IPMH January Weekend I: Alice Carter on Autism Spectrum Disorders


In the morning Alice Carter started out talking about internalizing problems in early childhood, such as anxiety or mood disorders. These are distinguished from externalizing disorders that include behavioral problems, such as hyperactivity and disruptive behaviors. Internalizing problems attract less attention from adults – both parents and researchers – than externalizing problems, but there are approximately the same proportions of young children suffering from both. Longitudinal studies offer evidence that these problems have stability over the course of childhood. Contrary to popular ideas, these difficulties are not so hard to distinguish from temperament or childhood “stages”; parents are good at identifying them in their children. Studies of young children do not find significant differences in the prevalence of these problems in boys versus girls; differences in socialization or parenting may account for the fact that by adolescents, there are more girls than boys with internalizing problems. 

Carter pointed out that we expect children to develop a set of social-emotional skills to help them in self-regulation and in relationships. These skills include the capacity to pay attention, compliance, empathy, mastery motivation, interest in peers, and play. Examples of responses of parents who confirm internalizing problems in their children on the ITSEA test (Carter and Briggs-Gowan 2006), are “looks unhappy sad without reason”, “worries a lot or is very serious”, “is very worried about getting dirty”, “hangs on you or wants to be in your lap when with other people”, or “is quiet or hangs back in new situations”. Carter developed the ITSEA and BITSEA (shorter, only 42 items).

In the afternoon, Carter discussed the early detection and intervention for autistic disorders in early childhood. This is important both because of the frequency (recent epidemiological estimates of 1/100 children diagnosed with ASD, boys 4 times more than girls) and because of the importance of early intervention. Interventions have the greatest impact when occur before 3 years old.

Because no blood tests have yet been identified, we must rely on behavioral observation. Most people identify the three core areas of significance as (These are also the criteria in DSM IV): 

1. Social interaction.

2. Communication.

3. Repetitive restrictive behaviors.

Carter says that the absence of expected social behaviors is more critical than the presence of odd social behaviors. There may be oddities of speech such as repeating words and atypical intonations such as questioning intonation when answering, “video speak”, or pronoun reversal.

Carter showed us videos demonstrating these signs. 

1. A 31-month old boy picked up the bubble gun and walked to his mother (who is holding the bubble solution), without looking at her, saying, “OK bubbles”. He tried the bubbles, repeatedly saying, “OK, bubbles” without variation in tone. He gave his mother eye contact twice during the sequence, but whenever he spoke, he averted his gaze, failing to integrate eye contact and verbal communication. 

2. In a film of another boy, there is a balloon, giving the adult and child the opportunity for joint attention. This child of 30 months is high functioning but when he speaks to the researcher, he has an unusual inflection and he does not look at her, nor at his mother. He is not muted, having a wonderful time, but not sharing his fun with anybody. He is not pointing to anybody.

3. There is a film of another child of the same age, running back and forth in front of the mirror. When left to his own devices, he would continue to run back and forth, repeating long sequences from a video he knows; he exhibits some unusual hand movements. He sometimes will jump up and down in place and wave his arms. He is also giving himself visual stimulation in an atypical gaze, to the ceiling, and he is toe walking. 

4. Another child does not respond to his name. He chooses one toy and does not explore the others. He does what is called “finger flicking” with his non-dominant hand. 

Carter says that children with ASD are like snowflakes. There is great heterogeneity – in terms of symptoms, cognitive abilities, linguistic functioning, behavior problems and adaptive behaviors. 

An important source of data is birthday party videos (Dawson et al, 2004), for example, one-year-old birthday party videos. Early markers across questionnaire and observational measures include proto-declarative pointing (points to show things far away); following a point; bringing object to show parent; interest in other children and people (not just when they want something from you); imitation (a real problem for learning); responding to name (looks right at you when you say his name); pretend play (hug or feeds dolls or stuffed animals); repetitive stereotypical behaviors (puts things in a special order over and over, repeats movement over and over). Pretend play – you also have to see what happens if you try to add to it or interrupt it. 

Though it is one of the most important goals in an intervention, developing greater competency in pretend play is one of the most difficult challenges. Kids will do stories they see on TV or in videos, but real creative pretend play is hard to teach. There are other things you can change more easily. For example, if you can be taught that you have to look at someone and say hello because that is socially acceptable. Also, manners are helpful in terms of your relationship to the world. Parents go with kids throughout different settings, so they are very helpful in terms of generalization because they can coach the child to use the skill in all the different settings that they move through.  Teaching children with ASD to generalize from one setting to another is very difficult. They also have what is called “sticky attention”. If you shake a rattle, the child will look at it, but then if you pick up a rattle in the other hand while still shaking the first rattle, the child with ASD will continue to look at the first rattle, while the neuro-typical child will look at the second. Parents tend to both over-report problems or normalize behaviors, so also use observation. 

Interestingly, there are some tasks that children with ASD do more easily than neuro-typical children (Kaldy et al, 2011). In passive viewing task, kids sit and watch a picture of a dot, and the longer the kid looks at a dot, the bigger the dot gets. In this task, the more distractors the harder it is to find the target, yet the more distractors you add, the better the ASD kids are in relation to their age peers. How do we use skills such as this to enhance their learning in other areas? If you look at pupil dilation that shows arousal, they do better because they maintain this aroused vigilant state during the trials better than the typical kids. 

Parental well-being: One of the most important jobs in helping a family with an ASD child is the support of the parents. They are faced with daunting challenges, for example making complex decisions about intervention plans (https://www.supportingchildcaregivers.com/a-cast-of-thousands), understanding the minds of their children when the motivation of their behaviors are so opaque, managing dysregulated behaviors, balancing the needs of all family members, including siblings, etc. These parents have hugely high rates of stress, depression, and anxiety (Davis & Carter, 2008). They struggle with feelings of confusion, guilt, and frustration. It is hard to explain the diagnosis to friends and family members who may not support the diagnosis.  

In numerous studies, Carter has demonstrated that sensory hypersensitivity exists, and it exists aside from psychiatric diagnoses (Ben-Sasson A et al, 2010). However, she points out that there is no evidence that sensory interventions are effective. She also responded to questions from the audience about dietary treatments, neuro-feedback, chelation, and many other recommended treatments for autism. Carter said that some of these interventions may have a positive effect, but they are not scientifically validated. 


Ben-Sasson A, Carter AS, Briggs-Gowan MJ (2010), The development of sensory over-responsivity from infancy to elementary school, J Abnorm Child Psychol, Springer Science+Busiiness Media, LLC 2010.

Carter, A. S., & Briggs-Gowan, M. J. (2006). Manual of the infant toddler, Social-emotional assessment. San Antonio: Harcourt.

Davis N, Carter AS (2008). Parenting stress in mothers and fathers of toddlers with autism spectrum disorders: Associations with child characteristics, J Autism Dev Disord 38:1278-1291.

Geraldine Dawson; Karen Toth; Robert Abbott; Julie Osterling; Jeff Munson; Annette Estes; Jane Liaw, Early Social Attention Impairments in Autism: Social Orienting, Joint Attention, and Attention to Distress, Developmental Psychology 2004; 40(2): 271-283.

Kaldy Z, Kraper C, Carter AS, Blaser E, (2011), Toddlers with Autism Spectrum Disorder are more successful at visual search than typically developing toddlers, Dev Sci Sept 14(5):980-8.

Read this blog in Spanish.

Photograph by Ginger Gregory









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