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Sensory correlates of difficult temperament characteristics in preschool children with autism
Research in Autism Spectrum Disorders 6 (2012) 988–995
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Sensory correlates of difficult temperament characteristics in preschool children with autism I-Ching Chuang a, Mei-Hui Tseng a,b,*, Lu Lu b, Jeng-Yi Shieh b a b
School of Occupational Therapy, College of Medicine, National Taiwan University, Taipei, Taiwan, ROC Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Taipei, Taiwan, ROC
A R T I C L E I N F O
A B S T R A C T
Article history: Received 12 December 2011 Accepted 20 January 2012
This study was aimed to investigate the rate of co-occurring sensory processing (SP) dysfunction in children with autism who had a difficult temperament characteristics, and the relationship between SP dysfunction and temperament characteristics in preschool children with autism. A total of 111 children aged 48–84 months, 67 children with autism and 44 age-matched typically developing children, participated in this study. Results of the study indicated that SP dysfunction was prevalent in children with autism who had difficult temperament characteristics, and that different SP patterns were associated with different temperament characteristics in preschool children with autism. In summary, the present findings highlight the importance of evaluating SP patterns in addition to assessing temperament in children with autism in order for clinicians to plan appropriate intervention programs and support children’s participation in their daily lives. Furthermore, the knowledge of the relationship between difficult temperament characteristics and SP dysfunction of the child can foster parental appreciation of individual differences in children, provide parents effective strategies to manage children’s behaviors, and promote adaptive parent–child interaction. ß 2012 Elsevier Ltd. All rights reserved.
Keywords: Sensory processing patterns Temperament Preschool children with autism
1. Introduction Autism is a neurodevelopmental disorder with three prominent characteristic areas of malfunction: impairments in social reciprocity, impairments in communication skills, and repetitive and restricted behaviors or interests (American Psychiatric Association, 2000; World Health Organization, 2007), all of which have a negative impact on the child’s development (Aldred, Green, & Adams, 2004; Elder, Valcante, Yarandi, White, & Elder, 2005; Ozonoff & Miller, 1995). In addition to these readily apparent core symptoms, the temperament of children with autism often influences their socialemotional development and long-term adjustment (Garon et al., 2009). Temperament refers to children’s behavioral style, or the manner in which they interact with their environment (Thomas & Chess, 1977). Thomas and colleagues identified nine dimensions of temperament: activity level, approach/withdrawal to new situations, adaptability to the changing context, quality of mood, threshold of responsiveness, intensity of reaction, distractibility, rhythmicity, and persistence (Chess & Thomas, 1996; Thomas, Chess, Birch, Hertzig, & Korn, 1963). Children who were rated at the end of the temperament dimensions often demonstrated poor behaviors and were considered as having difficult temperament characteristics (Xu, 1979).
* Corresponding author at: School of Occupational Therapy, College of Medicine, National Taiwan University, No. 17 Xu-Zhou Road, Taipei 10055, Taiwan, ROC. Tel.: +886 2 33668175; fax: +886 2 23958960. E-mail address: [email protected] (M.-H. Tseng). 1750-9467/$ – see front matter ß 2012 Elsevier Ltd. All rights reserved. doi:10.1016/j.rasd.2012.01.002
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Children with autism have frequently been reported to have difficult temperament characteristics, such as high activity level, withdrawal responses to new stimuli, and low persistence (Bailey, Hatton, Mesibov, Ament, & Skinner, 2000; Bieberich & Morgan, 1998, 2004; Hepburn & Stone, 2006; Kasari & Sigman, 1997). Increasing evidence shows that difficult temperament characteristics not only influence psychosocial adjustment of children with autism (Hepburn, 2003) but also interfere with intervention, and exacerbate functional impairment and parenting stress with the subsequent behavioral problems (De Pauw, Mervielde, Van Leeuwen, & De Clercq, 2011; Eaves, Ho, & Eaves, 1994; Kasari & Sigman, 1997; Konstantareas & Homatidis, 1989; Konstantareas & Papageorgiou, 2006). Besides difficult temperament characteristics, sensory processing dysfunction (SPD) has also been frequently noted in children with autism (Tomchek & Dunn, 2007; Watling, Deitz, & White, 2001) and the prevalence was 50–90% depending on the sample (Kientz & Dunn, 1997; Tomchek & Dunn, 2007; Watling et al., 2001). SPD is defined as difficulties in detecting, regulating, interpreting, and responding to sensory stimuli, including the behavioral responses to sensory input (Lane, Miller, & Hanft, 2000; Miller, Anzalone, Lane, Cermak, & Osten, 2007). For children with autism, unusual sensory responses, such as over- or under-responsivity to sensory stimuli, were commonly seen across several sensory domains, including tactile, oral, auditory, and visual (Baranek, David, Poe, Stone, & Watson, 2006; Kern et al., 2006; Kientz & Dunn, 1997; Tomchek & Dunn, 2007; Watling et al., 2001). The behaviors associated with SPD, such as high activity level, distractibility, and withdrawal (Dunn, 1997; Watling et al., 2001), paralleled the difficult temperament characteristics and impaired not only the ability of the child to sustain engagement with people or in activities, but also interaction with environment, and thus successful participation in daily life (Ashburner, Ziviani, & Rodger, 2008; Baker, Lane, Angley, & Young, 2008; Lecavalier, Leone, & Wiltz, 2006; Rogers, Hepburn, & Wehner, 2003; Tseng, Fu, Cermak, Lu, & Shieh, 2011). Dunn (2001) proposed that one’s temperament is the behavioral manifestation of his/her sensory processing patterns which reflect the nervous system functions. For instance, a child who has sensory avoiding pattern would be withdrawn in new contexts due to hypersensitivity to sensory events in the environment. Despite the great volume of research on temperament and SP dysfunction in children with autism, respectively, the rate of co-occurring SP dysfunction in children with autism who have difficult temperament characteristics, and the relationship between SP dysfunction and difficult temperament characteristics has not been investigated. Thus, the aim of this study was twofold: (1) to investigate the rate of co-occurring SP dysfunction in children with autism who had difficult temperament characteristics and (2) to examine the relationship between SP dysfunction and difficult temperament characteristics in preschool children with autism. Results of the study could provide the knowledge of sensory correlates of a child’s difficult temperament characteristics and help caregivers and clinicians make adjustments in the environment and plan appropriate intervention to support a child’s performance and participation in his/her daily life. 2. Method 2.1. Participants A total of 111 children, 67 children with autism (85.1% male, mean age: 64.21 months, SD: 9.01) and 44 age-matched typically developing children (50% male, mean age: 63.59 months, SD = 10.14) participated in this study. Their age ranged between 48 and 84 months. Children with autism were diagnosed by child psychiatrists according to DSM IV – Text revision autistic disorder and had the Catastrophic Illness Card with the diagnosis of autism issued by the Bureau of National Health Insurance, Department of Health, Taiwan. The children with autism were recruited from six developmental centers, one pediatric rehabilitation clinic of a medical center, and the Autism Society Taiwan. The typically developing children were recruited from three nursery schools and a kindergarten in the greater Taipei area. The exclusion criteria were children with physical disorders, blindness, or deafness. 