Gestural Processing in Individuals with Autism Spectrum Disorder. Heidi Stieglitz Ham. The University of Queensland Australia November 20, PDF Free Download

Gestural Processing in Individuals with Autism Spectrum Disorder Heidi Stieglitz Ham The University of Queensland Australia November 20, 2010 Same Neural System

Gesture Across the Spectrum Presentation Overview Gesture and Autism Definition and History of Dyspraxia Overview of the Cognitive Model of Apraxia and Limb Apraxia Battery Results and Patterns of Praxis Processing Conclusions

Learning Outcomes At the end of this presentation, attendees will be able to: Identify challenges in comparing gestural studies to one another. Understand that developmental dyspraxia is not a unitary disorder. Identify patterns of praxis processing based on a cognitive model of limb apraxia. Autism and Communication Her expression was blank, though not unintelligent, and there was no communicative gestures Kanner, L. (1943). Autistic disturbances in affective contact. Nervous Child, 2, 217-250.

DSM-IV Diagnostic Criteria Triad of Impairments Social Interaction Language and Communication Restrictive, repetitive and stereotypical patterns of behavior DSM-IV Criteria for Social Interaction and Communication Marked impairment in the use of multiple nonverbal behaviours such as eye-to to-eye gaze, facial expression, body postures, and gestures to regulate social interaction and Delay in, or total lack of, the development of spoken language (not accompanied by an attempt to compensate through alternative modes of communication such as gestures or mime)

Gestural Deficits in Autism Imitation deficits well- documented Noted deficits in communicative gestures Deficits in meaningless gestures Reversal Errors Mixed Findings for meaningful gestures, some results difficult to interpret Explanations Behind Imitation Deficits Motor Theory Identification Theory (Hobson) Self-Other Mapping Theory (Rogers &Pennington, 1991) Mirror Neuron Hypothesis- Williams, 2001 Apraxia often confused with motor theory, not well understood in autism. Research Johns Hopkins and Kennedy Krieger

Motor Theory Decreased Strength Deficits in motor planning Motor Coordination Deficits Noted Decreased or increased muscle tone ASD vs. DCD Imitation Deficits, (Green, 2002) Hobson s s Task, Pipe Rack and Stick Hobson, R.P. and Lee, J. (1999) Imitation and Identification in Autism. Journal of Child Psychology and Psychiatry, 40 pp. 649-659.

Imitation of Hobson s s Task Definition of Limb Apraxia A A deficit of purposeful movement (including imitation tasks) which cannot be explained by elementary motor or sensory defect, task incomprehension problems, or inattention to command. De Renzi and Faglioni, (1999) A deficit in gestural processing

Ominous Apraxia Path Praxis in children with autism is strongly correlated with the social, communicative, and behavioral impairments that define the disorder suggesting that dyspraxia may be a core feature of autism Motor signs can also serve as markers for deficits in parallel brain systems which are important for control of social and communication skills Dzuik et al., 2007 p. 734

History of Apraxia Liepmann s Legacy Ideational Apraxia: A disorder affecting the idea of the Gesture (Not Knowing What to Do) Ideomotor Apraxia: A disorder affecting the production of the gesture (Knowing What to Do but not How to Produce) Pictures from Cubelli, R., Marchetti, C., Boscolo, G. & Della Sala, S. (2000)., Cognition in Action, 2000 Geschwind s Disconnection Model of Apraxia Heschl s gyrus Primary Motor Cortex for Right Hand Wernicke s Area Corpus Callosum Ipsilateral Motor Association Cortex Right Premotor Area for control of Left hand Geschwind followed Liepmann's interpretations and advanced a neuronal system for limb praxis similar to that proposed by Wernicke for language processing. Geschwind, N. (1965). Disconnexion Syndromes in Animals and Man, Brain, 88, 237-294.

The Need for a New Model Previous research included unidimensional assessments of the praxis system. Could not account for differences in performance between meaningful and meaningless gestures. Could not account for deficits in discrimination or comprehension of gestures. Previous Models could not account for the mounting evidence regarding dissociations within the praxis system what if imitation is spared? Rothi, Ochipa, & Heilman, 1991 Heilman and Rothi proposed that movement formulae' or `visuokinaesthetic motor engrams' ' were stored in the left inferior parietal lobule (IPL), and that they were translated into an innervatory pattern in the SMA and then discharged to the motor cortex rather than in the convexity of the Primary motor cortex, as Geschwind had previously proposed. Rothi, L., Ochipa, C. & Heilman, K. (1991) A Cognitive Neuropsychological Model of Limb Praxis, Cognitive Neuropsychology, 8 (6), 443-458.

