"Inside the mirror"
A pilot study on the effects of dance movement intervention on interpersonal non-verbal attunement in adolescents with autism spectrum disorders.

Autism is described as a developmental disorder with a cluster of markers in i)
diminished ability to communicate, ii) reduced social functioning, and iii)
preference for stereotype routines (WHO, 1992; APA, 2000). A broad variety of
appearances is known to fit into these cores markers.
Causes of ASD are multilayered (Rogers, 2006; v.d. Gaag, 2001) and still not
clearly identified in their interplay. It is generally assumed that the
interaction of hereditary, neurobiological and developmental characteristics
and structures causes the atypical development of social engagement, empathy
and formation of theory of mind (Bennetto & Rogers, 2001; Aitken, 2008).
In ASD, due to atypical patterns in relationships with others, the (early)
nonverbal attunement between child and caregiver may not only be disturbed, but
there may, as a consequence, be retardation in the development of
intersubjectivity. Coming from an impaired nonverbal attunement in the
child-parent dyad and triad a lack of experience in perceptive and
proprioceptive movement traces will grow, which may lead to a lack of
experiential traces in neurological connectivity. Thus a limited plasticity in
brain-structures will determine perceptual sensitivity according to the earlier
experiences. Recent theories emphasize the involvement of shared neural
circuits in the impairment of social-emotional functioning (Keysers & Gazzola,
2006).
Research in dyadic interactions in children with ASD has shown that the
interaction partner adjusts to the pathological interaction behavior with
reduced frequency of intentional addressing towards the child nonverbally
(Wimpory, Hobson &Nash, 2007; Garcia-Peréz, Lee & Hobson, 2007). This may lead
to further abatement of the child/carer interactions.
Studies found in the literature have investigated the possibilities of the
child with Autistic Spectrum Disorder (ASD) to attune to a partner during
social interaction. They give attention to the role of imitation (e.g. Hobson
and Hobson, 2008) and deficient mirror neuron activity (e.g. Dapretto, Davies,
Pfeifer, Scott, Sigman, Bookheimer et al., 2006). However, the underlying
kinetic structures during non-verbal attunement have hardly been taken into
account. Furthermore, a strong accent has been given to the child*s capacity to
imitate. Only a few (behavioural) studies focus on the effects of the child
being imitated by the other. Some studies (e.g. Calvo-Merino, Grèzes,
Passingham & Haggard, 2006) suggest that the mirror neuron activation (MNS) is
modulated through sensory motor experiences that combine perception and
proprioception during dyadic movement experience. In brain imaging research
with fMRI, participants with ASD have shown reduced or atypical activation in
mirror neuron circuits during action observation and imitation (Dapretto
et.al., 2006). Recent theories broaden this perspective and emphasize the
involvement of shared neural circuits (for action and action observation) in
the impairment of social-emotional functioning (Keysers & Gazzola, 2006).
This pilot study will test a non-verbal intervention to find out its
effectiveness in increasing inter-personal attunement for adolescents with a
diagnosis in the autistic spectrum (ASD). Dance movement therapy/DMT has been
offered to children, adolescents and adults in multidisciplinary outpatient
therapy settings for many years, producing much anecdotal evidence from
therapists and caregivers. However, it has not yet been studied systematically.
From thorough analysis of video-taped clinical material and literature research
the current set up for a research study has been derived.
The aim of the intervention is to bring about relational movement experiences
in patients who do not have a clear sense of self and whose self perception is
not anchored in embodied experiences (Erfer, 1995, Loman 1995) through
experiences of shared movement activity.
The DMT intervention addresses the mutual engagement at a level from which the
child is capable to engage . This orientation to resources is facilitated
through the therapist*s sensitivity to, and knowledge of, movement analysis.
The child*s assessed movement profile outlines the movement capacities and
strengths and helps to identify the gaps in the movement repertoire. Moreover
this analysis provides the potential possibilities for the interaction
partner/therapist to join the kinetic patterns of the patient. The therapist
shapes the specified movement intervention with this information in mind and
also uses it to guide the parent-carer on how to attune to their child
nonverbally. The therapist arranges the situation for the participants to be
invited into movement activity. S/he offers sufficient containment for the
participant to bear the nonverbal contact and organizes the situation in a way
that stimulates the child*s intrinsic developmental impulse. The spontaneous
movement reaction of the child to the situation offers the potential to
reconnect with an autonomous developmental process (Samaritter, 1990).
In dance movement therapy (DMT) attuned movement intervention is used to
develop embodied interpersonal engagement in children with autism.
Participating in the mutual kinetic experience is a sensory, kinaesthetic
activity in non-conceptual shared (movement) space, time and weight. In view of
their function the MNS and social neuronal circuits are most likely to to be
modulated during this process.