2.2. Instruments 2.2.1. Sensory Profiles – Chinese version (SP-C) (Tseng & Cheng, 2008) The Sensory Profile – Chinese version (SP-C) was a Chinese translation of the Sensory Profile, which is a 125-item caregiver questionnaire (Dunn, 1999) for assessing how children response to sensory events in everyday life. The Sensory Profile, designed for children from 3 to 10 years of age, contains 4 quadrants: Registration, Seeking, Sensitivity, and Avoiding (Dunn, 2006), which represents four patterns of sensory processing and were used to describe the way a person responds to sensory events according to his or her sensory threshold and responding strategy. Caregivers render their answers through a 5-point Likert scale (almost never = 5, seldom = 4, occasionally = 3, frequently = 2, almost always = 1) and higher scores indicate better sensory processing abilities (Tseng & Cheng, 2008). The SP-C was validated for use in Taiwanese children by Tseng & Cheng (2008). The test–retest reliability is 0.79 with a 3-week interval, and Cronbach alpha for internal consistency ranged from 0.62 to 0.90 (Tseng & Cheng, 2008). The results of the discriminative validity study showed that all the section and factor scores of the SP-C were significantly different between children with and without autism (Tseng & Cheng, 2008). 2.2.2. Behavior Style Questionnaire – Chinese version (Xu, 1979) The Behavior Style Questionnaire – Chinese version (BSQ-C), translated from the Behavior Style Questionnaire (BSQ) (McDevitt & Carey, 1978) by the child development research group of the Child Mental Health Center of National Taiwan
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University Hospital, was used to measure children’s temperament. The BSQ-C contains 72 items measuring behaviors pertaining to the nine temperamental dimensions: Activity Level (the amount of physical movement during daily routines), Rhythmicity (consistency of physiological functions, such as sleeping or toileting), Approach-Withdrawal (the tendency to approach new objects or experiences), Adaptability (the ability to adjust or change behavior in socially desirable ways), Intensity (the depth or magnitude of emotional response), Mood (the quality of an emotional reaction in either a positive or negative direction), Persistence (pursuit of challenging tasks), Distractibility (the effectiveness of extraneous environmental stimuli in interfering with ongoing behaviors), and Threshold (the minimal amount of sensory stimulation necessary to elicit a response). Parents rate their child on each item using a 7-point scale from 1 ‘‘the child almost never demonstrates a particular behavior’’ to 7 ‘‘the child almost always exhibits that behavior’’. Higher scores of the dimensions are indicative of greater difficulty. Specifically, if the dimension score is one standard deviation above the mean, the child is scored in the difficult range. The difficult temperament constellation refers to high activity level, withdrawal from new stimuli, irregularity, low adaptability, high intensity, and negative mood (Thomas & Chess, 1977; Xu, 1979). In contrast, the easy temperament constellation consists of adequate activity level, approach to new stimuli, regularity, intensity, high adaptability, and a positive mood (Thomas & Chess, 1977; Xu, 1979). The coefficients of two-week test–retest reliability ranged from 0.38 to 0.73 (Chen, 1981). 2.3. Procedure The protocol for this study received approval from the Institutional Review Board of the National Taiwan University Hospital. The developmental centers, pediatric rehabilitation clinics, the Autism Society Taiwan, kindergartens and nursery schools in the greater Taipei area were contacted for their support of participant recruitment. Six developmental centers, one pediatric rehabilitation clinic, the Autism Society Taiwan, one kindergarten, and three nursery schools participated in this study. The cover letters and consent forms were distributed and the purpose and procedure were explained to parents by the researchers. Once signed consent forms were returned, a package of questionnaires was given to parents, including a demographic questionnaire, the SP-C and the BSQ-C. A total of 111 valid questionnaires were analyzed in this study. 2.4. Statistical analysis All statistical analyses were performed using SAS 9.1.3 (SAS Institute Inc., Cary, NC, USA). A two-tailed p 0.05 was considered statistically significant. Independent t-tests were used to compare group differences in the mean scores of each of the nine dimensions of temperament assessed by the BSQ-C and the four quadrant scores of the SP-C between children with autism and typically developing children. Multiple logistic regression analyses were conducted to investigate the relationship between SP dysfunction and each of the nine temperament characteristics in children with autism (coded ‘‘0’’ for a child without difficult temperament characteristics and ‘‘1’’ for a child with difficult temperament characteristics). The independent variables included gender, age, and four quadrant scores of the SP-C (Registration, Seeking, Sensitivity, and Avoiding). 3. Results 3.1. Temperament characteristics of children with autism and typically developing children As listed in Table 1, group differences were found in seven out of nine dimensions. Children with autism had a higher activity level, more negative moods, a higher threshold, and were more withdrawn, less adaptable, less persistent, and less distractible than typically developing children. Fig. 1 illustrated the percentage of children with autism and typically developing children who were scored in the difficult range on the nine temperament dimensions of the BSQ-C. As regard to the temperament dimensions of Activity Level, Approach-Withdrawal, and Adaptability, a much higher percentage of children with autism (29.9%, 34.3%, and 26.9%) scored in the difficult range than typically developing children (6.8%, 13.6%, and 9.1%) (x2 = 8.58, df = 1, p = 0.003; x2 = 5.89, df = 1, p = 0.015; x2 = 5.28, df = 1, p = 0.022). As for the temperament dimensions of Distractibility and Threshold, a lower percentage of children with autism (37.3% and 7.5%) scored in the difficult range than typically developing children (77.3% and 25%) (x2 = 17.03, df = 1, p < 0.001; x2 = 6.62, df = 1, p = 0.011). In regard to difficult temperament characteristics, the percentage of children with autism (34.3%) was about twice as high as that of typically developing children (18.2%) (x2 = 3.44, df = 1, p = 0.049). In contrast, there was a significantly higher percentage of typically developing children (65.5%) with easy temperament characteristics than children with autism (34.5%) (x2 = 10.99, df = 1, p = 0.001). 3.2. Co-occurring SP dysfunction in children with the difficult constellation of temperament characteristics Results showed that a higher percentage of children with autism scored in definite difference range on all four quadrants of the SP-C, including Registration (62.7%), Seeking (38.8%), Sensitivity (35.8%), and Avoiding (41.8%) compared to typically developing children (11.6–16.3%).
