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Friendship, Internalizing Symptoms, and ASD: Researchers Explain Their Findings

Date Last Revised: 
April 12, 2011

Drs. Micah Mazurek and Stephen Kanne of the Thompson Center for Autism and Neurodevelopmental Disorders at the University of Missouri recently published an article on friendship, “internalizing symptoms,” and children and teens with autism spectrum disorder (ASD) in the Journal of Autism and Developmental Disorders.* Their study was made possible by data provided by families participating in the Simons Simplex Collection project. Dr. Mazurek graciously agreed to be interviewed in order to share the study’s findings with the autism community. (IAN’s questions appear in bold at the beginning of paragraphs.)

Dr. Mazurek, your study explored four major questions about autism, anxiety, and friendship. Can you tell us about each of them?
Dr. Micah MazurekFirst, we wanted to find out was whether the 1,202 children and teens with ASD in our sample would have higher rates of anxiety and depression than typical children and teens do. Previous studies had often found this.

It turned out that our study confirmed the findings of previous studies. There were higher rates of anxious, depressed, and “internalizing symptoms” in our sample of children and teens with ASD than you would expect to find in typical children and teenagers.

Can you explain what “internalizing symptoms” are?
When psychologists talk about “internalizing symptoms,” they mean the kind of symptoms associated with anxiety and depression. “Externalizing symptoms” are more outwardly expressed. They might include acting-out behaviors such as aggression or impulsivity. Instead, “internalizing symptoms” are more inwardly experienced. These types of symptoms might include being anxious or afraid, worrying about the future, feeling self-conscious, being nervous, or feeling sad. Our study showed that children and teenagers on the autism spectrum were more prone to such symptoms than children and teens that do not have ASD.

What was your second research question?
We asked: Is greater autism severity associated with greater levels of anxiety?

How did you rate a person’s ASD severity?
Each child with ASD participating in the Simons Simplex Collection is assessed using the ADOS, or Autism Diagnostic Observation Schedule, which is a gold standard tool for diagnosing autism. The ADOS is an activity-based evaluation that focuses on a child’s social, communication, and play skills as well as repetitive behaviors. Each of these areas is carefully observed and coded by expert clinicians. Severity scores can then be generated.

What did you discover with regard to autism severity and anxiety?
Although we expected greater autism severity to be associated with higher levels of anxiety, we found the opposite. The more severe a child’s ASD symptoms, the fewer symptoms of depression and anxiety he or she tended to have.

When you got that result, how did you explain it?
We looked to theories about how anxiety develops, and realized that certain aspects of depression and anxiety tend to develop only in later childhood. For example, before children start to have certain types of anxious or depressed thoughts about themselves, they need to have a certain level of self-awareness. For other kinds of anxious thoughts, children must be able to imagine how other people view them. These two areas – self-awareness and awareness of others – are often affected by ASD. So, it actually makes sense that for children with more severe ASD, anxiety and depression may be less of a problem. On the other hand, higher functioning children may be more susceptible to these negative thought patterns.

What was your third research question?
Focusing back on friendship, we asked: Is greater ASD severity associated with having poorer friendships? We found this was the case. This makes sense, since difficulty with social interactions is a key feature of ASD.

The reason we cared about friendships was because we know, from research and clinical experience, that typical children who have even one good friend are protected somewhat from anxiety and depression. Even in the face of other challenges, friends can act as a buffer against negative thoughts and emotions.

In fact, our fourth research question asked if this same phenomenon applied to children and teens with ASD. Would having friends protect them from developing symptoms of anxiety and depression?

How did you measure or categorize the children’s friendships?
We divided them into four groups according to the quantity and quality of their friendships. The children in the first group had at least one friendship that involved shared activities outside of a pre-arranged group and was characterized by real give-and-take between the friends – or “reciprocity.” The children in the second group were similar, but their friendships were more limited as far as scope of interests and the give-and-take between friends. The third group had contact with friends, but only in the context of organized groups or at school. The fourth group had no relationships with peers that involved any real social give-and-take.

We had expected that having the highest quality type of friendship would be associated with having the fewest internalizing symptoms, which is how it works for typical children. However, it didn’t work the same way for children with ASD.

What did you find?
For our children and teens with ASD, it turned out that the those with no friendships and those with good friendships had the same level of internalizing symptoms, while those who were in between, with so-so friendships, had the most internalizing symptoms.

What do you think explains that?
The children with no friendships also tended to be the children with more severe symptoms of ASD. It may be that these children have less desire for friendship, and that they are not as aware of their differences or any social rejection they face. Because of this, they would be at lower risk for internalizing symptoms. The children with less severe ASD, on the other hand, would be most likely to want friendships and to have the skills to make friendships succeed. For these children, friendships may play a protective and supportive role. But the children in the middle, who want friends but can’t make friendships work very well, may be at risk for greater anxiety and stress as a result. That would explain why depressed mood and worry are highest for children with friendships of a poorer quality than they are for children with no friendships or better quality friendships.

Of course, these are just preliminary findings. Hopefully, researchers will be able to look more closely at these issues in the future.

Can you tell us how you became interested in the nature and quality of friendships among children and teenagers with ASD?
I’m a clinical child psychologist, and I have always been interested in how children develop friendships and other relationships with their peers. How do children develop socially? That was an important question for me.

Over the past seven years or so, I have become more and more involved in working with children with ASD. Through these interactions, I realized that many of them do have relationships that are very meaningful for them. That really contrasts with the assumption that people with ASD are not interested in social connection. Because there hasn’t been much research on the meaning and effects of friendship in the lives of people with ASD, I became very interested in learning more about this.

My work at the Thompson Center for Autism and Neurodevelopmental Disorders has included providing diagnostic evaluations and therapy for many different children and teens with ASD. It has been wonderful to get to know the personalities of each of these children – they are such fun and endearing individuals. Although they may share similar traits, each is so different from the other in terms of their interests and what makes them tick. I also have found that they vary in how they define friendship, and in what friendship means to them.

You must have needed a rich source of information to conduct this study. Where did your data come from?
We couldn’t have done the study without information provided by families participating in the Simons Simplex Collection (SSC), a comprehensive study collecting data from families with a child with ASD at twelve sites in the U.S. and one in Canada. Our center is one of the SSC sites, so we were very aware of the extensive data available through the SSC. We applied to use the SSC data for this project, and were able to examine information from more than 1,200 children and teens with ASD who had participated in extensive research evaluations at the various SSC sites.

Thanks to the participation of Simons Simplex families, we had detailed information about each child’s ASD diagnosis and symptoms, their level of cognitive functioning, and their current emotional functioning. We also had some information about the number and quality of their friendships.

What do you hope to focus on next in your research?
I am very interested in learning more about the point of view of people with ASD. How do children and teens with ASD define friendship, and what do their friendships mean to them? What do they value, and what do they find supportive, in terms of friendship? Are there aspects of their relationships that do tend to lessen anxiety and internalizing symptoms? What characterizes their relationships with typical peers, or with their friends who also happen to have ASD? What allows them to be successful with typical peers or other children with ASD?

These are all important questions because they can help us design better and more meaningful interventions. If we can find out which aspects of social relationships and friendships protect children with ASD from anxiety or bullying, for example, we can develop friendship interventions to target those things. Learning what is most meaningful and relevant for both children with ASD and their peers will ultimately allow us to have the most impact.

Thank you so much for sharing the results of your study with us.
Thank you for the opportunity. And my heartfelt gratitude to the Simons Simplex Collection families who made this study possible.

*Friendship and Internalizing Symptoms Among Children and Adolescents With ASD (Journal of Autism and Developmental Disorders, December 2010).

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