Here's Looking at You: Neural Effects of a Cognitive-Behavioral Social Skills Treatment on Eye Gaze Processing in Children with Autism—a Randomized, Comparative Study

Background: Social deficits are a hallmark of ASDs and may be related to underactivity in key brain regions involved in social cognition.  There is also evidence that activity in normative neural networks can be increased significantly by providing children with ASD with explicit instructions to attend to important social cues. Social skills training using a cognitive-behavioral (CBT) approach has been shown to be effective in improving social behavior deficits in children with ASDs.  However, there is a need for a greater understanding of the neural mechanisms underlying the behavioral changes in response to treatment. Further work is also needed to provide more randomized controlled trials with larger sample sizes and comparative treatment groups.

Objectives: This study examines the neural effects of a 12-week social skills treatment on the neural correlates of processing gaze in faces depicting varying emotions. A CBT approach was compared with a child-directed play approach.  

Methods: Verbally fluent children with ASD, 8-11 years of age, were randomized to the CBT or child-directed comparison group. Both treatments consisted of 12 weekly 90-minute sessions (4-6 children in each group with a 1:2 therapist to child ratio) with a concurrent parent component. The CBT treatment addressed 3 skill areas: Nonverbal communication, Emotion recognition, and Theory of mind Training (NETT). Behavioral assessments and fMRI were conducted at baseline, end of treatment, and at a 3-month follow up. While undergoing fMRI, children viewed images of emotionally expressive faces depicting anger, fear, disgust or a neutral expression. Faces displayed either a direct or averted gaze looking to the observer’s right or left.  Regression analyses were conducted to evaluate the relationship between brain activity and changes in social cognition and behavior.  

Results: Following treatment, children in the CBT group showed greater activity in the medial prefrontal cortex (MPFC), the ventrolateral PFC, temporoparietal junction (TPJ), and the superior temporal gyrus (STG) relative to baseline. These changes were most pronounced for the averted gaze condition. In contrast, children in the comparison group did not show any regions of increased activity post- vs. pre-treatment. When directly comparing the two groups on changes in brain activity, we found that children in the CBT group showed greater increases in regions relevant for theory of mind (MPFC and TPJ) and emotion recognition (STG) relative to the comparison group.

Conclusions: Findings from this study suggest that there may be an advantage to using a group cognitive-behavioral approach in increasing activity in social brain networks. Specifically, capitalizing on top-down explicit processing while reinforcing attention to key social cues, such as gaze direction, from the bottom up may facilitate perspective taking and thus lead to increased activity in the social brain network. Further analyses are being conducted as it will be important to assess whether these changes are maintained at follow up. This study contributes to our understanding of the neural underpinnings of the social deficits in autism and the plasticity of networks involved in social cognition underlying response to treatment.