On social compensation in autism, with Dr Lucy Livingston

Dr Lucy Livingston is a psychologist and Lecturer at Cardiff University in the Wales Autism Research Centre, who specialises in neurodevelopmental conditions such as autism spectrum disorder. During this podcast, she chats to Sue about a piece of work looking at compensatory mechanisms in adolescents with autism spectrum disorder.

You can find Lucy's lab group pages here and follow her on twitter here.

The article discussed in the podcast is:
Livingston, L. A., Colvert, E., Social Relationships Study Team, Bolton, P., & Happé, F. (2019). Good social skills despite poor theory of mind: exploring compensation in autism spectrum disorder. Journal of Child Psychology and Psychiatry, 60(1), 102-110.

Transcript

Sue: 0:08

[Podcast jingle][ringtone] Hello? Oh, it is recording. I see the little figure. Okay, great. I will do my little spiel and then I'll introduce you. Nice. Okay. Here I go. Hi, my name's Sue from the Salvesen Mindroom Research Centre at the University of Edinburgh, and I'm recording another PsychologiCALL, which is the little podcast that we set up during the COVID-19 pandemic to try and find a way to, um, put some evidence-based information out there into the conversations that we're all having at the moment about child and adolescent development and wellbeing and learning and so on and so forth. And I've been speaking on the phone to different psychologists about every week. And today I'm talking to Lucy Livingston who is based at Cardiff University, and she's going to be talking to me about some work that she's done looking at social skills and particularly compensation as social skills in autism. So hello, Lucy, how are you today?

Lucy: 1:09

Hi Sue, good, thanks!

Sue: 1:11

Good, thank you very much for joining me. Um, so let's start with, um, what you, what you discovered when you did this piece of research.

Lucy: 1:21

Um so in this piece of research, I guess our main finding was that there are some autistic people, particularly autistic adolescents, um, who are quite good at compensating, um, the difficulties that they have in theory of mind. And so these individuals, um, show quite good social skills in their behaviour, um, even though, um, they do still have difficulties, um, with infering the mental states of other people.

Sue: 1:54

Fantastic! Um, and so what, what kind of led you into this question? What made you think that this might be an interesting thing to examine?

Lucy: 2:05

Um, sure. So I guess, um, one of the main things that I was interested in, um, I was trying to understand a bit more about why there are such large individual differences amongst autistic people. Um, and in particular, we know that, um, some individuals develop much better social skills um, than others across their development. Um, and so this has kind of led some people to speculate about the possibility that some autistic people might be able to kind of compensate for underlying cognitive difficulties or differences, um... So that these individuals, um, actually appear, um, far more neuro-typical in their behavior, um, than um... than we might expect if we were to look at their cognitive profile. Um, and in particular, uh, I was particularly inspired by, um, work that some people had done including Uta Frith, um, on, uh, developmental dyslexia. And so there was kind of, uh, a number of studies that showed, um, that children with dyslexia, um, who typically have difficulties with reading, some of these individuals, um, go on an early adulthood to the, to, um, kind of show typical levels of reading. But that actually, um, when we kind of probe them with, um, cognitive tasks that get at, um, some of their underlying difficulties in phonological processing, um, it kind of indicates that the phonological processing difficulties haven't gone away. Um, but instead that they're, these individuals might be compensating for them, um, such that they then appear to be, um, reading typically.

Sue: 3:54

I see. So they've got to the same end point, but by a, perhaps a different process.

Lucy: 4:00

Yes, exactly. Um,...

Sue: 4:03

And so... yeah, sorry I'll let you speak![laughs] Well, I was gonna ask about the, so I guess this is a kind of a measurement question, but also a conceptual one, about the difference then between sort of social skills and then underlying cognitive skills. So perhaps we should start with the cognitive level. Um, you could just remind listeners or, or enlighten listeners about what we mean by theory of mind and, and what the sort of cognitive level of social abilities are that you were looking at.

Lucy: 4:36

Sure. So, um, theory of mind is a kind of a mental process, um, which we think that all, um, humans develop and it allows you to, um, be able to infer the mental state of other people, um, even when these mental states might differ from your own, um... In relation to autism, um, we think that theory of mind, um, uh, might be a theory of mind difficulties might be something that really characterizes, um, autism. Um, and so when we talk about the"Theory of Mind" theory of autism, um, this is a cognitive theory, um, that we think, um, helps us to understand, um, the behaviors that we see in autism. Um, so we, yeah, we kind of assume that the cognitive difficulties will then be reflected in behavior. Um, but the way that we measure the cognitive difficulties, cause we can't, you can't just observe cognitive difficulties, uh, we need to use experimental tasks such as a theory of mind task.