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Table 1 Independent t-tests of the mean scores of the nine temperament characteristics assessed by the BSQ-C and 4 quadrant scores of the SP-C between children with autism and typically developing children.
BSQ Activity level Rhythmicity Approach-withdrawal Adaptability Intensity Mood Persistence Distractibility Threshold SP-C Registration Seeking Sensitivity Avoiding
Autism (n = 67)
TD (n = 44)
Mean (SD)
Mean (SD)
4.35 3.68 3.96 3.37 4.00 3.28 4.43 4.33 4.06
3.74 3.57 3.52 2.72 3.77 3.03 4.05 4.91 4.85
(1.00) (0.96) (0.79) (0.87) (0.77) (0.59) (0.67) (0.81) (0.89)
54.10 (8.56) 95.14 (15.34) 75.30 (8.62) 104.43 (10.75)
t
p-value
(0.77) (0.84) (0.83) (0.76) (0.72) (0.69) (0.54) (0.59) (0.72)
3.45 0.67 2.75 4.14 1.59 1.97 3.28 4.08 5.08
0.001 0.50 0.005 <0.001 0.12 0.05 0.001 <0.001 <0.001
65.42 (7.09) 109.84 (11.40) 86.15 (7.79) 119.00 (12.53)
7.23 5.40 6.69 6.50
<0.001 <0.001 <0.001 <0.001
BSQ-C, Behavioral Style Questionnaire – Chinese version; SP-C, Sensory Profile – Chinese version; TD: typically developing children.
Fig. 1. Percentage of children with autism and typically developing children who scored in the difficult range on the nine temperament characteristics of the BSQ-C. BSQ-C, Behavioral Style Questionnaire – Chinese version; TD: typically developing children.
As regard to co-occurring SP dysfunction in children with difficult temperament characteristics, a higher rate (91.3%) of children with autism had at least one SP quadrant in the definite difference range as compared with typically developing children (50%) (Fig. 2). However, for children with easy temperament characteristics, the rate of co-occurring SP dysfunction was lower both in children with autism (60%) and in typically developing children (0%) (Fig. 2). 3.3. Relationships between SP dysfunction and difficult temperament characteristics in children with autism As regard to Activity Level, the fitted multiple logistic regression model revealed that children with more sensory seeking behaviors had a higher chance of having a high activity level. With regard to Adaptability, the fitted multiple logistic regression model showed that children who sought excessive sensory input or who avoided sensory input at a higher rate than others were more likely to show lower adaptability. For Intensity, the fitted multiple logistic regression model showed that children who were more sensitive to sensory stimulation would more likely have higher intensities of reaction (Table 2). As for Mood, the fitted multiple logistic regression model showed that children who missed the sensory input needed for greater participation were more likely to have a negative mood. For Persistence, the fitted multiple logistic regression model showed that children who missed sensory input needed for participation at a higher rate or who had fewer sensory avoiding behaviors would have higher chances of being less persistent (unable to stay on task). As for Distractibility, the fitted multiple logistic regression model showed that children with fewer sensory seeking behaviors would have higher chances of
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Percentage of co-occurring sensory processing dysfunction
992
100
91.3
80 60
60
Autism 50
TD
40
20 0
0 children with difficult temperament characteristics
children with easy temperament characteristics
Fig. 2. Percentage of co-occurring sensory processing dysfunction in children with autism and typically developing children who manifested either difficult or easy temperament characteristics. TD: typically developing children; SP-C, Sensory Profile – Chinese version.
Table 2 Multiple logistic regression models of difficult temperament characteristics assessed by the BSQ-C in children with autism (N = 67). Covariate Activity level Intercept Seeking Adaptability Intercept Seeking Avoiding Intensity Intercept Sensitivity Mood Intercept Registration Persistence Intercept Registration Avoiding Distractibility Intercept Seeking
Estimate
Standard error
Wald chi-square
p-value
Odds ratio
9.08 0.11
2.61 0.03
12.13 14.34
0.0005 0.0002
– 0.90
12.36 0.06 0.08
4.29 0.02 0.04
8.29 7.46 3.97
0.004 0.0063 0.0464
– 0.94 0.93
7.38 0.12
2.97 0.04
6.19 7.88
0.0128 0.005
– 0.89
3.84 0.10
2.25 0.04
2.92 5.37
0.0877 0.0205
– 0.90
3.24 0.06 0.06
2.78 0.03 0.03
1.36 3.62 4.54
0.2427 0.057 0.0332
0.94 1.06
4.91 0.05
2.01 0.02
5.94 4.98
0.0148 0.0257
– 1.05
BSQ-C, Behavioral Style Questionnaire – Chinese version.
being distracted (Table 2). For the temperament characteristics of Rhythmicity, Withdraw, and Threshold, no factor was entered in the multiple logistic regression models. 4. Discussion 4.1. Temperament characteristics of children with autism and typically developing children In agreement with previous studies, our results showed that children with autism had a higher activity level, were more withdrawn, less adaptable, had more negative mood, were less persistent, had lower distractibility, and higher threshold than typically developing children (Bailey et al., 2000; Hepburn & Stone, 2006; Landry, 2000). The findings that children with autism had lower distractibility and were less adaptable to changes in their routines or environments were consistent with their core symptoms. 4.2. Co-occurring SP dysfunction in children with the difficult constellation of temperament characteristics This is the first study examining the rate of co-occurring SP dysfunction in children with autism who had difficult temperament characteristics and we found that SP dysfunction is prevalent in children with difficult temperament characteristics regardless of whether or not they were autistic. Thus, assessment of SP function is recommended for children with difficult temperament characteristics.