Cubelli et al? Confusion exists between cognitive and anatomic functions Rothi states that motor schemes perform skilled movements which are stored in the SMA The structure and function of the SMA is far from understood Challenges Identifying Anatomical Loci Apraxia resulting from pure basal ganglia lesions rare (Heilman, 2001) Dominant parietal lobe The failure to identify one specific area resulting in praxis suggests that praxis is mediated by a distributed modular network (Hanna-Pladdy, Heilman, & Foundas, 2001) Thalamus implicated connections to prefrontal area and inferior parietal lobe PET study: left inferior temporal gyrus, left parahippocampal gyrus, and the left angular gyrus (Rumiati, 2005) PET study: Angular and middle frontal gyri in the left hemisphere and in the supramarginal gyrus and inferior parietal lobe in the right hemisphere (Peigneux, 2004)

Verbal Stimuli Visual Stimuli (Object) Visual Stimuli (Gesture) Phonological Analysis Visual Analysis Phonological Input Structural Description System Input Non-Lexical Route Action Semantic System Output Gestural Buffer Visuo-Motor Conversion Mechanism Motor Output Verbal Stimuli Visual Stimuli (Object) Visual Stimuli (Gesture) Phonological Analysis Visual Analysis Phonological Input Structural Description System Input Input/Conceptual Route Action Semantic System Output Gestural Buffer Visuo-Motor Conversion Mechanism Motor Output

Verbal Stimuli Visual Stimuli (Object) Visual Stimuli (Gesture) Phonological Analysis Visual Analysis Phonological Input Structural Description System Input Output/Production Route Action Semantic System Output Gestural Buffer Visuo-Motor Conversion Mechanism Motor Output Imitation and Gestural Processing in Autism Imitation behaviour cannot be localised to a single brain system, but rather different types of imitation involve different cognitive and neural systems. Important to test meaningless and meaningful gestures as well as different types of gestures (transitive, IG) Hamilton, Brindley, & Frith (2007) Imitation and action understanding in autistic spectrum disorders: How valid is the Mirror Neuron Hypothesis?

Types of Gestures Meaningful Gestures Meaningless Gestures Transitive Gestures Intransitive Gestures Pantomimes Hand Positions Finger Postures Actions with Objects Iconic Symbolic Expressive Actions without Objects Transitive Gestures = Object Use

Intransitive Gestures The use of an object is constrained by its function, the intransitive gestures vary according to different sociocultural contexts (the same meaning may be expressed by different gestures, the same gesture may convey different meanings) Cubelli et al. 2000 Paul Ekman Lie to Me A symbolic gesture has a precise meaning or set of meanings known to all members of a culture or sub-culture.

Lost in Translation Norwegians Shocked by Satanist Bush Shock greeting from Bush daughter, a headline in the Norwegian Internet newspaper Nettavisen said above a photograph of Bush s daughter Jenna, smiling and showing the sign. Bush Shocks Foreigners With Satanic Sign Intransitive Gestures

Pantomimes Design of the Apraxia Battery

Recognition of Object Use Recognition of Intransitive Gestures

Action Semantic Function Knowledge Intransitive Gesture Comprehension Pantomime Comprehension Tasks (Roy and Square, 1995) The Semantic System stores the knowledge about objects and tools, their function and the way in which they are used. Bartolo s Pantomime Comprehension Task

Pantomime Comprehension Task Association Task

Comprehension of Intransitive Gestures Production of Gestures Transitive Gestures Object Use Use This Object Direct Imitation Pantomimes Verbal Modality Visual Modality Tactile Modality Direct Imitation Intransitive Gestures Verbal Modality Visual Watch Video Clips of Social Scenarios Direct Imitation

Production of Transitive Gestures Actual Use Direct Imitation of Object Use Production of Pantomimes Verbal Show me how you would use a ball Visual Show me how you would use this object Tactile Show me how you would use this object Direct Imitation Clip

Production of Intransitive Gestures Verbal: Example: A football player just made the winning touchdown, what gesture would he make? Visual: Social Scenarios View Example Clip Direct Imitation Intransitive Gestures Production in Visual Modality Example taken from Bartolo Apraxia Battery PhD thesis, 2002 Drawing by Italian artist Claudio Villa

Intransitive Gestures Goldenberg and Meaningless Gestures LBD patients demonstrated deficits in hand postures and RBD patients demonstrated imitation deficits in finger position. Hypothesis is that hand positions require knowledge about the human body and finger postures require greater visuoperceptual skills. Goldenberg, G. (1999). Matching and Imitation of Hand and Finger Postures in Patients with Damage in the Right or Left Hemispheres. Neuropsychologia, 559-566.

