4 Separate Papers. Write a one-page review, single spaced of each of the assigned readings. Article responses should include a description of the article itself and a reaction to the article. I will a

KeywordsParent–child interaction Autism severity Communication Relationship-based treatment Attachment Introduction When Kanner (1943) rst described the syndrome of aut- ism, he considered the condition to be a biologically based impairment in affective contact between the children and other people. Here he was highlighting a feature of the children’s relatednesstowards others, how they related to strangers (such as Kanner himself) as well as to people with whom they might have an enduring relationship.At the same time, and less centrally, Kanner’s descriptions included reference to the children’s relationships with others, for instance as re ected in their seemingly dimin- ished responses to separation from their parents.

The contrast between relatedness and relationships is one between qualities of moment-to-moment social inter- action and interpersonal engagement, and enduring modes of interpersonal relation (whether of attachment, friend- ship, rivalry, hostility or affection) that have speci city to the individuals involved. Relationships are dynamic sys- tems that evolve over time, and are characterized by the endurance and the strength of connectedness between individuals (Reis et al.2000). In the case of relationships between children and parents, they alter as developmental This work was conducted as part of the clinical doctorate of the rst author (NB) carried out at Walden University, and is an adaptation of her dissertation. Portions of the work were presented at the International Meeting for Autism Research (Imfar) in San Diego, CA, May 2011.

N. M. Beurkens (&) Horizons Developmental Resource Center, 3120 68th Street SE, Caledonia, MI 49316, USA e-mail: [email protected] J. A. Hobson R. P. Hobson Institute of Child Health, University Collge London, 30 Guilford Street, London WC1N 1 EH, UK e-mail: [email protected] R. P. Hobson e-mail: [email protected] J. A. Hobson R. P. Hobson Tavistock Clinic, 120 Belsize Lane, London NW3 5BA, UK 123 J Autism Dev Disord (2013) 43:168–178 DOI 10.1007/s10803-012-1562-4 needs change (Bugental2000; Harach and Kuczynski2005; Laursen and Bukowski1997). This is notwithstanding that relationships implicate particular qualities of relatedness between or among the people involved in those relation- ships, and that interactions can be viewed in the context of overall relationships (Loulis and Kuczynski1997). Among many forms of dif culty that can affect parent–child rela- tionships, stresses in parenting an atypically developing child can create negative feelings toward the child, alter parent expectations, and lead to a reduced sense of parent- ing competence (Van Hooste and Maes2003).

One aim of the present paper is to tease out this dis- tinction between relatedness and relationships as applied to relations between children with autism and their parents.

We investigate how the severity of children’s autism is related to independent measures of child-parent interaction (relatedness) on the one hand, and child-parent relationship on the other. Although the study was not intended to examine thedeterminantsof patterns of interaction and relationship within the child-parent system, our aim was to investigate how closely each of these correspond with children’s severity of autism as assessed using the cali- brated severity metric of the Autism Diagnostic Observa- tion Schedule (Gotham et al.2009; Lord et al.2002). The ndings may be relevant for understanding the dynamics of social engagement, and perhaps highlight the potential for fostering optimal development among children with autism.

At the outset, it is critical to appreciate the bidirec- tionality of parent–child relations (Bell1968; DeMol and Buysse2008; Kuczynski et al.2003; Sameroff and Chandler1975). Just as children’s characteristics affect their relations with parents so too, interpersonal interac- tions and relationships with adults affect children’s devel- opment and functioning (Sameroff2009). Over time, each participant and the relationship as a whole undergo trans- formation (Fogel2009). It would seem inevitable that a child’s autism will in uence parent–child interactions. As among typically developing and developmentally delayed populations, there are also likely to be forms of parental behaviour that encourage or impede the children’s devel- opment (Siller and Sigman2002).

Relatedness, Relationships, and Autism There is limited evidence concerning the relation between autism severity and parent–child interactions and/or rela- tionships, although these are clearly matters of importance (Markus et al.2000). On the level of relatedness, the more verbal and cognitively able the child, the more caregivers tend to engage in mutual play and positive feedback, whereas parents of children with autism who have poorer joint attention and fewer expressive language skills spend more time keeping their child physically contained andoriented to tasks (Kasari et al.1988). When toddlers with autism show higher levels of externalising problems, their mothers use signi cantly more active/physical coping strategies and report greater levels of parenting stress (Gulsrud et al.2010). Gulsrud et al. (2010) reported how, with an intervention targeting joint attention, mother–child emotional co-regulation improved.

