Papers 1 - 4

O R I G I N A L P A P E R

Autism Severity and Qualities of Parent–Child Relations

Nicole M. Beurkens • Jessica A. Hobson •

R. Peter Hobson

Published online: 7 June 2012

� Springer Science+Business Media, LLC 2012

Abstract The aim of this study was to examine how

severity of autism affects children’s interactions (related-

ness) and relationships with their parents. Participants were

25 parent–child dyads that included offspring who were

children with autism aged from 4 to 14 years. The severity

of the children’s autism was assessed using the calibrated

severity metric of the Autism Diagnostic Observation

Schedule (Gotham et al. in J Autism Dev Disord

39:693–705, 2009). Parent–child dyads were videotaped in

10-min semi-structured play interactions, and qualities of

interpersonal relatedness were rated with the Dyadic

Coding Scales (Humber and Moss in Am J Orthopsychiatr

75(1):128–141, 2005). Quality of relationships between

parents and children were evaluated with a parent self-

report measure, the Parent Child Relationship Inventory

(Gerard in Parent–Child Relationship Inventory (PCRI)

manual. WPS, Los Angeles, 1994). Multivariate regression

analysis revealed that severity of autism was inversely

related to patterns of parent–child interaction but not to

reported quality of parent–child relationship. We consider

the implications for thinking about relatedness and rela-

tionships among children with autism, and opportunities

for intervention.

Keywords Parent–child interaction � Autism severity � Communication � Relationship-based treatment � Attachment

Introduction

When Kanner (1943) first 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 relatedness towards 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 reflected 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 specificity 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 first

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 (Bugental 2000; Harach and Kuczynski 2005;

Laursen and Bukowski 1997). 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 Kuczynski 1997). Among

many forms of difficulty 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 Maes 2003).

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 the determinants of 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

findings 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 (Bell 1968; DeMol

and Buysse 2008; Kuczynski et al. 2003; Sameroff and

Chandler 1975). 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 (Sameroff 2009). Over time, each

participant and the relationship as a whole undergo trans-

formation (Fogel 2009). It would seem inevitable that a

child’s autism will influence 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 Sigman 2002).

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 and

oriented to tasks (Kasari et al. 1988). When toddlers with

autism show higher levels of externalising problems, their

mothers use significantly 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 influence

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 McGrew 2009). Hoffman et al. (2009)

reported a significant 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; Warfield 2005).

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) 43:168–178 169

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contexts involving joint action and attention (Kasari et al.

1990), face-to-face interaction (Dawson et al. 1990),

greetings and farewells (Hobson and Lee 1998), and con-

versations (Capps et al. 1998; Garcı́a-Pérez et al. 2007).

On the other hand, there is also evidence that children

with autism are not so atypical in certain features of their

attachments. Several published studies indicate how young

children with autism do respond 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 Mundy 1989; Yirmiya and Sigman 2001).

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 reflect 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 (Gerard 1994) 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 identified 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.

170 J Autism Dev Disord (2013) 43:168–178

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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 specificity in classification 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 reflects 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 reflect interactions that are unpro-

ductive and involve friction between the child and parent;

low scores on communication reflect 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 reflect a sense of indifference,

lack of pleasure, and/or conflict.

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 (Gerard 1994) 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 reflects

the amount of pleasure and fulfillment 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, T scores, 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 to T scores, normalized standard scores with a mean

of 50 and a standard deviation of 10. A T score which is

more than one standard deviation below the mean (i.e. less

than 40) suggests problems in the domain the scale reflects

and very low T scores (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) 43:168–178 171

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(DCS), and the parent-reported features of parent–child

relationship on the Parent–child Relationship Inventory

(PCRI) are given in Table 1, 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 significantly 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 (d range = 0.71–0.78) for

overall interaction, coordination, communication, enjoyment,

and mood, and large (d range = 0.91–0.98) for emotional

expression, 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 (d range =

0.07–0.16) with the exception of small effect sizes

(d range = 0.24 and 0.28) for the sub-scales of overall

interaction and emotional expression. This suggests that our

autism sample showed marked difficulties 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 mean T score was in the low range.

This score might reflect 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 (T score 30–39)

indicate parental difficulty in talking to a child and in

‘getting through’ to that child. Figure 2 presents numbers

of parents with low (T score \ 40) and very low (T score \ 30) scores, by individual scales.