Meaningless Gestures Goldenberg, G. (1999). Matching and imitation of hand and finger postures with damage in the left or right hemisphere. Neuropsychologia, 37, pp. 559-566. Imitation of Hand Positions

Imitation of Finger Positions Apraxia in Autism Study

Questions Driving Current Research Do individuals with autism fail to imitate secondary to deficits in praxis processing and not due to deficits in emotional connectedness or Theory of Mind only? What might we learn about these patterns of praxis processing? What if meaningless gesture imitation is more impaired than production of meaningful gestures or vice versa? Does this information provide us with clues to the underlying cognitive deficits of this population? Predictions Individuals with autism will be more affected in the recognition of intransitive than in object related gestures. Intransitive gestures in verbal and visual modality will be more difficult than pantomimes in the same modality. Imitation deficits will extend to meaningless gestures. Patterns of praxis processing will be identified similar to adult patients with limb apraxia

Inclusion in the Study Parent Interview Social Communication Questionnaire Autism Diagnostic Observation Schedule (ADOS) Wechsler Abbreviated Scales of Intelligence Beery Visual Motor Integration Test Beery Visual Perceptual Test Working Memory Test Battery for Children Digit Recall, Word List Matching, Listening Recall Following Standardized Tests, administered the newly designed Apraxia Battery for Children Informed Consent All parents of participants received and signed a statement of volunteer consent for the research study that allowed videotaping of testing sessions. Permission was granted for all videotapes and photos to be used solely for educational purposes.

Disclosure Statement I have no financial or nonfinancial interest in any organizaiton whose products or services are described, reviewed, evaluated or compared in the presentation. Group Matching Participant Group ASD (N=19) CA VIQ PIQ FSIQ M 12.15 106.05 102.52 106.0 SD 2.35 18.95 22.73 21.07 Range 7.58-15 81-144 144 72-155 79-153 TD (N=23) M 12.00 107.56 112.8 111.47 SD 2.12 12.9 18.86 16.49 Range 17.3-15.8 15.8 87-134 69-143 79-139

Cognitive Measures Used in Assessment Sessions Participants TD (N=23) ASD (N=19) Range Mean (SD) Range Mean (SD) VMI 78 136 102.4 (13.4) 72 109 87.6 (10.4) VP 19 30 26.5 (2.5) 20 30 25.8 (2.6) Digit Recall 71 145 107.0 (21.6) 71 141 98.6 (20.2) Working Memory Word List Matching 77 143 106.0 (16.2) 70 120 91.8 (15.1) Listening Recall 68 126 100.3 (16.8) 66 109 85.7 (12.9) Note. TD = Typically Developing Group; ASD = ; VMI= Visual Motor Integration; VP=Visual Perception Results Group Results of Meaningful Gesture Recognition and Imitation Objects, Intransitive Gestures and Pantomimes Two Patterns of Praxis Processing A Selective Deficit of Intransitive Gestures Verbal and Visual Modalities

Meaningful Gesture Experiment Recognition and Imitation Transitive Gestures Intransitive Gestures Pantomimes Gestural Codes for Meaningful Gestures Hand Posture Error Arm Posture/Trajectory Amplitude Timing Verbal Response Only I Don t t Know Body Part as Object Reversal Error

Meaningful Gesture Imitation

Recognition and Imitation Tasks Recognition ASD (N = 19) (mean ± SD) TD (N = 23) (mean ± SD) Object Use*** 18.16 ± 0.69 19.26 ± 0.81 Intransitives*** 14.11 ± 2.35 17.26 ± 1.32 Pantomimes*** 15.95 ± 3.47 18.09 ± 1.39 Imitation Object Use*** 12.37 ± 4.52 19.22 ± 0.80 Intransitives*** 13.05 ± 3.73 19.54 ± 0.92 Pantomimes*** 9.32 ± 5.03 18.83 ± 1.66 Note. ***t <.001; **t <.01. Asterisks indicate differences between groups. Recognition Task Group Final Model OR p-value Pantomime 1.00 reference Intransitive Gestures.62.001 Transitive Gestures 2.6 <.001 ASD 1.00 reference TD 2.3 <.001 Cognitive Variables Visual Perception 1.00.70 Listening Recall 1.01.14 FSIQ 1.00.53 Word List Matching 1.00.68 Digit Recall Visual Motor Int. for Pantomime.98.005 for IG 1.00.68 for Object 1.00.85 within ASD 1.01.27 within TD.98.04