From a complementary perspective, parents may in uence the development of their children with autism. Siller and Sigman (2002,2008) studied the extent to which a caregiver’s behaviour was synchronized with a child’s focus of attention and ongoing activity. The researchers videotaped interactions between caregivers and children with autism, and reported a correlation between the synchronization of such relations and children’s subsequent joint attention and language develop- ment. Ruble et al. (2008) reported that parent responsiveness was associated with the children’s propensity to initiate social interactions with adults, and in this case parent interactions were not associated with the child’s adaptive behavior or cognitive level, nor with child and parent demographics (but see Spiker et al.2002). Yet in all such research, one needs to be very cautious about interpreting correlations in terms of cause-effect relations.

On the level of relationships, Koren-Karie et al. (2009) reported that secure attachment among children with aut- ism was related to a variety of developmental competencies and greater parental sensitivity, but not to the severity of clinical features of autism (also see van Ijzendoorn et al.

2007). On the other hand, greater severity of autism may be associated with higher levels of individual and family burden (Stuart and McGrew2009). Hoffman et al. (2009) reported a signi cant relationship between child autism severity and parent ill-health, level of depression, and negative perceptions of spouse, as well as the degree of closeness, or attachment level, between mother and child.

Indeed, research on a variety of disabilities has yielded evidence that symptom severity is associated with greater levels of burden for parents and the family system, creating more strained relationships (Baker et al.2005; Pakenham et al.2005; War eld2005).

There are additional grounds for distinguishing between relatedness and relationships among individuals with aut- ism. On the one hand, there is evidence that across the lifespan, individuals with autism are atypical in various aspects of their interpersonal relatedness. For example, direct observations of infants (e.g., Charman et al.1997), as well as retrospective parental reports (e.g., Wimpory et al.

2000), reveal that even very young children with autism have impairments in the frequency or intensity of eye contact, turn-taking, and referential looking. Among older children with autism, there are reports of the children’s abnormalities in coordinating expressions of affect, ges- tures and eye contact with other people, for example in J Autism Dev Disord (2013) 43:168–178169 123 contexts involving joint action and attention (Kasari et al.

1990), face-to-face interaction (Dawson et al.1990), greetings and farewells (Hobson and Lee1998), and con- versations (Capps et al.1998; Garc ´ a-Pe´ rez et al.2007).

On the other hand, there is also evidence that children with autism arenotso atypical in certain features of their attachments. Several published studies indicate how young children with autismdorespond to separation from and reunion with their caregivers, at least in the short-term (e.g., Shapiro et al.1987; Willemsen-Swinkely et al.2000; Sigman and Mundy1989; Yirmiya and Sigman2001).

Many (not all) 2- to 5-year-old children with autism are like matched developmentally delayed children in showing somewhat variable mood changes such as fretting when their caregiver leaves them, and upon reunion they tend to spend more time alongside the caregiver than a stranger.

When allowance is made for their sometimes idiosyncratic behavior, a substantial number of children with autism are rated as securely attached (Rogers et al.1991; Shapiro et al.

1987). Therefore the children’s relationship with their caregivers is clearly special, even though their qualities of relatedness are atypical. The relatively coherent forms of jealousy seen among children with autism (e.g., Bauminger 2004) may re ect such attachment processes, and account for the dissociation between jealousy and atypicalities in the children’s expressions of other social emotions such as guilt and concern (Hobson et al.2006).

In the present study, we employed independent mea- sures of autism severity, parent–child relatedness and parent–child relationship, in order to evaluate the relations among these variables. Children’s performance on the Autism Diagnostic Observation Schedule (ADOS: Lord et al.2002) served as an index of autism severity (Gotham et al.2009). We employed the Dyadic Coding Scales of Humber and Moss (2005) to assess interpersonal related- ness during videotaped semi-structured parent–child inter- actions. The DCS includes ratings of social coordination, communication, appropriate role assumption, emotional expression, responsivity/sensitivity, tension/relaxation, mood, and enjoyment. Finally, the Parent–Child Relation- ship Inventory (Gerard1994) was used to gather systematic parent report of support, satisfaction with parenting, involvement, communication, limit setting, autonomy, and role orientation.

