Social visual orienting in typical and atypical development.

L'Infant research ha ampiamente dimostrato l’importanza e gli effetti che le interazioni precoci hanno sullo sviluppo mentale del bambino (Stern, 1985; Tronick Tronick, 1989; Emde, 1985; Greenspan, 1997). Nell’ambito dello sviluppo atipico (SA) diversi studi mettono in luce la presenza di alterazioni precoci della sfera interattiva genitore bambino che hanno una ricaduta negativa sullo sviluppo mentale del bambino, già in parte compromesso dai deficit neurobiologici (Dawson, Hill, Spencer, Galpert, & Waston, 1990; Doussard-Rossevelt, Bazhenova, & Porges, 2003; Hodapp, 2002; Kasari, Sigman, Mundy & Yirimiya, 1988; Venuti, Esposito, 2008; Venuti, de Falco, Esposito, Bentenuto, Villotti & Bornstein, 2008; de Falco, Cimmino, La Femina & Venuti, 2008). Scopo generale dello studio è la verifica degli effetti di un intervento genitore bambino con SA il cui obiettivo è la promozione di una modalità interattiva maggiormente sincronica e responsiva. In particolare si intende indagare gli effetti del trattamento su tre aree specifiche: l’interazione genitore bambino, le rappresentazioni del genitore e lo sviluppo del bambino. Lo studio è stato condotto su quattro diadi genitore bambino con SA, con età compresa tra i 30 e i 54 mesi. Due bambini hanno una diagnosi di Disturbo Pervasivo dello Sviluppo (PDD) e uno di Ritardo Mentale (RM). La ricerca è stata effettuata mediante il disegno sperimentale su singolo soggetto senza gruppo di controllo. Per valutare degli effetti del cambiamento nelle tre aree indagate sono state applicate diverse misure pre e post trattamento e misure osservative ripetute nel tempo. Per tutte le misure ripetute sono state calcolati i livelli di attendibilità sul 33% delle osservazioni attraverso il test k di Cohen. L’analisi degli andamenti delle sedute mettono in evidenza la presenza di incrementi percentuali significativi in diverse aree indagate. In particolare, si è rilevato l’aumento del livello di disponibilità emotiva e di sincronia della diade; un aumento delle attribuzioni positive rispetto al proprio figlio e alle capacità genitoriali; infine, rispetto allo sviluppo del bambino si è registrato un aumento del livello di autoregolazione e di intenzionalità sebbene in misura diversa nei tre soggetti.

This thesis is composed of two individual but interconnected studies. The first study investigated the gestural ability of aphasic patients in comparison with healthy speakers, by analysing both qualitatively and quantitatively co-speech gestures during a story-retelling task. The objective was to understand the relation between language and gesture ability in the aphasic patient: whether impairments in language production influence gesture production, as suggested by the long existing notion “asymbolia†. If this is not the case, gesture then may play a very potential role in aphasic daily communication and rehabilitation, as suggested by researchers and clinicians (e.g., Marshall, 2006; Rodriguez et al., 2006) who proposed the use of gesture as a compensatory and facilitative means to assist aphasic individuals to communicate. In our first study, four aphasic patients and four age-matched healthy speakers were recruited. They were requested to retell stories after watching eight short films from the cartoon “Tweety and Silvester†. Both verbal and non-verbal production from the participant were video-taped for analyses. Group and individual analyses were performed to examine representational and non-representational gestures in per-100-word and per-minute measures. We found that in aphasic subjects, as a group, gestures were quantitatively indistinguishable from those produced by normal controls. Also, qualitative analyses demonstrated that the aphasic subjects tended to use representational gestures to cue or substitute for difficult-to-name words. This supports the notion that gesture may cue naming and may be a potential treatment approach in aphasia rehabilitation. The second study explored treatment efficacy of three approaches in aphasia rehabilitation – the Gesture-based, the Language-based, and the Combined approach, aiming to understand the effects elicited by these techniques in improving single word naming ability in aphasic patients. Previous research suggested that gesture training can facilitate word naming (see Rose, 2006 for review). Language-based treatment aiming to reconstruct concepts and restore phonological information on difficult-to-name words has been widely studied, but the therapeutic role played by gesture in language recovery has been rarely considered. Our second study recruited four chronic aphasic patients with word-finding difficulty to explore the effects of three types of treatment – Gesture-based, Language-based, and Combined, on the retrieval of nouns and verbs. It was hypothesized that gesture and language-based treatments alone would yield positive effects and that combined treatment would result in the largest improvement of single-word naming. In gesture-based treatment, patients were trained to produce a gesture that can be mapped onto a corresponding word. In language-based treatment, Semantic Feature Analysis and Phonological Component Analysis were used. The combined treatment includes the same materials used in the gesture-based and language-based treatments, but materials were alternated across sessions. Training materials included verbs of hand-related actions and nouns of manipulable objects. We found that all types of treatment, as hypothesized, led to significant item-specific improvement in both verb and noun naming. Three of four subjects showed the largest recovery following combined treatment, especially on verbs. This suggests that gesture, when combined with logopedic treatment, can boost naming skills.