Sue: 5:44

Right, and so, and so this technical skill, if you like of, um, of, of modeling what other people are thinking, right, and especially, I guess their sort of complex thoughts is, is something that we can capture in the lab and that we assume is a useful, important underpinning skill in your day to day life. Because, you know, we're always sort of when we're working out what to say next in a conversation, we're partly also working out what the person we're speaking to speaks about what we said last, for example, that kind of thing. Is that, is that right?

Lucy: 6:23

Yes, exactly. Yeah.

Sue: 6:25

And so then, so then, so you're looking at this gap between that cognitive skill and the, and the sort of day to day social skills. So perhaps you could tell me a bit more about that level then what sort of, I don't know if"day to day" is quite the right phrase, but what sort of, um, you know, um, superficially observable things where you're looking at in terms of social skills.

Lucy: 6:47

So in terms of just in general, um, you know, social skills might be, um, you know, how you respond to other people, whether you kind of respond appropriately to their questions, whether or not you, um, kind of can pick up on, um, uh, you know, uh, turns in the conversation, whether or not, um, uh, yeah, and this might then kind of feed into a more kind of real life social things. So for example, whether or not you have good social relationships, whether or not you get on with other people. Um, yeah. And in terms of autism, um, the types of difficulties that we might see in these social skills, um, would be, um, things, um, you know, like difficulties, understanding others, um, difficulties understanding where the conversation is going to go, um, predicting what, uh, what someone's going to say next. Um, and this is what can make it more difficult for autistic people, um, to connect and make relationships with other people.

Sue: 8:00

And so did you, how did you capture that specifically in this study? Did you just ask people to rate their own social skills or did you observe them somehow? What was the, what was the measure for that?

Lucy: 8:15

So, um, so in this study we, um, use the ADOS, um, which is a kind of semi-structured interview that an experimenter does with the autistic person. And, um, it basically, um, involves kind of some um... some questions and also some games, um, and the experimental will code for certain particular behaviors that they observed, um, in the autistic person. So there's no kind of self reporting for the autistic person themselves.

Sue: 8:50

I see. I see. So you've got a kind of directly observed measure and, and so then what's the kind of analysis. So how did you capture, cause you're trying to capture a sort of gap aren't you between these two different kinds of measures. So perhaps you could tell us a bit about that analysis and, and actually, um, also just who was involved in this study, right? So who your participants were, sorry, I should have, I should have asked that already![laughs].

Lucy: 9:18

Participants, um, were, um, autistic adolescents, um, around kind of 12 years old. Um, and these individuals were tested in person. Um, so researchers went and visited them at their homes. Um, and the, the particular kind of analysis that we did is we wanted to compare two groups of individuals. So individuals, um, who, uh, showed good, uh, social skills, um, uh, when observed by the experimenter, um, but showed poor theory of mind task performance, and compare that group to individuals who also show, um, poor theory of my performance, but show much better um... Sorry, I've mixed that up![laughs] So both groups are showing poor theory of mind performance. Um, and one group is showing, um, the kind of clear social difficulties in their behavior and the other group is showing a much better social skills.

Sue: 10:25

Right...

Lucy: 10:26

This later group that we kind of call our high compensation group, and we wanted to try and directly compare those two groups of people, um, to see if there were any kind of differences in their characteristics, which might tell us something about the processes involved in compensation.

Sue: 10:44

Right, absolutely. So what are the, what are the resources that those people might be drawing on in order to compensate so effectively the kind of cognitive, um, differences that they're experiencing.

Lucy: 10:58

Exactly, yeah.

Sue: 10:59

And so what, what were those, where... Where was that compensation coming from? And then, did you get a clear answer to that question? That's not always the case when we're doing research, is it?[laughs]

Lucy: 11:10

We thought that kind of domain general skills would be particularly important. So we had measured IQ, um, and also executive function, um, so things like planning, um, ability to, um, shift between different sets and abilities to inhibit your behavior. Um, and we also, um, thought that potentially, um, kind of based on reports from autistic people and also clinicians, um, that the high compensators might actually, um, have, um, higher mental health symptoms compared to the low compensators. And this has come from, uh, yeah, as I say, reports that, um, compensating, um, you know, on a daily basis, um, for, uh, things that you, that you might find difficult, um, it is really exhausting, um, really, uh, yeah, really tiring and it does actually have a negative impact on your wellbeing. Um, so in the end, what we found, um, was that, um, IQ is really important, um, particularly, um, verbal IQ, um, executive function seems to be even more, even more important than IQ. So we still find differences between the two groups, um, in executive function ability, um, uh, over and above, um, IQ. So when we take IQ into account, um, and we did find that, uh, the high compensators reported uh, greater anxiety, um, than the low compensators.