Our single prediction was that with increasing severity of children’s autism as assessed on the ADOS, qualities of parent–child relatedness would be negatively affected, as expressed through lower scores on the Dyadic Coding Scales. Although we consider there to be some degree of dissociation between relatedness and relationships in aut- ism, we were uncertain about the degree to which severity of autism might affect parent–child relationships, and made no prediction in this respect.Methods Participants Participants were 25 children with autism aged between 4 and 14 years (M=7.4 years, SD=2.2 years). Although there was a wide age range, the majority of the children (92 %) were aged 10 or younger. The children were mainly male (19 males, 6 females) and took part in the procedures along with the parent identi ed by the family as the primary caregiver (80 % mothers, 20 % fathers). Four of the primary parents were single parents and the remaining 21 were in two-parent households. Primary parents ranged in age from 33 to 61 years. The primary parents were well educated (some college:

n=6; college degree:n=11; postgraduate education: n=8). Participants were recruited from autism organiza- tions throughout West Michigan. The ethnic breakdown of child participants was as follows: African American 4 %, Hispanics 4 %, Caucasian 88 %, and Asian 4 %. All partic- ipant children had received a previous clinical diagnosis of an autism spectrum disorder, and this was in keeping with the results of ADOS administration in the present study.

Procedure Child participants were evaluated with the ADOS in a clinic setting by the primary researcher, who was trained to admin- ister and score the ADOS at the University of Michigan. The appropriate ADOS protocol was selected based on the age and language level of each child. The two four-year-old children received a Module 1 and a Module 2, the 21 5–10-year-old children received Module 1 (n=5), Module 2 (n=11) or Module 3 (n=5), the 12-year-old child received a Module 3 and the 14-year-old child was administered a Module 2.

Parent participants were provided with the PCRI parent questionnaire to read and complete in the clinic setting.

The PCRI was scored by the primary researcher using the scoring procedures in the manual.

The videotaped parent–child interaction session occur- red within the clinic setting, and consisted of a 10-min interaction period during which the primary parent and child were provided with a standard set of play materials appropriate for the age and developmental level of the child, for instance balls, active games, board/card games, blocks, puzzles, and bean bags. The parent and child were invited to settle and to use the materials together in whatever ways they wished. Parents were asked to set limits and boundaries as they would with the child at home.

The parent–child interaction videos were rated by a team of two coders—a primary coder, and secondary coder for reliability—both of whom were blind to the children’s diagnoses, hypotheses and predictions of the study, and the results of all other measures used in the study. 170J Autism Dev Disord (2013) 43:168–178 123 Measures Severity of Autism The Autism Diagnostic Observation Schedule (ADOS; Lord et al.2002) is widely considered a gold standard instrument for identifying clinical features of autism spectrum disorder.

The ADOS is a standardized assessment of communication, social interaction, behavior, sensory stereotypies, and play or imaginative use of materials. One of four modules is administered based on the individual’s developmental and language level. Structured activities and materials provide standard contexts in which social interactions, communica- tion, and other behavior relevant to autism spectrum disor- ders are observed.

Recently revised algorithms for the ADOS allow for increased speci city in classi cation of clinical features (Gotham et al.2009), as well as increased alignment between the various modules used with participants of differing ages and functioning levels (Gotham et al.2008). A calibrated severity score, called the autism severity metric, is calculated to identify severity of clinical features independent of par- ticipant demographics. This metric, ranging from 1 to 10, allows for standardized comparison of total scores across modules. A severity metric score of 1–3 is considered ‘‘nonspectrum,’’ a severity metric score of 4–5 is considered ‘‘autism spectrum disorder,’’ and a severity metric score of 6–10 is considered consistent with the diagnosis of ‘‘aut- ism.’’ This method of scoring is a departure from the current ADOS manual, but re ects current research conducted by the test authors (Gotham et al.2009), who gave permission for its use in the context of the current study.