Numerosi studi considerano il sottotrattamento del dolore pediatrico uno dei problemi più critici associati alla cura e degenza ospedaliera (Schechter et al., 2002). La soluzione risiede in una valutazione accurata e sistematica dello stato di algesia del paziente (Reaney, 2007); tuttavia, vi è una notevole reticenza all’impiego costante e regolare di scale di valutazione del dolore nei reparti pediatrici (Zernikow et al., 2005). Questa tesi si propone due obiettivi: innanzitutto, osservare l’atteggiamento degli operatori sanitari circa l’impiego di scale di valutazione del dolore nelle Unità Operative pediatriche di due Ospedali del Trentino. In particolare, si vuole stabilire se a livello locale sussistono le medesime condizioni evidenziate dalla letteratura internazionale sull’argomento; quindi, indagare le cause del problema, e verificare l’effetto che una semplice restituzione con feedback costruttivo ha sulle modalità di valutazione del dolore pediatrico nelle U.U.O.O. così trattate.

In the last decade, neurobiological studies have focused efforts on investigating the biological substrates (i.e., cerebral structures, neurotransmitters, and hormones) underlying parental attuned behavior to salient infant stimuli (i.e., infant cries), that plays an important role in child affective, social, and cognitive development (Venuti, 2007; Bornstein, 2002). Both human and animal studies have primarily focused on the neurobiology of mothers and have shown that subcortical and cortical cerebral structures such as the prefrontal cortex, thalamocingulate network, hypothalamus, amygdala, and substantia nigra are important in maternal motivation and attuned behaviors (Barrett & Fleming, 2010; Swain, Lorberbaum, Kose, & Strathearn,2007). However, there is a lack of literature concerning gender differences and only a few studies have investigated the sensitivity of response to infant stimuli in non-parent adults (Caria, de Falco, Venuti, Lee, Esposito, Rigo, Birbaumer & Bornstein, 2012; Glocker, Langleben, Ruparel, Loughead, Gur & Sachser, 2009; Parsons, Young, Kumari, Stein & Kringelbach, 2011; Montoya, Landi, Kober, Worhunsky, Rutherford, Mencl, Mayes & Potenza, 2012). In this research project we focused our investigations on mechanisms in human adults (parents and non-parents) involved in parental care, and in specific: (a) on neural mechanisms underlie BOLD response to infant vocalizations, crying in particular; (b) on brain changes (grey matter volume) occurring during the early postpartum period in new fathers. Using functional magnetic resonance imaging (fMRI), in the first study (second chapter) we looked at gender differences in resting-state brain activation associated with the cry condition at the default mode network (DMN) level in a sample of healthy adults (parents and nonparents). The design was balanced by parental status and gender. The DMN is preferentially activated when individuals are not involved in externally oriented tasks, namely during the mind wandering and it is deactivated during external goal-oriented activities. In the second longitudinal study (third chapter) we investigated in new fathers the GM volumes change amongst 2-4 weeks and 3-4 months postpartum in brain areas responsible for parental behaviors over time during the early postpartum period. Anatomical changes and their relationships with parenting behaviors have never been examined in human fathers despite the importance of paternal care for child development. In the third study (fourth chapter) we investigated, using fMRI and behavioral (Response Time RT) techniques, how the pattern of cerebral activation when listening to infant cry modulates concomitant behavioral tasks, which could require or not require the attention toward the cry stimuli, and thus affecting parental responsiveness.