From Fig. 2, it can be seen how most of the parents in the

study reported problems with Communication (Low n = 11,

Very Low n = 7). Very low T scores (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 difficulties

with Involvement (Low n = 5, Very Low n = 1). Items on

the Involvement scale reflect the parent’s propensity to spend

time with their children and get to know them. Very low

scores on this scale can reflect 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

(Green 1991). A Bonferroni adjustment was considered, but

this would potentially increase the likelihood of committing

Table 1 Descriptive data for study variables

Variable M (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

172 J Autism Dev Disord (2013) 43:168–178

123

a Type II error (Nakagawa 2004). Therefore, the adjustment

was not made for this analysis.

The results of the regression for ADOS predicting DCS

are shown in Table 2. 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 signifi- cance for predicting tension/relaxation and enjoyment, and

not significant 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 significantly associated with almost

all of the DCS subscales (r range = 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. Table 3 provides 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 calibrated

severity score were entered into a linear regression, 50 %

of the variance (R2 = 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 (Table 3) 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

not significantly 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 significant, 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 difficulties 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

finding 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 Tens

Typ-Secure Typ-Dis/Con Autism Fig. 1 Scores 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

Su pp

or t

Sa tis

fa ct io n

In vo

lve m

en t

Co m

m un

ica tio

n

Li m

it Se

tti ng

Au to

no m

y

Ro le O

rie nt

at io n

PCRI Subscale

N u

m b

e r

o f

P a

re n

ts (

o u

t o

f 2

5 )

Low Very Low

Fig. 2 Number of parents with low (T score \ 40) or very low (T score \ 30) PCRI scores

J Autism Dev Disord (2013) 43:168–178 173

123

possible interpretation of this exploratory and unanticipated

finding 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 findings 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

interpersonal relatedness appeared to constitute an impor-

tant bridge between ADOS severity scores and qualities of

dyadic interaction.

Here the results contrast with another finding, namely

the low correlation between the same features of autism

severity and aspects of the parent–child relationship as

reported by the parents. For instance, ADOS severity

scores did not predict parental satisfaction, involvement,

or communication, where satisfaction reflected the amount

of pleasure and fulfillment 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

findings on relatedness, is whether the results might reflect

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 specific 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 conflict, whereas

a high score would be given when there is mutual

responsiveness, enjoyment, and harmonious and agreeable

interactions with genuine interpersonal interest.

Table 2 Multivariate regression for ADOS predicting DCS

Dependent variables B SE t p R2 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

p Values uncorrected for multiple comparisons

Table 3 Correlation coefficients for autism severity and parent– child interaction, including partial correlations with ADOS module

controlled

DCS subscale r Partial r

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

174 J 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 findings 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) are also connected with interpersonal engagement

and relatedness in parent–child interactions.

When we turn to the findings 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, specifically 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 identified 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 difficulties 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

for other 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 specific 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 findings

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 of

concordance (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 difficulties in parent–

child interactions influence, rather than reflect, children’s

clinical presentation, although of course there may be com-

plex cycles of cause and effect.

The findings 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 influence their

own development through their interactions and relation-

ships with parents (Bell 1968; Cummings et al. 2000;

Sameroff and Chandler 1975). For example, children’s

behavioral and relational difficulties can lead to parenting

stress, which may alter parenting behavior and perpetuate

the children’s difficulties (Hastings 2002). 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 specific interactive behaviors (Arnold et al. 1993;

Hoagwood et al. 2001). Yet in the field of autism, many

interventions do not target the areas of social-communi-

cative difficulty that are core features of autism (Charman

et al. 2004), nor do they follow recommendations to

include parents in the treatment process (Howlin 2000).

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 significant 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 Perales 2003). An intervention

designed to reduce problematic behavior in children with

autism demonstrated that shifting parents from either an

J Autism Dev Disord (2013) 43:168–178 175

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 Odom 2007), communication (Symon 2005;

Vismara et al. 2009), school-readiness skills (Ozonoff and

Cathcart 1998), shared engagement and problem solving

(Wieder and Greenspan 2003), 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

(Gernsbacher 2006). 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 Woods 2006).

Indeed, it may prove that rather than implementing specific

‘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 (Gutstein 2009; Gutstein et al.

2007; Hobson and Hobson 2011). In keeping with this

view, Green et al. (2010) reported significant 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 Vismara 2008).

Acknowledgments NB 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.

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