Patterns of Parent–Child Relatedness The Dyadic Coding Scales were developed by Humber and Moss (2005) to rate qualitative aspects of parent–child interaction for school-age children. While not commercially available, permission for use of this measure for the present study was granted by its developers. Nine domains are rated on a scale of 1–7, indicating the quality of the following aspects of interaction: coordination, communication, partner roles, emotional expression, responsivity/sensitivity, ten- sion/relaxation, mood, and enjoyment. For example, low scores on co-ordination re ect interactions that are unpro- ductive and involve friction between the child and parent; low scores on communication re ect ignoring behavior, withdrawal, incongruent utterances, and/or awkward silen- ces; and low scores on emotional expression indicate intense and/or constricted emotional exchanges. An overall rating is also assigned based on the overall quality of parent–child interaction. Here low scores re ect a sense of indifference, lack of pleasure, and/or con ict.This tool was designed for and used within a study analyzing school-age attachment and mother–child inter- action, and has yielded good inter-rater reliability in a previous study of children with autism (Hobson et al.

2008). In the present study, on the basis of seven cases rated independently, the intra-class correlations (ICC) for each subscale were between 0.83 and 0.98 (where values above 0.80 are considered excellent).

Parent–Child Relationship The Parent–Child Relationship Inventory (Gerard1994)is a self-report questionnaire for parents of children ages 3 through 15 years, and takes approximately 15 min to complete. The inventory assesses parents’ views on par- enting and aspects of the parent–child relationship. The seven scales cover parental support, satisfaction with par- enting, involvement, communication, limit setting, auton- omy, and role orientation. For instance, Satisfaction re ects the amount of pleasure and ful llment derived from par- enting (e.g. ‘I get as much satisfaction from having chil- dren as other parents do.’), Involvement has to do with a parent’s level of knowledge of and interaction with the child (e.g. ‘I spend a great deal of time with my child’), Communication concerns parents’ perception of the effectiveness of their communication (e.g. ‘I can tell by my child’s face how he or she is feeling’), and Autonomy focuses on the parent’s ability to promote the child’s independence (e.g. ‘I worry a lot about my child getting hurt’). The scales are rated on a scale of 1 (strongly agree) to 4 (strongly disagree), yielding raw scores,Tscores, and standardized scores for each scale. Higher scores indicate more positive parent–child relationships. Separate scoring sheets and norms are provided for mothers and fathers. The measure was standardized on over 1,100 parents across the United States. Reliability, as determined by internal con- sistency, had a median alpha of 0.82, and the mean test– retest correlations were 0.81. PCRI raw scores are con- verted toTscores, normalized standard scores with a mean of 50 and a standard deviation of 10. ATscore which is more than one standard deviation below the mean (i.e. less than 40) suggests problems in the domain the scale re ects and very lowTscores (i.e. below 30) indicate the possi- bility of very serious problems.

Results Descriptive Data Descriptive data from the Autism Diagnostic Observation Schedule (ADOS) calibrated severity metric, the play- based observation coded with the Dyadic Coding Scales J Autism Dev Disord (2013) 43:168–178171 123 (DCS), and the parent-reported features of parent–child relationship on the Parent–child Relationship Inventory (PCRI) are given in Table1, where the standard deviations and ranges convey the substantial ranges of scores on each measure.

Calibrated Severity Scores of the ADOS In keeping with the children’s previous clinical diagnosis, scores on the calibrated severity metric of the ADOS ran- ged from 4 (mild autism/Autism Spectrum Disorder) to 10 (severe autism). Autism severity was not associated with chronological age in this sample,r(25)=0.11, NS. Autism severity was also not associated with the ADOS Module the child received,r(25)=-0.23, NS.

Parent–child Interaction on the DCS It may be helpful to represent the current results on the DCS in relation to those previously reported by Humber and Moss (2005).

As can be seen in Fig.1, children with autism in the current sample received scores that were signi cantly lower than typically developing securely attached children. The effect sizes for these differences were medium for tension/relaxation (d\0.5) and for overall interaction, coordination, commu- nication, enjoyment and mood (drange=0.71–0.78) for overall interaction, coordination, communication, enjoyment, and mood, and large (drange=0.91–0.98) for emotionalexpression, roles, and sensitivity/responsivity. On the other hand, the children with autism in the present sample received scores that were as low as those received by a parent–child dyads in which children had disorganized/controlling attachment patterns. The effect sizes for comparisons between our autism sample and the disorganised/controlling sample of Humber and Moss were all negligible (drange= 0.07–0.16) with the exception of small effect sizes (drange=0.24 and 0.28) for the sub-scales of overall interaction and emotional expression. This suggests that our autism sample showed marked dif culties in parent–child relatedness. Although several of the children in the current sample were older than those in the Humber and Moss (2005) study, chronological age was not associated with any of the subscales of the Dyadic Coding Scales,r(24) range=0.11 to 0.39, all NS.