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4.3. Relationships between SP dysfunction and difficult temperament characteristics in children with autism Results of this study showed that compared to the group without difficult temperament characteristics, those who had difficult temperament characteristics had a higher risk for SP dysfunction after adjusting for the effects of the other covariates, such as demographic variables and other dysfunctional dimensions, in the fitted final logistic regression model. Children with autism with sensory seeking behaviors were more likely to have temperament characteristics in a difficult range for both Activity Level and Adaptability, i.e., the more sensory seeking behaviors, the higher activity level, and the lower adaptability. This is probably because sensory seekers often engaged in activities actively to obtain as much sensory stimulation as they can from the environment to regulate themselves, thereby resulting in high activity levels and longer time to adapt to a new environment (Dunn, 1997; Tseng et al., 2011). Hence, for children with autism having temperament characteristics of a high activity level and low adaptability, clinicians or parents need to obtain information about the kind of sensations they crave and incorporate the sensations into their daily life repertoires (Dunn, 1997). Furthermore, it is interesting to note that the SP pattern of Seeking was associated with the temperament characteristics of Distractibility for children with autism, i.e., the fewer sensory seeking behaviors, the higher distractibility (easy to be soothed). The finding is inconsistent with the conventional notion that children with more seeking behaviors would be more easily distracted, i.e., shorter attention span (Dunn, 2006). This may be due to the fact that the Distractibility dimension contains more items (6 out of 8 items) related to soothability. Further, children with few sensory seeking behaviors might be those who are easily content with the sensory input in the environment such that they are easily soothed. Children with autism having sensory avoiding behaviors were more likely to have the temperament characteristic of Low Adaptability, i.e., the more sensory avoiding behaviors, the lower the adaptability. Sensory avoiders usually control or limit sensory input deliberately throughout the day to avoid activating their low neurological threshold (Dunn, 1997). This may cause them additional challenges particularly in new environment and result in low adaptability (Baranek et al., 2002). When serving children with autism with low adaptability, clinicians or parents may need to respect their avoiding responses to the overwhelming environmental stimuli and make the necessary adjustment such as limiting excessive sensory input, and then gradually increasing the variety of sensory experiences to facilitate their functioning and adaptation (Dunn, 1997). In contrast, the children with autism who had fewer sensory avoiding behaviors were more likely to have the difficult temperament characteristics of Low Persistence. This is probably because children with autism who had fewer sensory avoiding behaviors approached a variety of sensory events and demonstrated low persistence on a task. Children with autism having poor registration were more likely to have the difficult temperament characteristics of both Mood and Persistence. That is, children with autism who often missed the sensory input needed for participation had negative mood and were less persistent. This is probably because children who did not register meaningful sensory stimuli usually could not enjoy themselves in activities (Chawarskam, Klin, & Volkmar, 2008; Dunn, 1997). The finding that poor registration was associated with less persistence is not consistent with Dunn’s proposition that poor registration leads to persistence in tasks due to no distraction by external stimuli (Dunn, 2001). Perhaps, Dunn’s proposition is only applicable to the populations without autism. Thus, when serving children with autism who had negative mood or were less persistent, it is important for clinicians or parents to enhance children’s sensory registration, for example, by increasing the weight of objects or selecting brightly colored objects in daily routine tasks (Dunn, 1997, 2006). Children with autism having sensory sensitivity behaviors, were more likely to have the difficult temperament characteristic of High Intensity, i.e., the higher the sensory sensitivity, the more intense the response. This finding was consistent with previous findings that children with autism who were hypersensitive to sensory experiences had intense responses, such as disruptive behavior or fight responses (Baranek, Foster, & Berkson, 1997). When serving children with autism who had intense responses, clinicians or parents might need to be cautious about the sensory input not to heighten their arousal level, for example, by using touch pressure input rather than light touch stimuli (Dunn, 1997). Temperament has been viewed as an interaction between sensory reactivity (Fox & Polak, 2004) and environmental experience (Bates, 1989; Karreman, de Haas, van Tuijl, van Aken, & Dekovic, 2010; Rothbart, Ahadi, & Evans, 2000; Thomas & Chess, 1977). Further, research evidence has shown that modifying sensory stimulation from environment can improve sensory processing function and meet children’s sensory needs (Dunn, 2006; Miller et al., 2007; Thomasgard, 2003). Results of this study add to available research in the field by providing the knowledge of sensory correlates of difficult temperament characteristics in children with autism, and help clinicians and parents to design and implement effective interventions or supportive strategies in order to promote functioning and adaptation in children with autism. 4.4. Limitation In this study, all participants were recruited from the greater Taipei area and generalization of the results should be made with caution. Furthermore, since the focus of this study was on the relationships between sensory processing and temperament characteristics, factors such as parenting styles, severity of autism, and cognitive functioning which might influence a child’s temperament characteristics (Giancola, Mezzich, & Tarter, 1998; Konstantareas & Papageorgiou, 2006) were not included. It is recommended that such factors be considered in future studies.
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5. Conclusion This is the first study examining the rate of co-occurring SP dysfunction in preschool children with autism who were demonstrated to have difficult temperament characteristics, and the relationship between SP dysfunction and each difficult temperament characteristic. Results of the study indicated that SP dysfunction is prevalent in preschool children with autism with difficult temperament characteristics, and that different SP patterns were associated with different difficult temperament characteristics in preschool children with autism. Further, results of the study supported Dunn’s proposition that one’s temperament is the behavioral manifestation of his/ her sensory processing patterns. The sensory seeking behavior was associated with high activity level and low adaptability; the sensory avoiding behavior was associated with low adaptability; the poor registration behavior was associated with negative mood and less persistence; the sensory sensitivity behavior was associated with high intensity. In summary, the present findings highlight the importance of evaluating both the SP patterns and temperament in children with autism in order for clinicians to plan appropriate intervention programs and support participation in daily lives. Furthermore, the knowledge of the relationship between difficult temperament characteristics and SP dysfunction of the child can foster parental appreciation of individual differences in children, provide parents effective strategies to manage children’s behaviors, and promote adaptive parent–child interaction.