One of the main aims of awake surgery for glioma patients is to preserve quality of life, while maximizing tumor resection. Focusing on an important yet understudied aspect of quality of life, this thesis investigates to what extent written language may be affected by a glioma or glioma surgery. By reviewing current assessments of reading and spelling in awake surgery studies, we aimed to provide a better understanding of how neuroanatomical theories may guide neurosurgical practice, and to evaluate how examinations of written language in glioma patients can be improved. To provide a direct clinical application for this knowledge, we developed a theory-driven written language battery specifically for glioma patients. Lastly, we tested its efficacy and evaluated reading and spelling performance in neurosurgical practice. The studies in this thesis have provided a better understanding of written language in neurosurgical practice. In particular, it has contributed to prediction and prevention of written language disorders in glioma patients undergoing awake surgery, and it has resulted in a valid examination tool to carefully monitor reading and spelling in this patient group.

This doctoral thesis outlines the review and experimental studies conducted during my Ph.D. that aimed to clarify the neurocognitive processes underlying socioemotional behavior in neurotypical and Autism Spectrum Disorders (ASD) individuals, a clinical population with impairments in the socioemotional core. The thesis is divided into four chapters. Chapter 1 is concerning the involvement of the hypothalamus in socioemotional behavior. Indeed, despite the large number of studies on the relationship between hypothalamic neuropeptides and social behavior in ASD, only a few studies investigated the association between the hypothalamus and socioemotional response in ASD. Results from this review highlighted anatomical hypothalamic atrophy and functional hypothalamic hypoactivation during face processing and social interaction tasks. The above results from the review highlighted the need to have an appropriate paradigm to investigate hypothalamic involvement in socioemotional behavior. For this reason, in Chapter 2, I performed a systematic review of the neuroimaging studies that used a classical conditioning paradigm to study socioemotional behavior. Results raised the presence of a gap in the literature: indeed, it has been shown that (1) no study used a purely social unconditioned stimulus; (2) the literature mainly focused on conditioning to aversive stimuli, whereas no study focused on conditioning to positive stimuli. Building on this evidence, an EEG study, described in Chapter 3, aimed to investigate whether classical conditioning also underlies the acquisition of socioemotional preference using a novel conditioning paradigm employing more ecological positive and neutral social stimuli. Results show that even with a short period of classical conditioning an increase in valence and attractiveness of positive conditioned stimuli, which was previously neutral may be performed. Then, explorative analysis of the event-related potentials (i.e., the Late Positive Potential, LPP) highlights differences about the LPP elicited by the positive conditioned stimuli concerning neutral conditioned stimuli. Finally, as a side project, Chapter 4 illustrates an investigation that aimed to explore differences in sleep between ASD and neurotypical populations and describe their relationship with the impaired socioemotional characteristics.

