activities as Determined Standard Day Analysis hr
Duration, min/24 Autistic Kinds of Activities
Mean
Games with
books
Playing on own Active playing with toys, riding bikes, etc
Sleeping School Errands and out¬
ings Television Basic care All other activities Total *P
fP %P
< <