Parent Report of Relationship Quality On the PCRI, all of the subscales, with the exception of Communication, received mean scores consistent with non- problematic parenting. With regard to the domain of Communication, the meanTscore was in the low range.

This score might re ect how parents of children with aut- ism may struggle to communicate well with their children including simple conversation and the ability to talk with their children. Low Communication scores (Tscore 30–39) indicate parental dif culty in talking to a child and in ‘getting through’ to that child. Figure2presents numbers of parents with low (Tscore\40) and very low (Tscore\30) scores, by individual scales.

From Fig.2, it can be seen how most of the parents in the study reported problems with Communication (Lown =11, Very Lown=7). Very lowTscores (less than 30) often indicate the parent feels helpless in his/her attempts to communicate with the child and discover the child’s needs.

There were also several parents who reported dif culties with Involvement (Lown=5, Very Lown=1). Items on the Involvement scale re ect the parent’s propensity to spend time with their children and get to know them. Very low scores on this scale can re ect how parents feel there is a great distance between themselves and their children.

Autism Severity and Parent–Child Relations Two separate multivariate regressions were conducted to examine the relations between autism symptom severity (ADOS) and a) parent–child interaction (DCS), and b) par- ent–child relationship (PCRI). Ideally, given seven predictor variables, a sample size of 44 participants would have been utilized to achieve an alpha of 0.05 with a large effect size (Green1991). A Bonferroni adjustment was considered, but this would potentially increase the likelihood of committing Table 1Descriptive data for study variables VariableM(SD) Range ADOS 6.88 (1.51) 4–10 DCS Coordination 4.04 (1.43) 2–6 Communication 3.76 (1.71) 1–7 Partner roles 3.80 (1.08) 2–6 Emotional expression 3.40 (1.78) 1–7 Responsivity 3.60 (1.26) 2–6 Attention/relaxation 3.96 (1.51) 1–7 Mood 4.00 (1.58) 1–7 Enjoyment 3.84 (1.49) 1–6 Overall 3.84 (1.37) 2–6 PCRI Support 48.80 (6.22) 36–59 Satisfaction 48.28 (7.93) 33–66 Involvement 44.32 (7.28) 23–53 Communication 35.44 (7.72) 21–53 Limit setting 48.60 (9.22) 23–69 Autonomy 51.12 (9.67) 24–70 Role orientation 51.88 (8.90) 31–64 172J Autism Dev Disord (2013) 43:168–178 123 a Type II error (Nakagawa2004). Therefore, the adjustment was not made for this analysis.

The results of the regression for ADOS predicting DCS are shown in Table2. The data suggest that the calibrated severity scores on the ADOS predict the DCS subscale scores of co-ordination, communication, emotional expres- sion, responsivity, and mood, as well as overall scores,F(9, 15)=3.38,p\.05. The results were just shy of signi - cance for predicting tension/relaxation and enjoyment, and not signi cant for partner roles. It is plausible that parents and children experience tension and/or enjoyment within their interactions based on factors other than symptom severity.

It is important to note that the ADOS Module received by the child was also signi cantly associated with almost all of the DCS subscales (rrange=0.35–0.62). This suggests that general development/language level may also make an important and independent contribution to quality of parent–child interaction. Table3provides partial cor- relations between the children’s calibrated severity scores on the ADOS and the subscales of the DCS, after con- trolling for variance associated with the ADOS Module received. When both ADOS Module and calibratedseverity score were entered into a linear regression, 50 % of the variance (R 2=0.49) in the DCS overall interaction score was explained,F(2, 22)=10.93,p\.001.

A question arises, whether there are particular items of the ADOS that correspond most closely with subscales of the DCS. The present study was not designed to address this question, especially insofar as items on the ADOS vary depending on the Module employed. On informal review, it was evident that most of the correlations reported between autism Calibrated Severity Scores and the subscales of the DCS (Table3) were very similar to those between uncalibrated ADOS social-affect raw scores (range-0.37 to-0.63), whereas the correlations for ADOS scores on restricted and repetitive behaviour and interests were sub- stantially lower (range-0.12 to-0.34). Not surprisingly, therefore, ADOS indices of social-affect (although raw scores were not calibrated across Modules) were most closely related to the DCS relatedness measures.