My PhD project mainly focused on understanding how a child or adolescent copes with pain associated with a disease, intended in a broader sense (i.e. procedures, treatments and disease-related). I tried to prove an innovative perspective that can help understand the wide variation in children’s pain experience, by considering intra-interpersonal influences, contextual factors, and intrapsychic factors that focus on needs, defenses, and self-structure. Overall, the whole project involved three pediatric units in Italy: the pediatric wards of Trento and Rovereto hospitals and the pediatric clinic of San Gerardo hospital, Monza (Milan). This doctoral thesis has achieved five goals: 1. Providing a selective overview on current relevant topics in the pediatric pain research and state of the art regarding the existing models of pediatric pain. 2. Developing a multi-dimensional protocol with an intra-method design for the assessment of pediatric pain in several chronic illnesses (cystic fibrosis, rheumatic diseases, cancer), by using also a battery of projective tests (drawings) to screen the emotional adjustment. 3. Validating the protocol by extending the methodology of projective drawings’ scoring with a control group and adding other assessment variables on a single cohort of patients (with malignant hematologic cancer) to test the new model that I developed. Quantitative analysis phase preceded qualitative analysis phase within the same framework to yield a parallel mixed analysis. 4. Planning specific training modules about pain management, starting from a bottom-up process concerning the local health professionals’ needs. I investigated these training needs through a series of open-ended questions, analyzed by a thematic analysis method. 5. Evaluate treatment’s feasibility, acceptability, and satisfaction of a problem-solving skills training for parents of children who have received an intensive pain rehabilitation from one pediatric pain rehabilitation program (Seattle Children's Hospital). I provided a methodological contribute within the mixed-method approach (statistical analysis and grounded theory). The results presented and their implications, are discussed in a clinical perspective since the rationale of this dissertation is that effective pain assessment must be multidimensional, multidisciplinary and at the same time feasible and practical to meet each pediatric patient’s needs.

Despite a large body of research has investigated child attachment during middle childhood, only a limited number of studies has focused on children with Autism Spectrum Disorder. Additionally. The few studies available on this topic have exclusively used self-reported measures to assess quality of attachment, overlooking the role of internal representations, which are considered to play a fundamental role since attachment is internalized. Therefore, no studies examined the way in which child attachment representations are associated with child diagnosis, parenting and caregiving environment in ASD. In the first study, we assessed attachment representations in children with ASD, Learning Disabilities (LD) and Typical development (TD). In particular, we investigated possible group differences on perceived attachment to parents, self-protective strategies and quality of attachment implicit representations using the Dynamic Maturational Model of Attachment and Adaptation (DMM). The Study 2 focused on the caregiving environment and its influence on child attachment implicit representations. To this aim, we assessed parenting stress and parental style in mothers and fathers of children with ASD and TD, examining whether parents of children with ASD differ from those of matched TD group. Secondly, we examined which caregiving environment dimensions contribute significantly in predicting at-risk attachment representations, assessing separately the contribution of maternal and paternal parenting stress and parental interactive social style. In the third study maternal and paternal attachment style were assessed to test the hypothesis of attachment continuity across generations. Firstly, we investigated whether parents of children of ASD reported higher level of attachment-related avoidance/anxiety compared to their TD counterpart. Next, the associations between attachment style of both mothers and fathers and quality of child attachment representations was tested, by examining the moderation effect of child ASD diagnosis. The Study 4 investigated the role of other potential child attachment predictors. Due higher co-occurrence of ASD and difficulties in identifying, describing and distinguishing one’s own feelings, the predictive effect of alexithymia on child explicit attachment representations was tested. Moreover, we also examined whether children with ASD reported higher level of alexithymia compared to controls. The Study 1 showed that children with ASD are able to develop secure and coherent attachment implicit representations, albeit with a lesser extent compared to typically developing children. They were able to engage the attachment interview, confirming the suitability of this method in this clinical sample. Importantly, children with ASD showed high-risk attachment implicit representations and greater presence of unresolved trauma and modifiers, despite no differences emerged on perceived attachment to parents. The lack of group difference on perceived attachment suggested that implicit and explicit attachment representations of children with ASD originate from different sources of information. It is plausible that low reflective functioning, impaired metacognition as well as altered psychobiological processes of children with ASD contributed to attachment maladaptive information processing. Secondly, we replicated the well-established finding of higher parenting distress in parents of children with ASD compared to controls also in fathers. Moreover, the Study 2 documented less didactic and limit/setting style in parents of children with ASD. In accordance to a bidirectional perspective, these parenting behaviors were interpreted as parental functional responses to adapt to child unusual social-communication. Interestingly, data revealed a significant effect of maternal parenting stress and social exchange style on child attachment implicit representations. Thus, the study supports the coexistence of both child-driven and parent-driven effects in the context of parent-child relationship in ASD. Similarly, the Study 3 documented that children with ASD who have an insecurely attached primary caregiver showed at-risk attachment implicit representations. In other words, the continuity of attachment security across generations revealed a clear effect in ASD, suggesting that these children may be more susceptible to this mechanism compared to controls. In addition, parents of children with ASD reported higher attachment-related avoidance in comparison to their TD counterpart. This difference could be associated to the significant couple adjustment associated to the impact of rear a child with ASD. In addition, the Study 4 showed that alexithymia, but not ASD predicts perceived attachment to parents highlighting the different nature of attachment explicit and implicit representation. Moreover, our results confirmed higher co-occurrence of alexithymia and ASD also in school-age, extending literature on adulthood. Our findings pointed out that children with ASD (without intellectual disability) showed higher rates of at-risk self-protective strategies (attachment pattern). These results may be related to several factors associated with ASD symptoms, such as the more frequent disruptions of interpersonal exchanges with the caregiver across development, the difficulties in social information processing and reflective functioning. The higher exposure to adverse childhood experience (e.g. bullying), may explained the higher occurrence of unresolved trauma in these children. Up to date, to the best of our knowledge, these are the first studies on group differences and parental predictors of attachment implicit representations in school-age children with ASD. Therefore, these studies brought initial data to ASD literature on attachment representations, suggesting that these children are at increased risk of developing maladaptive information processing. Limitations of the studies and clinical implications are discussed.