Imitation Task Group Final Model OR p-value Pantomime 1.00 reference Intransitive Gestures 2.30 <.001 Transitive Gestures 1.90.003 ASD 1.00 reference TD 19.0 <.001 Cognitive Variables Visual Perception* 1.10.004 Listening Recall* 1.04.004 Digit Recall 0.99.005 Word List Matching 1.00.50 Visual Motor Int..99.26 FSIQ TD.96.02 ASD 1.00.96 Recognition Results Pantomime Intransitive Transitive OR = 1.00 OR =.62 OR = 2.6

Imitation Results Pantomime Transitive Intransitive OR = 1.00 OR = 1.90 OR = 2.3 Results TD group outperformed the ASD group on all tasks of recognition [OR=2.3, p <.001] and imitation [OR=19.0, p <.001] Intransitive gesture recognition was performed more poorly than pantomime or object recognition Intransitive gesture imitation was performed better than pantomime and transitive gesture imitation Increase in Visual Perception and Listening Recall associated with greater imitation success [OR = 1.10, p =.004 ; OR = 1.04, p =.004] Visual Motor Integration did not predict imitative success

Verbal Stimuli Visual Stimuli (Object) Visual Stimuli (Gesture) Phonological Analysis Visual Analysis Phonological Input Structural Description System Input Cognitive model of praxis processing (Cubelli et al., 2000) Action Semantic System Output Gestural Buffer Visuo-Motor Conversion Mechanism Motor Output Interpretation of Findings Intransitive gestures were not well-recognised in the ASD group Dual-route model accounts for the reversed pattern of performance: poorer recognition of intransitive gestures than objects and pantomimes and better imitation of intransitive gestures than objects and pantomimes This finding suggests the non-lexical route was used to process intransitive gesture imitation Object-related gestures were better recognised and statistically better than intransitive gestures suggesting that they were processed another way - the lexical route

Intransitive Gesture Imitation ASD (N=19) TD (N=7) Statistic p-value % errors % given type % errors % given type Hand 6.9 ± 4 53.2 ± 22 1.5 ± 1 41.7 ± 46 F 1,24 = 0.87 0.360 Arm 6.9 ± 4 35.2 ± 29 1.5 ± 1 3.6 ± 9 F 1,24 = 3.65 0.068 Amplitude 6.9 ± 4 14.0 ± 13 1.5 ± 1 0.0 ± 0 F 1,24 = 4.56 0.043 Timing 6.9 ± 4 10.9 ± 21 1.5 ± 1 0.0 ± 0 F 1,24 = 1.11 0.303 Reversal 6.9 ± 4 6.4 ± 12 1.5 ± 1 22.6 ± 37 F 1,24 = 2.67 0.116 Note. Percent of gestures with the specific error type among all gestures with an error (mean ± SD). ASD =, TD = Typically Developing Group. Pantomime Imitation ASD (N=19) TD (N=11) Statistic p-value % errors % given type % errors % given type Hand 10.7 ± 5 62.7 ± 24 2.5 ± 2 53.0 ± 47 F1,28 = 4.99 0.034 Arm 10.7 ± 5 52.9 ± 23 2.5 ± 2 22.6 ± 33 F1,28 = 1.20 0.282 Amplitude 10.7 ± 5 6.1 ± 12 2.5 ± 2 0.0 ± 0 F1,28 = 2.24 0.146 Timing 10.7 ± 5 3.0 ± 6 2.5 ± 2 9.1 ± 30 F1,28 = 0.00 0.962 Body Part Orientation 10.7 ± 5 5.6 ± 9 2.5 ± 2 1.8 ± 6 F1,28 = 0.07 0.786 Distance 10.7 ± 5 12.2 ± 14 2.5 ± 2 9.1 ± 30 F1,28 = 1.04 0.316 Reversal 10.7 ± 5 6.6 ± 8 2.5 ± 2 0.0 ± 0 F1,28 = 5.96 0.021 Note. Percent of gestures with the specific error type among all gestures with an error (mean ± SD). ASD =, TD = Typically Developing Group.