In contrast with the correlations between autism severity and measures of personal relatedness, autism severity was notsigni cantly associated with any of the PCRI parent– child relationship subscales (where correlations ranged from 0.10 to 0.39). The results of the regression for ADOS predicting PCRI (support, satisfaction, involvement, com- munication, limit setting, autonomy and role orientation) were not signi cant,F(7, 17)=0.94,p=.50. Therefore there appeared to be little relation between ADOS scores and PCRI scores. On the other hand, ADOS Module was related to the Communication subscale of the PCRI, r(25)=0.44,p\.05. This suggests that the parent- reported dif culties communicating with children with autism may have been linked to the child’s developmental level/language functioning.

Individual differences in scores on the PCRI were not related to observations of parent–child relatedness on the DCS, with only one exception. There was a counter-intuitive nding that the DCS subscale tension/relaxation was inver- sely related to the PCRI subscales of Support (p\.05), Limit Setting (p\.05), and Autonomy (p\.01). One 1 2 3 4 5 6 7 Ov Coord Com Em Ex Enj Mood Role Sens TensTyp-Secure Typ-Dis/Con Autism Fig. 1Scores from the Dyadic Coding Scales from children with autism (current study) and Children without Autism (as reported by Humber and Moss 2005).Note: Typ- Secure=typically developing securely attached children (n=71) and Typ-Dis/ Con=typically developing children with disorganised/ controlling attachment (n=18) 0 5 10 15 20 25 Support Satisfaction Involvement Communication Limit Setting Autonomy Role Orientation PCRI Subscale Number of Parents (out of 25) Low Very Low Fig. 2Number of parents with low (Tscore\40) or very low (Tscore\30) PCRI scores J Autism Dev Disord (2013) 43:168–178173 123 possible interpretation of this exploratory and unanticipated nding may be that more relaxed parent–child dyads inclu- ded a permissive parent who tended not to set as many limits or promote the child’s independence.

Discussion The principal ndings of this study were clear-cut. Within a group of 25 children with autism aged between 4 and 14 years, there was evidence that with increased severity of autism as measured by the calibrated severity scores of the ADOS, qualities of videotaped parent–child interaction such as co-ordination, communication, emotional expres- sion, responsivity, and mood were adversely affected.

Therefore features of autism (including those apparent in communication and social interaction) as rated in stan- dardized ADOS assessments were good predictors of less satisfactory parent–child interactions. Impairments in interpersonalrelatednessappeared to constitute an impor- tant bridge between ADOS severity scores and qualities of dyadic interaction.Here the results contrast with another nding, namely the low correlation between the same features of autism severity and aspects of the parent–childrelationshipas reported by the parents. For instance, ADOS severity scores did not predict parental satisfaction, involvement, or communication, where satisfaction re ected the amount of pleasure and ful llment derived from parenting, involvement had to do with a parent’s level of knowledge of and interaction with the child, and communication concerned parents’ perception of the effectiveness of their communication.

One possible source of scepticism in interpreting the ndings on relatedness, is whether the results might re ect little more than the outcome of applying similar measures in two settings. However, the differences between the ADOS and the DCS extend beyond the obvious and important contrast between a semi-structured procedure conducted by a stranger (ADOS), and a measure applied to natural parent–child interactions (DCS). A major focus of the ADOS is upon speci c forms of emotional/communi- cative behaviour exhibited by the participant, for instance (depending on the module) facial expression, pointing, eye contact, joint attention, and showing. Although qualities of dyadic engagement such as rapport or shared enjoyment are also taken into account, the emphasis is on particular forms of behaviour exhibited by the child. In contrast, DCS ratings apply to more global qualities of child–adult interaction. In the case of communication, for example, low scores are given for a dearth of communication involving withdrawal and awkward silences, whereas high scores are given for clear, direct and meaningful words and gestures, comfortable silences, and a balance in who does the talking and listening. A low overall rating on the DCS would correspond to disinterest, inaccessibility, lack of pleasure, and the presence of discord and con ict, whereas a high score would be given when there is mutual responsiveness, enjoyment, and harmonious and agreeable interactions with genuine interpersonal interest.