Autism Spectrum Disorder (ASD) is a condition that carries high costs for families and the healthcare system, requiring extensive management both in terms of diagnosis and treatment. The implementation of AI-based systems in clinical practice represents a possible supportive solution that can help clinicians by providing more systematic meth- ods to monitor child behavior. The main advantage over more traditional observational approaches is to offer quantitative and refined analysis solutions that can be ecological at the same time. The relevance of AI in clinical applications can have a role both in the challenge of early detection and in designing intervention programs better tai- lored to the specific functioning of children with ASD. The research project presented in this dissertation focused on developing AI-based systems for fine-grained analysis of autism-related social behaviors and their validation in concrete clinical environments. Specifically, in Chapter 2, our first study is presented, which targets on implementing a computational phenotyping system to address the need for new early markers of the condition. Through fine-grained analytics of facial dynamics in videos, we identified a set of features that distinguished young (6-12 months) infants with ASD (18 ASD, 15 non-ASD) during unconstrained at-home interactions. In Chapters 3 and 4, we introduce EYE-C, a Behavior Imaging model for robust analysis of eye contact episodes in eco- logical therapist-child interactions. The system was validated in the clinical setting for personalized early intervention. First, we investigated the influence of extracted features in categorizing spectrum heterogeneity across a sample of 62 preschool (<6 years) chil- dren with ASD. Further, we tested our metrics as predictors of early intensive treatment outcomes in a sub-sample of 18 subjects with ASD. The project aims to demonstrate the feasibility of effective computational systems that are robust to the high variability of unstructured interactions, with emphasis on the applicative value in real-world scenar- ios. Even though based on limited sample sizes, the work presented may offer interesting insights into the perspective of integrating AI into clinical practice. The research project was funded by an FBK scholarship and developed in a double in- ternship at ODFLab (University of Trento) and the FBK Data Science for Health (DSH) research unit.