Acknowledgments We gratefully acknowledge Professor Anne Henderson for her valuable comments on the manuscript. We especially thank all parents and children for participating in this study. We are also grateful to the Autism Society Taiwan, the Department of Physical Medicine and Rehabilitation of the National Taiwan University Hospital, First Child Development Center, Bo-Ai Child Development Center, Zhong-He Child Development Center, Cheng-Zhong Child Development Center, AiZhi Child Development Center, Potential Development Center for Children with Autism for their assistance with recruiting children with ASD, and Sheng-Ya Nursery School, Hsin-Yi Foundation Nursery School, Xinhu Kindergarten, and Pisces Nursery School for their assistance with recruiting typically developing children. We sincerely thank Ruei-Mei Syu, Jin-Hua Liao, and Huei-WunWu for helping with data collection. 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Sensory correlates of difficult temperament characteristics in preschool children with autism I-Ching Chuang a, Mei-Hui Tseng a,b,*, Lu Lu b, Jeng-Yi Shieh b a b
School of Occupational Therapy, College of Medicine, National Taiwan University, Taipei, Taiwan, ROC Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Taipei, Taiwan, ROC
A R T I C L E I N F O
A B S T R A C T
Article history: Received 12 December 2011 Accepted 20 January 2012
This study was aimed to investigate the rate of co-occurring sensory processing (SP) dysfunction in children with autism who had a difficult temperament characteristics, and the relationship between SP dysfunction and temperament characteristics in preschool children with autism. A total of 111 children aged 48–84 months, 67 children with autism and 44 age-matched typically developing children, participated in this study. Results of the study indicated that SP dysfunction was prevalent in children with autism who had difficult temperament characteristics, and that different SP patterns were associated with different temperament characteristics in preschool children with autism. In summary, the present findings highlight the importance of evaluating SP patterns in addition to assessing temperament in children with autism in order for clinicians to plan appropriate intervention programs and support children’s participation in their daily lives. Furthermore, the knowledge of the relationship between difficult temperament characteristics and SP dysfunction of the child can foster parental appreciation of individual differences in children, provide parents effective strategies to manage children’s behaviors, and promote adaptive parent–child interaction. ß 2012 Elsevier Ltd. All rights reserved.
Keywords: Sensory processing patterns Temperament Preschool children with autism
1. Introduction Autism is a neurodevelopmental disorder with three prominent characteristic areas of malfunction: impairments in social reciprocity, impairments in communication skills, and repetitive and restricted behaviors or interests (American Psychiatric Association, 2000; World Health Organization, 2007), all of which have a negative impact on the child’s development (Aldred, Green, & Adams, 2004; Elder, Valcante, Yarandi, White, & Elder, 2005; Ozonoff & Miller, 1995). In addition to these readily apparent core symptoms, the temperament of children with autism often influences their socialemotional development and long-term adjustment (Garon et al., 2009). Temperament refers to children’s behavioral style, or the manner in which they interact with their environment (Thomas & Chess, 1977). Thomas and colleagues identified nine dimensions of temperament: activity level, approach/withdrawal to new situations, adaptability to the changing context, quality of mood, threshold of responsiveness, intensity of reaction, distractibility, rhythmicity, and persistence (Chess & Thomas, 1996; Thomas, Chess, Birch, Hertzig, & Korn, 1963). Children who were rated at the end of the temperament dimensions often demonstrated poor behaviors and were considered as having difficult temperament characteristics (Xu, 1979).
* Corresponding author at: School of Occupational Therapy, College of Medicine, National Taiwan University, No. 17 Xu-Zhou Road, Taipei 10055, Taiwan, ROC. Tel.: +886 2 33668175; fax: +886 2 23958960. E-mail address: [email protected] (M.-H. Tseng). 1750-9467/$ – see front matter ß 2012 Elsevier Ltd. All rights reserved. doi:10.1016/j.rasd.2012.01.002
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Children with autism have frequently been reported to have difficult temperament characteristics, such as high activity level, withdrawal responses to new stimuli, and low persistence (Bailey, Hatton, Mesibov, Ament, & Skinner, 2000; Bieberich & Morgan, 1998, 2004; Hepburn & Stone, 2006; Kasari & Sigman, 1997). Increasing evidence shows that difficult temperament characteristics not only influence psychosocial adjustment of children with autism (Hepburn, 2003) but also interfere with intervention, and exacerbate functional impairment and parenting stress with the subsequent behavioral problems (De Pauw, Mervielde, Van Leeuwen, & De Clercq, 2011; Eaves, Ho, & Eaves, 1994; Kasari & Sigman, 1997; Konstantareas & Homatidis, 1989; Konstantareas & Papageorgiou, 2006). Besides difficult temperament characteristics, sensory processing dysfunction (SPD) has also been frequently noted in children with autism (Tomchek & Dunn, 2007; Watling, Deitz, & White, 2001) and the prevalence was 50–90% depending on the sample (Kientz & Dunn, 1997; Tomchek & Dunn, 2007; Watling et al., 2001). SPD is defined as difficulties in detecting, regulating, interpreting, and responding to sensory stimuli, including the behavioral responses to sensory input (Lane, Miller, & Hanft, 2000; Miller, Anzalone, Lane, Cermak, & Osten, 2007). For children with autism, unusual sensory responses, such as over- or under-responsivity to sensory stimuli, were commonly seen across several sensory domains, including tactile, oral, auditory, and visual (Baranek, David, Poe, Stone, & Watson, 2006; Kern et al., 2006; Kientz & Dunn, 1997; Tomchek & Dunn, 2007; Watling et al., 2001). The behaviors associated with SPD, such as high activity level, distractibility, and withdrawal (Dunn, 1997; Watling et al., 2001), paralleled the difficult temperament characteristics and impaired not only the ability of the child to sustain engagement with people or in activities, but also interaction with environment, and thus successful participation in daily life (Ashburner, Ziviani, & Rodger, 2008; Baker, Lane, Angley, & Young, 2008; Lecavalier, Leone, & Wiltz, 2006; Rogers, Hepburn, & Wehner, 2003; Tseng, Fu, Cermak, Lu, & Shieh, 2011). Dunn (2001) proposed that one’s temperament is the behavioral manifestation of his/her sensory processing patterns which reflect the nervous system functions. For instance, a child who has sensory avoiding pattern would be withdrawn in new contexts due to hypersensitivity to sensory events in the environment. Despite the great volume of research on temperament and SP dysfunction in children with autism, respectively, the rate of co-occurring SP dysfunction in children with autism who have difficult temperament characteristics, and the relationship between SP dysfunction and difficult temperament characteristics has not been investigated. Thus, the aim of this study was twofold: (1) to investigate the rate of co-occurring SP dysfunction in children with autism who had difficult temperament characteristics and (2) to examine the relationship between SP dysfunction and difficult temperament characteristics in preschool children with autism. Results of the study could provide the knowledge of sensory correlates of a child’s difficult temperament characteristics and help caregivers and clinicians make adjustments in the environment and plan appropriate intervention to support a child’s performance and participation in his/her daily life. 2. Method 2.1. Participants A total of 111 children, 67 children with autism (85.1% male, mean age: 64.21 months, SD: 9.01) and 44 age-matched typically developing children (50% male, mean age: 63.59 months, SD = 10.14) participated in this study. Their age ranged between 48 and 84 months. Children with autism were diagnosed by child psychiatrists according to DSM IV – Text revision autistic disorder and had the Catastrophic Illness Card with the diagnosis of autism issued by the Bureau of National Health Insurance, Department of Health, Taiwan. The children with autism were recruited from six developmental centers, one pediatric rehabilitation clinic of a medical center, and the Autism Society Taiwan. The typically developing children were recruited from three nursery schools and a kindergarten in the greater Taipei area. The exclusion criteria were children with physical disorders, blindness, or deafness. 