Sue: 12:47

Hmm. That's really interesting. So, so basically those high compensators are just, they're just working really hard, right? And they're using all of their intellect and their sort of planning and working memory and, you know, inhibition-type abilities to, um, to create this kind of, you know, acceptable social face if you like to go out into the world.

Lucy: 13:16

Yeah...

Sue: 13:16

Yeah, yeah... And did you, um, were you able to look at gender differences? Because that's certainly been a topic of interest hasn't it, when it comes to things like compensation and I guess the closely related phenomenon as sort of camouflaging or masking, um, is that something that you weren't able to examine?

Lucy: 13:37

We did have a look at gender differences and we didn't find any, um, but we think, um, that we were potentially underpowered and, um, had a much lower number of females in the study. Um, so I definitely think that there needs to be more, more investigation into any of these potential, um, gender differences.

Sue: 14:01

Mmh... So you, you mentioned earlier the words... You mentioned, I've written down on the... I've scribbled down on a bit of paper,"appropriateness", right? So there's something I think is really interesting in this whole area of inquiry is the extent to which, you know, this, this phenomenon that we're talking about, things like social skills, right. Do we mean social skills or do we mean neuro-typical social norms? And, and even at the cognitive level, when we're talking about, you know, sort of detecting or, or, or inferring the mental states of others, do we mean inferring the mental states of neurotypical people who are sort of in the majority and get to call the shots so often about what's considered the, the right way to behave, or the right thing to think? So, I don't know if you have any insights into this, you know, into these sorts of drivers of this phenomenon. I don't know if any participants talked about this, or if you had any thoughts about this kind of dimension of it, you know, if everyone was autistic, would we have this compensation issue for example?

Lucy: 15:13

Sure. So, I guess, um, I guess some of these questions are kind of addressed in a, in a followup study that I did, um, which was a qualitative study, where I actually, um, asked autistic people, um, you know, I asked them more specific questions about what, what, what these strategies are that they might be using in social situations and, um, you know, more information about the context of how they work. Um, and one of the things that really did come through was that, um, that, you know, the, uh, the motivation, um, to use a lot of these strategies and to, you know, um, appear a certain way, um, was really driven by, um, kind of pressure put on them by other people, whether that be society, or their parents, or their peers. Um, and there, there was really the sense that they were, um, yeah, as you say, kind of, um, trying to reach some neuro-typical norm even if it didn't really seem, um, it didn't really make sense to them, you know, why it was so important that you need to make eye contact or, you know, make small talk about the weather, for example, they just did it anyway, um, to try and fit in. Um, and another thing that really came through was that, um, uh, autistic people spoke about, um, how it, it, it... Often it did matter who their interaction partner was. Um, so that sometimes they felt that, um, you know, social interaction with other, with non-autistic people, um, kind of fell apart, um, because they thought that they were being misinterpreted rather than they had made some misattribution, um, about the non-autistic person. And there's definitely a sense that when interacting with another autistic person, um, that there seems to be that mutual understanding, um, and maybe, you know, less pressure to adhere to some of these social norms, um, that makes interactions so much easier and less stressful. Um, yeah.

Sue: 17:23

Yeah, it's so interesting, isn't it? It's so interesting.[laughing] I feel like the researchers are sort of finally catching up with some stuff that's probably been, you know, um, pretty prominent in the autistic community for a while.[laughs].

Lucy: 17:37

Yeah, yeah, for sure. Yeah. And actually trying to use these ideas to then think about the ways that we do measure social behavior and, um, and things like theory of mind, um, because it, yeah, it potentially does matter who you're interacting with.

Sue: 17:54

Absolutely! So that was going to be my next question, maybe just as we sort of slightly move towards the end of the podcast is, you know, what, what the implication of this work is, um, uh, I guess in terms of how we might measure things in the future or the questions we might ask, but also, you know, for any parents with autistic kids who are listening or for any autistic teenagers who hear this, or, or for teachers and so on, you know, how can we, um, respond to this information and maybe nurture, um, you know, sort of, um, better mental health for autistic people, uh, maybe help them avoid feeling the need to compensate, but also, you know, help them build those relationships with, with the people around them who are often not going to be autistic, right? So there's a, there's a bit of a tension there isn't there between such as the drivers that make you want to, to fit in and the drivers that, that, that are sort of saying, you know, be who you are and, you know, um, have that, have that kind of strong pride in your identity as it is. What's your thoughts about what we could be doing in families or in practitioner settings with this kind of information?