Table 2Multivariate regression for ADOS predicting DCS Dependent variablesBSEtpR 2 Power Co-ordination-0.49 0.17-2.92 .01 0.27 0.80 Communication-0.73 0.18-3.99 .00 0.41 0.97 Partner roles-0.18 0.15-1.21 .24 0.06 0.21 Emotional expression-0.58 0.21-2.72 .01 0.24 0.74 Responsivity-0.39 0.15-2.52 .02 0.21 0.68 Tension relaxation-0.39 0.19-2.00 .06 0.15 0.48 Mood-0.44 0.20-2.21 .04 0.18 0.56 Enjoyment-0.34 0.19-1.75 .09 0.12 0.39 Overall-0.50 0.16-3.18 .00 0.31 0.86 pValues uncorrected for multiple comparisons Table 3Correlation coef cients for autism severity and parent– child interaction, including partial correlations with ADOS module controlled DCS subscalerPartialr Coordination-0.52**-0.48* Communication-0.64**-0.65** Partner roles-0.25-0.16 Emotional expression-0.49*-0.45* Responsivity-0.47*-0.41* Tension/relaxation-0.39-0.33 Mood-0.42*-0.36 Enjoyment-0.34-0.27 Overall interaction-0.55**-0.52** *p\.05; **p\.01 174J Autism Dev Disord (2013) 43:168–178 123 Of course, contrasts between measures do not imply that the phenomena being measured are totally distinct. In the present instance, there is no implication that children’s potential for social relatedness as assessed on the ADOS is independent of child-parent relatedness as evaluated using the DCS. The present ndings suggest just the opposite.

The point is that those features of relatedness that are so important for assessing the severity of autism (on the ADOS) arealsoconnected with interpersonal engagement and relatedness in parent–child interactions.

When we turn to the ndings on parent–child relation- ships, it should be noted that these are not altogether in keeping with other evidence that children’s symptom severity may have a negative impact on parent–child relationships. Hoffman et al. (2009) reported that chil- dren’s autism symptom severity was related to their rela- tionships with their mothers, speci cally in the areas of attachment and closeness. These results emerged in the context of a study of maternal stress levels, and portray aspects of relationship that differ from those identi ed by means of the PCRI. It was also the case that in the present study, a number of parents’ responses on the PCRI inclu- ded reference to dif culties over communication and involvement with their offspring.

The results may be considered from a number of per- spectives. To begin with, they support the conceptual dis- tinction between two partly separable aspects of social experience and behavior: interpersonal relatedness and relationships. Of course it is not possible completely to divorce qualities of moment-to-moment interpersonal con- nectedness and adjustment on the one hand, and features of the relationships between any two individuals engaged in such interactions. Yet if we consider the case of autism, biological factors that might seriously disrupt many aspects of affected children’s relatedness to people do not neces- sarily have the same impact on the children’s relationships.

For instance, as Hobson et al. (2006) discuss, patterns of attachment and associated feelings such as jealousy might be spared among individuals with autism, even when their intersubjective engagements (and especially, their feelings forother people) might lack coherence. Results from the present study are in keeping with the view that relationships between children with autism and their parents are not determined by the same factors that appear to constrain certain aspects of interpersonal relatedness.

Certain limitations to the study are worth highlighting.

Firstly, it remains to establish how speci c is the lack of correlation between ADOS measures of autism severity and parent reports of qualities of parent–child relationships. It would be helpful to compare the present results with ndings when the same ADOS measures are assessed in relation to other forms of parent report, for instance reports on the children’s communicative abilities, so that the degree ofconcordance (or lack of concordance) between these dif- ferent kinds of measure might be evaluated. Secondly, cross- sectional studies such as this need to be complemented by longitudinal research, if one is to trace how far impairments in interpersonal relatedness either shape, or are shaped by, other features of autism. Correlations do not establish the direction in which causal arrows point. In this respect, we stress the dangers of supposing that dif culties in parent– child interactions in uence, rather than re ect, children’s clinical presentation, although of course there may be com- plex cycles of cause and effect.

The ndings need to be set within an appropriate theo- retical framework for understanding the development of child-parent relations, from both relatedness and relation- ship perspectives. As discussed in the Introduction, previ- ous research has demonstrated that children in uence their own development through their interactions and relation- ships with parents (Bell1968; Cummings et al.2000; Sameroff and Chandler1975). For example, children’s behavioral and relational dif culties can lead to parenting stress, which may alter parenting behavior and perpetuate the children’s dif culties (Hastings2002). On the other hand, such vicious cycles of interaction are not inevitable, nor need they be pervasive. The present results highlight not only the impact of autism on child–parent relatedness, but also the potential for child–parent relationships to develop despite such challenges.