2.2. Instruments 2.2.1. Sensory Profiles – Chinese version (SP-C) (Tseng & Cheng, 2008) The Sensory Profile – Chinese version (SP-C) was a Chinese translation of the Sensory Profile, which is a 125-item caregiver questionnaire (Dunn, 1999) for assessing how children response to sensory events in everyday life. The Sensory Profile, designed for children from 3 to 10 years of age, contains 4 quadrants: Registration, Seeking, Sensitivity, and Avoiding (Dunn, 2006), which represents four patterns of sensory processing and were used to describe the way a person responds to sensory events according to his or her sensory threshold and responding strategy. Caregivers render their answers through a 5-point Likert scale (almost never = 5, seldom = 4, occasionally = 3, frequently = 2, almost always = 1) and higher scores indicate better sensory processing abilities (Tseng & Cheng, 2008). The SP-C was validated for use in Taiwanese children by Tseng & Cheng (2008). The test–retest reliability is 0.79 with a 3-week interval, and Cronbach alpha for internal consistency ranged from 0.62 to 0.90 (Tseng & Cheng, 2008). The results of the discriminative validity study showed that all the section and factor scores of the SP-C were significantly different between children with and without autism (Tseng & Cheng, 2008). 2.2.2. Behavior Style Questionnaire – Chinese version (Xu, 1979) The Behavior Style Questionnaire – Chinese version (BSQ-C), translated from the Behavior Style Questionnaire (BSQ) (McDevitt & Carey, 1978) by the child development research group of the Child Mental Health Center of National Taiwan
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University Hospital, was used to measure children’s temperament. The BSQ-C contains 72 items measuring behaviors pertaining to the nine temperamental dimensions: Activity Level (the amount of physical movement during daily routines), Rhythmicity (consistency of physiological functions, such as sleeping or toileting), Approach-Withdrawal (the tendency to approach new objects or experiences), Adaptability (the ability to adjust or change behavior in socially desirable ways), Intensity (the depth or magnitude of emotional response), Mood (the quality of an emotional reaction in either a positive or negative direction), Persistence (pursuit of challenging tasks), Distractibility (the effectiveness of extraneous environmental stimuli in interfering with ongoing behaviors), and Threshold (the minimal amount of sensory stimulation necessary to elicit a response). Parents rate their child on each item using a 7-point scale from 1 ‘‘the child almost never demonstrates a particular behavior’’ to 7 ‘‘the child almost always exhibits that behavior’’. Higher scores of the dimensions are indicative of greater difficulty. Specifically, if the dimension score is one standard deviation above the mean, the child is scored in the difficult range. The difficult temperament constellation refers to high activity level, withdrawal from new stimuli, irregularity, low adaptability, high intensity, and negative mood (Thomas & Chess, 1977; Xu, 1979). In contrast, the easy temperament constellation consists of adequate activity level, approach to new stimuli, regularity, intensity, high adaptability, and a positive mood (Thomas & Chess, 1977; Xu, 1979). The coefficients of two-week test–retest reliability ranged from 0.38 to 0.73 (Chen, 1981). 2.3. Procedure The protocol for this study received approval from the Institutional Review Board of the National Taiwan University Hospital. The developmental centers, pediatric rehabilitation clinics, the Autism Society Taiwan, kindergartens and nursery schools in the greater Taipei area were contacted for their support of participant recruitment. Six developmental centers, one pediatric rehabilitation clinic, the Autism Society Taiwan, one kindergarten, and three nursery schools participated in this study. The cover letters and consent forms were distributed and the purpose and procedure were explained to parents by the researchers. Once signed consent forms were returned, a package of questionnaires was given to parents, including a demographic questionnaire, the SP-C and the BSQ-C. A total of 111 valid questionnaires were analyzed in this study. 2.4. Statistical analysis All statistical analyses were performed using SAS 9.1.3 (SAS Institute Inc., Cary, NC, USA). A two-tailed p 0.05 was considered statistically significant. Independent t-tests were used to compare group differences in the mean scores of each of the nine dimensions of temperament assessed by the BSQ-C and the four quadrant scores of the SP-C between children with autism and typically developing children. Multiple logistic regression analyses were conducted to investigate the relationship between SP dysfunction and each of the nine temperament characteristics in children with autism (coded ‘‘0’’ for a child without difficult temperament characteristics and ‘‘1’’ for a child with difficult temperament characteristics). The independent variables included gender, age, and four quadrant scores of the SP-C (Registration, Seeking, Sensitivity, and Avoiding). 3. Results 3.1. Temperament characteristics of children with autism and typically developing children As listed in Table 1, group differences were found in seven out of nine dimensions. Children with autism had a higher activity level, more negative moods, a higher threshold, and were more withdrawn, less adaptable, less persistent, and less distractible than typically developing children. Fig. 1 illustrated the percentage of children with autism and typically developing children who were scored in the difficult range on the nine temperament dimensions of the BSQ-C. As regard to the temperament dimensions of Activity Level, Approach-Withdrawal, and Adaptability, a much higher percentage of children with autism (29.9%, 34.3%, and 26.9%) scored in the difficult range than typically developing children (6.8%, 13.6%, and 9.1%) (x2 = 8.58, df = 1, p = 0.003; x2 = 5.89, df = 1, p = 0.015; x2 = 5.28, df = 1, p = 0.022). As for the temperament dimensions of Distractibility and Threshold, a lower percentage of children with autism (37.3% and 7.5%) scored in the difficult range than typically developing children (77.3% and 25%) (x2 = 17.03, df = 1, p < 0.001; x2 = 6.62, df = 1, p = 0.011). In regard to difficult temperament characteristics, the percentage of children with autism (34.3%) was about twice as high as that of typically developing children (18.2%) (x2 = 3.44, df = 1, p = 0.049). In contrast, there was a significantly higher percentage of typically developing children (65.5%) with easy temperament characteristics than children with autism (34.5%) (x2 = 10.99, df = 1, p = 0.001). 3.2. Co-occurring SP dysfunction in children with the difficult constellation of temperament characteristics Results showed that a higher percentage of children with autism scored in definite difference range on all four quadrants of the SP-C, including Registration (62.7%), Seeking (38.8%), Sensitivity (35.8%), and Avoiding (41.8%) compared to typically developing children (11.6–16.3%).