Lucy: 19:19

Um, I guess, I guess there's a couple of things. Um, so, you know, firstly in this study, um, you know, the study was kind of the first study to directly investigate this, and find that there are these individuals that have huge discrepancies between, um, cognitive, um, uh, cognitive differences, um, and how they beha-, appear in behaviour. Um, and because we judge people on their behaviour all the time, um, you know, there may really be autistic people out there whose, you know, genuine difficulties are completely, um, under-recognized. And I often hear about, um, autistic, um, autistic girls in particular, um, talking about this, um, that, uh, you know, they're just not getting the right support, um, at school or, or, um, or, you know, when moving into adulthood in, in, in the workplace because, you know, they just appear to be doing"so well" in inverted, in inverted commas. So I think firstly, just getting people to be more, just be more aware of, of, of kind of how, how certain autistic people can appear, you know, superficially, um, neuro-typical um, would be, um, my, my first point to make, um, because particularly if these individuals are at kind of heightened risk for mental health problems. Yeah. Um, and I guess more broadly in society, um, I would kind of just champion, uh, you know, more, you know, greater acceptance of all differences. So, you know, not just autistic differences, but just, just people, you know, not fitting into neat boxes. And I think if that was just more pervasive across society, um, than, you know, people would feel less, um, less pressured to kind of, to change their behaviours in quite extreme ways that are not in accordance with who they truly feel that they are. Um, yeah. And the other, the other implication that came out of this is it, it got me thinking about, um, some of the kinds of social skills training that goes on for autistic people. Um, and you know, maybe sometimes this, this training is really useful for people. Um, but, but maybe actually, when you start to think about what, what, what, what social skills training is, is almost teaching people, compensatory strategies, to kind of allow them to superficially appear neurotypical. Maybe that's not the best thing, um, for, for young autistic people. Um, so maybe some, we need to kind of rethink some of our interventions. And I guess it would be about finding a balance as you say, between, you know, um, enabling them to have, have meaningful friendships with other people, but also, you know, allowing them to be themselves and to not, um, you know, not, not kind of burden themselves with, with always feeling like they have to be... be someone else.

Sue: 22:39

Yeah. Yeah. We need some, we need some social skills training for the friends, right?[laughs] For the neurotypical friends!"How to make friends with your autistic buddy","how to be a better friend".

Lucy: 22:53

Yeah...

Sue: 22:55

So, uh, before we finish, I just wanted to ask, so I believe you are now a lecturer at Cardiff University and I guess that's a relatively new posts if I'm, if I've followed your career correctly.

Lucy: 23:09

Yeah!

Sue: 23:09

So, um, so, so sort of of fresh, fresh from your PhD and post-docs and into this, you know, into the, the Holy grail of the kind of academic posts, I wondered if you had some, you know, um, excellent and up-to-date advice for, you know, maybe PhD students or post-docs who are listening and, um, feeling, you know, little daunted by the, uh, the kind of context in which we find ourselves at the moment.

Lucy: 23:41

Yeah...

Sue: 23:41

What's your... What would you... What would you pass on to those people who might be listening?

Lucy: 23:46

Sure, well, other than a massive dose of luck? I think one of the things that, um, uh, I think made it easier for me to make the transition from out of my PhD, um, into an academic post, um, was, um, was actually the type of, um, PhD, um, supervisor I had. Um, so I was supervised by Frankie Happé, who really just allowed me to completely follow my own interests, um, completely change ideas that I wasn't interested in, um, and really, you know, took serious my, my own, um, ideas. Um, and so I think that, um, working with people, you know, be that your supervisor or, or collaborators who really will, um, you know, not necessarily dictate to you what you need to do, but allow you to flourish with your own ideas. Um, I think really makes such a difference. Um, and something that someone once told me many years ago, which I didn't take seriously, was that when you go for a PhD interview, you should interview your supervisor. Um, you know, you should decide if, you know, if you think that person is the right person to help you in your career. And I always thought that was a completely ridiculous thing to say, because I thought I'm just going to take whatever PhD I can get, but I think it's really important to, to find the right supervisors and mentors who, um, allow you to follow your own interest and, um, yeah. And develop, develop new skills that you want to learn as well.

Sue: 25:26

Um, that is a lovely thing to end on. And I would just echo your comments because I've worked with Frankie as well, and she is a particularly exceptional person.[laughs] So, um, yeah, absolutely. But it's great! And I mean of course y our, your, you'll learn, your, you'll have learned your supervision trade from her, so that's another fantastic supervisor out in the world now!

Lucy: 25:51

[laughs] Thank you!

Sue: 25:54

Well, we should probably draw to a close. Thank you so much for your time there, Lucy. It's really fascinating talking about this work. I find it super interesting and important. For anyone who is listening, you'll be able to find out more about Lucy's work and about... a link to the specific paper that we've been talking about by following the links on the podcast page, which is at ed.ac.uk/salvesen-research. Thank you so much, Lucy!

Lucy: 26:21

Thanks!

Sue: 26:25

Bye!

Lucy: 26:25

Bye!

Sue: 26:29

[ringtone] Okay we did it! I thought that went quite smoothly![podcast jingle]