The project aims at contributing some empirical evidence of treatment effects
of DMT with ASD. We expect i) to replicate similar results in a series of
individual treatment processes and ii) to find contrasting results in a series
of individual cases that follow *treatment as usual* (which might be
psycho-education, parental counseling).
Aims:
1) To show the effects of DMT on nonverbal interpersonal engagement in
adolescents with ASD
2) To evaluate if any increase in nonverbal interpersonal engagement can be
related to an increase of activity in mirror neurons
3) To assess whether an increase in nonverbal interpersonal engagement can be
recognized by caregivers/key workers in their systematic reports on the child*s
overt nonverbal interpersonal engagement behavior.

As this is the first phase of study in this area and there are no validated
instruments for measuring non-verbal interpersonal engagement in this
population we will have to define our focus to in-depth single case studies. To
strengthen the results we will apply a triangulatory, convergent measurement
set-up: Outcomes from movement pattern analysis of nonverbal communicative
behaviour and a standardized questionnaire on social behavior will be related
to the analysis of data obtained by fMRI scans of the areas involved with
mirror neuron activity during action-observation. The analysis of this data
will be contrasted to analysis of data collected throughout the intervention,
using a reversal design in which blocks of attuned movement will be alternated
by non-specific movement interventions.
In quasi experimental design the results of pre/post intervention data analysis
of the intervention group (N7) will be compared to the results of a control
group (N7) of adolescents who did not follow the intervention.
Testing will take place as follows: Pre and post intervention on neuronal
regulation will be gathered through fMRI scans. Dr. C. Keysers, head of the
research group social neuroscience at the Dutch institute for neuroscience
Amsterdam (NL) will supervise data collection/task design and the related data
analysis.
Data from movement patterns showing engagement (e.g. eye contact) will be
collected via videotapes of sessions. Based on Laban Movement Analysis
observation tools three independent qualified raters will blindly assess
event-related movement patterns from a) videotaped movement observation
sessions pre/post intervention b) video samples of sessions at the end of each
intervention block 1, 6, 12, 18, 24 (Cruz & Koch, 2004).
At pre and post intervention carer-parents will complete the VISK (CSBQ), a
Dutch standardized social behavior questionnaire for children with ASD to
define the child*s nonverbal engagement profile.
The pilot will be undertaken to test the overall design, procedures for
collecting data using fMRI/videotape/movement observation and questionnaire. If
positive outcomes are demonstrated following the pilot a main study with more
participants and follow up is envisaged.

MEASUREMENT INSTRUMENTS:
- standardized questionnaires on the social behaviour (CBCL & VISK) of children
completed by caregiver
- movement pattern data-analysis of non-verbal communicative behaviour as
observed from video-vignettes by independent movement observers trained as
raters in Laban based Movement Analysis (LMA)
- functional brain-imaging scans (fMRI).

The intervention will consist of 24 DMP sessions, conducted in a reversal
design in which blocks of attuned movement will be alternated by non-specific
movement intervention

The study is not expected to have any intrusive aspects for the participating
adolescents.
The frequency of two weekly sessions during twelve weeks is considered to
provide regularity without burdening participants more than usual treatment
programmes. Outcome on usefulness of the proposed intervention would benefit
more in general the treatment planning of the ASD population in outpatient
settings. The study is expected to contribute to embodied neuronal structures
and therefore considered to modify the developmental impact of the condition.