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Table 1 Independent t-tests of the mean scores of the nine temperament characteristics assessed by the BSQ-C and 4 quadrant scores of the SP-C between children with autism and typically developing children.
BSQ Activity level Rhythmicity Approach-withdrawal Adaptability Intensity Mood Persistence Distractibility Threshold SP-C Registration Seeking Sensitivity Avoiding
Autism (n = 67)
TD (n = 44)
Mean (SD)
Mean (SD)
4.35 3.68 3.96 3.37 4.00 3.28 4.43 4.33 4.06
3.74 3.57 3.52 2.72 3.77 3.03 4.05 4.91 4.85
(1.00) (0.96) (0.79) (0.87) (0.77) (0.59) (0.67) (0.81) (0.89)
54.10 (8.56) 95.14 (15.34) 75.30 (8.62) 104.43 (10.75)
t
p-value
(0.77) (0.84) (0.83) (0.76) (0.72) (0.69) (0.54) (0.59) (0.72)
3.45 0.67 2.75 4.14 1.59 1.97 3.28 4.08 5.08
0.001 0.50 0.005 <0.001 0.12 0.05 0.001 <0.001 <0.001
65.42 (7.09) 109.84 (11.40) 86.15 (7.79) 119.00 (12.53)
7.23 5.40 6.69 6.50
<0.001 <0.001 <0.001 <0.001
BSQ-C, Behavioral Style Questionnaire – Chinese version; SP-C, Sensory Profile – Chinese version; TD: typically developing children.
Fig. 1. Percentage of children with autism and typically developing children who scored in the difficult range on the nine temperament characteristics of the BSQ-C. BSQ-C, Behavioral Style Questionnaire – Chinese version; TD: typically developing children.
As regard to co-occurring SP dysfunction in children with difficult temperament characteristics, a higher rate (91.3%) of children with autism had at least one SP quadrant in the definite difference range as compared with typically developing children (50%) (Fig. 2). However, for children with easy temperament characteristics, the rate of co-occurring SP dysfunction was lower both in children with autism (60%) and in typically developing children (0%) (Fig. 2). 3.3. Relationships between SP dysfunction and difficult temperament characteristics in children with autism As regard to Activity Level, the fitted multiple logistic regression model revealed that children with more sensory seeking behaviors had a higher chance of having a high activity level. With regard to Adaptability, the fitted multiple logistic regression model showed that children who sought excessive sensory input or who avoided sensory input at a higher rate than others were more likely to show lower adaptability. For Intensity, the fitted multiple logistic regression model showed that children who were more sensitive to sensory stimulation would more likely have higher intensities of reaction (Table 2). As for Mood, the fitted multiple logistic regression model showed that children who missed the sensory input needed for greater participation were more likely to have a negative mood. For Persistence, the fitted multiple logistic regression model showed that children who missed sensory input needed for participation at a higher rate or who had fewer sensory avoiding behaviors would have higher chances of being less persistent (unable to stay on task). As for Distractibility, the fitted multiple logistic regression model showed that children with fewer sensory seeking behaviors would have higher chances of
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Percentage of co-occurring sensory processing dysfunction
992
100
91.3
80 60
60
Autism 50
TD
40
20 0
0 children with difficult temperament characteristics
children with easy temperament characteristics
Fig. 2. Percentage of co-occurring sensory processing dysfunction in children with autism and typically developing children who manifested either difficult or easy temperament characteristics. TD: typically developing children; SP-C, Sensory Profile – Chinese version.
Table 2 Multiple logistic regression models of difficult temperament characteristics assessed by the BSQ-C in children with autism (N = 67). Covariate Activity level Intercept Seeking Adaptability Intercept Seeking Avoiding Intensity Intercept Sensitivity Mood Intercept Registration Persistence Intercept Registration Avoiding Distractibility Intercept Seeking
Estimate
Standard error
Wald chi-square
p-value
Odds ratio
9.08 0.11
2.61 0.03
12.13 14.34
0.0005 0.0002
– 0.90
12.36 0.06 0.08
4.29 0.02 0.04
8.29 7.46 3.97
0.004 0.0063 0.0464
– 0.94 0.93
7.38 0.12
2.97 0.04
6.19 7.88
0.0128 0.005
– 0.89
3.84 0.10
2.25 0.04
2.92 5.37
0.0877 0.0205
– 0.90
3.24 0.06 0.06
2.78 0.03 0.03
1.36 3.62 4.54
0.2427 0.057 0.0332
0.94 1.06
4.91 0.05
2.01 0.02
5.94 4.98
0.0148 0.0257
– 1.05
BSQ-C, Behavioral Style Questionnaire – Chinese version.
being distracted (Table 2). For the temperament characteristics of Rhythmicity, Withdraw, and Threshold, no factor was entered in the multiple logistic regression models. 4. Discussion 4.1. Temperament characteristics of children with autism and typically developing children In agreement with previous studies, our results showed that children with autism had a higher activity level, were more withdrawn, less adaptable, had more negative mood, were less persistent, had lower distractibility, and higher threshold than typically developing children (Bailey et al., 2000; Hepburn & Stone, 2006; Landry, 2000). The findings that children with autism had lower distractibility and were less adaptable to changes in their routines or environments were consistent with their core symptoms. 4.2. Co-occurring SP dysfunction in children with the difficult constellation of temperament characteristics This is the first study examining the rate of co-occurring SP dysfunction in children with autism who had difficult temperament characteristics and we found that SP dysfunction is prevalent in children with difficult temperament characteristics regardless of whether or not they were autistic. Thus, assessment of SP function is recommended for children with difficult temperament characteristics.