Patterns of Praxis Processing Recognition Comprehension Meaningful Conceptual Level Production Level Pantomimes Transitive Intransitive RN CH Pantomimes + + Intransitive + - Pantomimes + - Intransitive + - RN CH Verbal - - Visual - - Tactile - - Imitation - - Use + - Verbal - - Visual - - Imitation - - Meaningless + + RN Examples

Verbal Stimuli Visual Stimuli (Object) Visual Stimuli (Gesture) Phonological Analysis Visual Analysis Phonological Input Structural Description System Input Ideational Apraxia of the Procedural Type Action Semantic System Output Gestural Buffer Visuo-Motor Conversion Mechanism Motor Output CH Examples

Verbal Stimuli Visual Stimuli (Object) Visual Stimuli (Gesture) Phonological Analysis Visual Analysis Phonological Input Structural Description System Input Gestural Agnosia of Intransitive Gestures and Ideational Apraxia of the Semantic Type Action Semantic System Output Gestural Buffer Visuo-Motor Conversion Mechanism Motor Output Intransitive Gestures

Selective Impairment of Intransitive Gestures in Verbal and Visual Modalities Recognition Comprehension Meaningful Meaningless Conceptual Level Production Level Pantomimes Transitive Intransitive JK Object + Intransitive - Pantomimes + Object + Intransitive + Pantomime + Verbal + Visual + Use + Verbal - Visual - Imitation + Meaningless + Verbal Stimuli Visual Stimuli (Object) Visual Stimuli (Gesture) Phonological Analysis Visual Analysis Phonological Input Structural Description System Input Gestural Agnosia and Ideational Apraxia of the Procedural Type (limited to intransitive gestures) Action Semantic System Output Gestural Buffer Visuo-Motor Conversion Mechanism Motor Output

JK Profile No difficulty comprehending gestures IQ above normal limits including verbal IQ Visual perceptual skills, three subtests of working memory, and visual motor integration tests all performed within normal limits Production of pantomimes in verbal and visual modalities as well as imitation of meaningless gestures were performed above cutoff JK Verbal Response Only

DS Verbal Response Only DS Verbal Response Only

Interpretation of Findings Intransitive Gestures and Pantomimes rely on different cognitive processes to perform. Deficits in social cognition affect performance of intransitive gestures in individuals with autism Verbal Response Only was only identified in ASD group Suggests that when gestural production tasks require on-line processing necessitating recruitment of socio-cognitive cognitive demands, this pattern emerges Meaningless Gestures in Autism

Meaningless Gesture Imitation Hand Finger ASD: 6.79 (2.50); TD: 8.96 (.92); p=.002 ASD: 7.45 (2.05); TD: 8.98 (1.04); p=.007

Results of Meaningless Gesture Imitation Independent and Cognitive Variables Group Matching Task Task OR p-value ASD 1.00 reference TD 2.20 <.001 Hand 1.10.111 Finger 1.00 reference Hand.86.53 Finger 1.00 reference Word List Matching.99.115 Visual Motor Integration 1.00.61 Full Scale IQ 1.00.72 Significant Interactions of Hand and Finger Imitation Interactions Finger Match Finger Match Visual Perception Listening Recall Digit Recall Task OR Finger Imitation 1.20.01 Hand Imitation.96.67 p-value TD 1.50.003 Finger Imitation.81.006 Hand Imitation 1.10.22 Finger Imitation 1.00.56 Hand Imitation 1.04.004 Finger Imitation.99.114 Hand Imitation.96 <.001

Results TD group outperformed the ASD group [OR = 2.2, p =.001] Hand and Finger Imitation were not significantly different from one another and they were not significantly correlated VMI, WLM, FSIQ, and Hand Matching did not significantly contribute to imitation success No Group X Task Interaction but CV X Task and CV x Group interactions were identified Finger Matching associated with increased success of finger imitation but not hand imitation [OR=1.20, p =.01] This effect stronger in the TD group [OR = 1.50, p =.003]

Interpretation of Findings Imitation deficits are not explained by motor difficulties alone Cognitive variables were differentially associated with either hand imitation or finger imitation performance suggesting that the underlying cognitive mechanisms sub serving hand and finger imitation may differ Hand and finger imitation appear to be task dependent suggesting further research is required for meaningless gesture imitation in autism Task of finger matching was a better predictor of finger imitation than a visual perception task using shapes and objects Conclusions Imitation needs to be considered as part of an overall praxis processing system and not in isolation Individuals with autism performed more poorly in tasks including recognition, comprehension, and production Gestural deficits could not be fully explained by the underlying cognitive mechanisms including Visual Motor Integration or Visual Perceptual Skills Patterns of praxis processing have been identified similar to cases of limb apraxia in adult patient populations

Thank you to my supervisory team (alphabetical order): Angela Bartolo, (University of Lille) Martin Corley, (University of Edinburgh) Thusha Rajendran, (University of Strathclyde) Sara Swanson, (PI, MCW); Aniko Szabo, (MCW)

Thank you to the Division of Neuropsychology at MCW and to the families who participated in the study. Also, thank you to the University of Edinburgh Department of Psychology in Scotland.

Gestural Processing in Individuals with Autism Spectrum Disorder. Heidi Stieglitz Ham. The University of Queensland Australia November 20, 2010