The results may also be considered from the viewpoint of intervention. Research on the bidirectional nature of parent–child interactions has shown that child development can be changed in a positive manner as a result of parents altering speci c interactive behaviors (Arnold et al.1993; Hoagwood et al.2001). Yet in the eld of autism, many interventions do not target the areas of social-communi- cative dif culty that are core features of autism (Charman et al.2004), nor do they follow recommendations to include parents in the treatment process (Howlin2000).

Yet again, there is encouraging evidence that interven- tions aimed at creating change in parents and, thus, in parent–child relations may be effective in reducing the severity of autism and/or reducing its impact on the parent– child relationship (Green et al.2010). Training mothers in mindfulness, for example, has led to signi cant reduction in maladaptive behavior of their children with autism (Singh et al.2006). Mothers involved in that study reported an increase in overall parenting satisfaction, increased satisfaction with their parenting skills, and an increase in mindfulness with their children. A program aimed at increasing parental responsiveness to children with autism had a positive impact on the children’s social-emotional development (Mahoney and Perales2003). An intervention designed to reduce problematic behavior in children with autism demonstrated that shifting parents from either an J Autism Dev Disord (2013) 43:168–178175 123 authoritarian or permissive style of parenting to a more authoritative style resulted in positive behavior changes in the child (Whittingham et al.2009). Other studies have also shown that providing training to parents yields improve- ments in joint attention (Aldred et al.2004; Jones et al.2006; Schertz and Odom2007), communication (Symon2005; Vismara et al.2009), school-readiness skills (Ozonoff and Cathcart1998), shared engagement and problem solving (Wieder and Greenspan2003), reduced problematic behavior (Whittingham et al.2009; Solomon et al.2008; Sofronoff et al.2004), and improved emotional co-regula- tion (Gulsrud et al.2010). Training parents of children with autism to interact with their child has been successful at reducing symptoms regardless of initial symptom severity (Solomon et al.2007).

Findings such as these stress the importance of under- standing social reciprocity as a two-way street, and changing both children and those with whom they interact (Gernsbacher2006). Interventions for children with autism which focus upon parent–child interaction and target communication may have important implications for the children’s development (Aldred et al.2004; Green et al.

2010; Kasari et al.2008; Wetherby and Woods2006).

Indeed, it may prove that rather than implementing speci c ‘training’ procedures, a focus of intervention for children with autism might be the pacing, structuring, and sensitive adjustment of everyday activities that involve children and their parents. This can increase opportunities for deeper interpersonal engagement, co-ordination, communication, and so on, as might happen (for example) in Relationship Development Intervention (Gutstein2009; Gutstein et al.

2007; Hobson and Hobson2011). In keeping with this view, Green et al. (2010) reported signi cant improvement in parent–child synchrony, communication, and shared attention when treatment focussed on the parent–child communication system. Whatever the case in these respects, an important challenge is to determine how best to modify and foster parent–child interaction in order to promote social engagement and social development, given the characteristics and environment of particular children (Howlin et al.2009; Rogers and Vismara2008).

AcknowledgmentsNB acknowledges the support of her disserta- tion committee members in carrying out the work, with appreciation to Dr. Magy Martin, Dr. Rodney Ford, and Dr. Andrea Miller. We are deeply grateful to the parents and their children who took part in this project. JH and RPH gratefully acknowledge the Foundation for Autism Research and Remediation (FARR) for grant support that enabled the authors to provide consultation to NB during her dis- sertation, coding on the DCS variables, and preparation of the man- uscript for dissemination. We also thank Fionnuala Larkin and Joanna Shepherd for their assistance with coding. We thank the Tavistock Clinic NHS and Portman Trust for the opportunity to spend a sab- batical at the Center for Advanced Study in Behavioral Sciences where this paper was completed. References Aldred, C., Green, J., & Adams, C. (2004). A new social commu- nication intervention for children with autism: Pilot randomized controlled treatment study suggesting effectiveness.Journal of Child Psychology and Psychiatry, 45(8), 1420–1430.

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