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4.3. Relationships between SP dysfunction and difficult temperament characteristics in children with autism Results of this study showed that compared to the group without difficult temperament characteristics, those who had difficult temperament characteristics had a higher risk for SP dysfunction after adjusting for the effects of the other covariates, such as demographic variables and other dysfunctional dimensions, in the fitted final logistic regression model. Children with autism with sensory seeking behaviors were more likely to have temperament characteristics in a difficult range for both Activity Level and Adaptability, i.e., the more sensory seeking behaviors, the higher activity level, and the lower adaptability. This is probably because sensory seekers often engaged in activities actively to obtain as much sensory stimulation as they can from the environment to regulate themselves, thereby resulting in high activity levels and longer time to adapt to a new environment (Dunn, 1997; Tseng et al., 2011). Hence, for children with autism having temperament characteristics of a high activity level and low adaptability, clinicians or parents need to obtain information about the kind of sensations they crave and incorporate the sensations into their daily life repertoires (Dunn, 1997). Furthermore, it is interesting to note that the SP pattern of Seeking was associated with the temperament characteristics of Distractibility for children with autism, i.e., the fewer sensory seeking behaviors, the higher distractibility (easy to be soothed). The finding is inconsistent with the conventional notion that children with more seeking behaviors would be more easily distracted, i.e., shorter attention span (Dunn, 2006). This may be due to the fact that the Distractibility dimension contains more items (6 out of 8 items) related to soothability. Further, children with few sensory seeking behaviors might be those who are easily content with the sensory input in the environment such that they are easily soothed. Children with autism having sensory avoiding behaviors were more likely to have the temperament characteristic of Low Adaptability, i.e., the more sensory avoiding behaviors, the lower the adaptability. Sensory avoiders usually control or limit sensory input deliberately throughout the day to avoid activating their low neurological threshold (Dunn, 1997). This may cause them additional challenges particularly in new environment and result in low adaptability (Baranek et al., 2002). When serving children with autism with low adaptability, clinicians or parents may need to respect their avoiding responses to the overwhelming environmental stimuli and make the necessary adjustment such as limiting excessive sensory input, and then gradually increasing the variety of sensory experiences to facilitate their functioning and adaptation (Dunn, 1997). In contrast, the children with autism who had fewer sensory avoiding behaviors were more likely to have the difficult temperament characteristics of Low Persistence. This is probably because children with autism who had fewer sensory avoiding behaviors approached a variety of sensory events and demonstrated low persistence on a task. Children with autism having poor registration were more likely to have the difficult temperament characteristics of both Mood and Persistence. That is, children with autism who often missed the sensory input needed for participation had negative mood and were less persistent. This is probably because children who did not register meaningful sensory stimuli usually could not enjoy themselves in activities (Chawarskam, Klin, & Volkmar, 2008; Dunn, 1997). The finding that poor registration was associated with less persistence is not consistent with Dunn’s proposition that poor registration leads to persistence in tasks due to no distraction by external stimuli (Dunn, 2001). Perhaps, Dunn’s proposition is only applicable to the populations without autism. Thus, when serving children with autism who had negative mood or were less persistent, it is important for clinicians or parents to enhance children’s sensory registration, for example, by increasing the weight of objects or selecting brightly colored objects in daily routine tasks (Dunn, 1997, 2006). Children with autism having sensory sensitivity behaviors, were more likely to have the difficult temperament characteristic of High Intensity, i.e., the higher the sensory sensitivity, the more intense the response. This finding was consistent with previous findings that children with autism who were hypersensitive to sensory experiences had intense responses, such as disruptive behavior or fight responses (Baranek, Foster, & Berkson, 1997). When serving children with autism who had intense responses, clinicians or parents might need to be cautious about the sensory input not to heighten their arousal level, for example, by using touch pressure input rather than light touch stimuli (Dunn, 1997). Temperament has been viewed as an interaction between sensory reactivity (Fox & Polak, 2004) and environmental experience (Bates, 1989; Karreman, de Haas, van Tuijl, van Aken, & Dekovic, 2010; Rothbart, Ahadi, & Evans, 2000; Thomas & Chess, 1977). Further, research evidence has shown that modifying sensory stimulation from environment can improve sensory processing function and meet children’s sensory needs (Dunn, 2006; Miller et al., 2007; Thomasgard, 2003). Results of this study add to available research in the field by providing the knowledge of sensory correlates of difficult temperament characteristics in children with autism, and help clinicians and parents to design and implement effective interventions or supportive strategies in order to promote functioning and adaptation in children with autism. 4.4. Limitation In this study, all participants were recruited from the greater Taipei area and generalization of the results should be made with caution. Furthermore, since the focus of this study was on the relationships between sensory processing and temperament characteristics, factors such as parenting styles, severity of autism, and cognitive functioning which might influence a child’s temperament characteristics (Giancola, Mezzich, & Tarter, 1998; Konstantareas & Papageorgiou, 2006) were not included. It is recommended that such factors be considered in future studies.
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5. Conclusion This is the first study examining the rate of co-occurring SP dysfunction in preschool children with autism who were demonstrated to have difficult temperament characteristics, and the relationship between SP dysfunction and each difficult temperament characteristic. Results of the study indicated that SP dysfunction is prevalent in preschool children with autism with difficult temperament characteristics, and that different SP patterns were associated with different difficult temperament characteristics in preschool children with autism. Further, results of the study supported Dunn’s proposition that one’s temperament is the behavioral manifestation of his/ her sensory processing patterns. The sensory seeking behavior was associated with high activity level and low adaptability; the sensory avoiding behavior was associated with low adaptability; the poor registration behavior was associated with negative mood and less persistence; the sensory sensitivity behavior was associated with high intensity. In summary, the present findings highlight the importance of evaluating both the SP patterns and temperament in children with autism in order for clinicians to plan appropriate intervention programs and support participation in daily lives. Furthermore, the knowledge of the relationship between difficult temperament characteristics and SP dysfunction of the child can foster parental appreciation of individual differences in children, provide parents effective strategies to manage children’s behaviors, and promote adaptive parent–child interaction.
Acknowledgments We gratefully acknowledge Professor Anne Henderson for her valuable comments on the manuscript. We especially thank all parents and children for participating in this study. We are also grateful to the Autism Society Taiwan, the Department of Physical Medicine and Rehabilitation of the National Taiwan University Hospital, First Child Development Center, Bo-Ai Child Development Center, Zhong-He Child Development Center, Cheng-Zhong Child Development Center, AiZhi Child Development Center, Potential Development Center for Children with Autism for their assistance with recruiting children with ASD, and Sheng-Ya Nursery School, Hsin-Yi Foundation Nursery School, Xinhu Kindergarten, and Pisces Nursery School for their assistance with recruiting typically developing children. We sincerely thank Ruei-Mei Syu, Jin-Hua Liao, and Huei-WunWu for helping with data collection. 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