Autism Spectrum Disorder (ASD) is characterized by difficulties in social communication and restricted, repetitive patterns of behavior and interests (American Psychiatric Association, 2013). These key characteristics of autism each create a number of difficulties for individuals with autism and also their parents. It is well established that parenting a child with ASD is stressful, impacting on mental health and overall quality of life (Baker-Ericzn, Brookman-Frazee, & Stahmer, 2005; Davis & Carter, 2008; Eisenhower, Baker, & Blacher, 2005; McStay, Dissanayake, Scheeren, Koot, & Begeer, 2013). However, there are some doubts or gaps in the literature of parenting children with ASD which we addressed in this thesis. Two main goals of this thesis were: a) examining well-being of parents of children with ASD, b) focusing on the parents’ responses to cries of infants with ASD and typical development, considering two types of responses: emotional and physiological. Therefore, this thesis is composed of two parts. The first part in which we aimed to examine well-being of parents of children with ASD has been divided into two sections. The first one dealt with similarities and differences between mothers and fathers in terms of parenting stress, parental mental health and attitude (Chapter 2). Results indicated that mothers of children with ASD reported higher level of depression than fathers and considerable percentages of both mothers and fathers had scores above the clinical cut-points of stress showing that they experience clinically significant levels of parenting stress. Moreover, in terms of parental attitude, mothers engaged with their children in more social exchange than fathers do. 8 The final chapter in Part 1 (Chapter 3) evaluated whether maternal well-being and sense of competence are affected by the outcomes of children receiving intervention. The results suggested that child and family factors, including mothers’ age, were linked to maternal well-being. However treatment-related changes in children’s communication, and parenting satisfaction contributed to well-being above and beyond other factors. A mediation analysis indicated that mothers whose children make treatment gains in communication skills experience a reduction in their level of negative well-being as a consequence of increased parental sense of competence with regards to parenting satisfaction. The second part of the thesis aimed to evaluate emotional and physiological responses of parents of children with ASD during infant crying. This part begins by laying out the theoretical dimensions of the research, and then proceeds as follows: a) the first experiment was concerned with the preparation and validation the cry episodes as unpleasant acoustic stimuli (Chapter 4); b) the second one examined emotional and physiological responses of non-parents adults while listening of infant crying (Chapter 5); c) the last experiment focused on parents of children with ASD and parents of typically developing children, examining their emotional and physiological responses during the listening of crying of children with ASD and of typically developing (TD) children (Chapter 6). Findings from Chapter 4 indicated that all cry episodes, regardless of the types (e.g., cries of children with ASD or cries of typically developing children) were perceived as unpleasant by non-parents adults. The following study in Chapter 5 showed that cries of children with ASD (ASD cry) were reported more stressed, aroused and less pleasant compare to cries of typically developing children (TD cry) by non-parents adults; however, similar pattern was not seen in the physiological responses of listeners. Results 9 from the final experiment (Chapter 6) showed that parents of children with ASD and parents of TD children were not differentiated in their self-reports of stress, arousal and valence levels for ASD cry and TD cry. However, their physiological responses showed that parents of children with ASD have higher heart rate than parents of TD children during ASD cry and TD cry. Moreover, the analysis on the comparisons between ASD cry and TD cry suggested both parents perceived ASD cry more stressful, aroused and less pleasant, but physiological responses of parents of children with ASD did not show the differences between ASD cry and TD cry. The overall structure of the thesis takes the form of seven chapters, including a general introduction (Chapter 1). The importance of those findings for future theoretical and clinical work is considered in detail in the end of related chapters and in the general discussion chapter (Chapter 7).

In the last two decades several studies have been trying to explore a possible role for gut microbiota in Autism Spectrum Disorders (ASD), supported by the high incidence of gastrointestinal disorders among ASD children and by the now well recognized existence of the brain-gut-microbiota axis (the complex system of bidirectional interactions between central nervous system, gastrointestinal tract and microorganisms inhabiting the gut). Nevertheless, results about alterations in gut microbiota composition and/or activity in ASD are to date strongly contrasting. A possible explanation could be that these studies tend to treat ASD as a unique pathology, whereas it includes different cognitive-behavioural phenotypes. Moreover, they do not consider factors which are important for children’s gut flora development, such as type of delivery, nutritional history (e.g. formula milk during lactation) and medical history (e.g. antibiotics intake) as well as factors that may affect the present composition of microbiota, such as the current diet (e.g. the strong food selectivity that often occurs in ASD children) and the presence of gastrointestinal disorders. In this study, I developed an interview to parents to assess whether there are differences related to the above mentioned aspects between ASD children and typically developing children and among ASD themselves, considering differences in cognitive level and severity of autistic traits. I also explored the use of special diets such as gluten-, lactose and casein free diets, the reasons for their adoption and the possible benefits for the child. Moreover, I decided to include in this interview also a section dedicated to parental difficulties in managing mealtime in order to collect information useful to plan future interventions. I found differences between ASD- and typical children in the incidence of gastrointestinal disorders and food selectivity. Especially, some children initially eat everything and then switch to a more and more restricted diet. This could be considered an early symptom of the pathology. I also found an association between gastrointestinal disorders and severity of autistic traits. Furthermore, I collected faecal samples from ASD families (two parents, an ASD child and a typically developing sibling) and analysed them with metaproteomics and bioinformatics techniques in order to assess microbiota activity and evaluate it in light of ASD phenotype, nutritional habits, gastrointestinal disorders and genetic proximity. Demonstrating the existence of a different microbiota composition in ASD or at least in a subgroup could allow to identify a biomarker of a possible development of ASD and to design preventive interventions, even through probiotics intake. Moreover, it could help to better understand the molecular mechanism underlying this pathology.

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.

Mother child relationship is the first and the most important social relationship as it has implications on psychological and neural development of the individual. Here we investigated mother child relationship focusing on different aspects and using a combination of behavioural and neuroimaging techniques. In the first study we addressed the association between brain connectivity and interpersonal competences which are at the basis of every social interaction including the ones involved in mother-child relationship. Several studies suggests that higher White Matter (WM) integrity - an index of increased brain connectivity - , is associated with better cognition and behavioural performance. To test the hypothesis that higher WM integrity is associated with higher interpersonal competence we used Diffusion Tensor Imaging (DTI), a neuroimaging technique which allows to study in vivo the anatomy of boundless of axons conveying information in the brain. Then we correlated this information with a self-reported measure of interpersonal competences: the Adolescent Interpersonal Competence Questionnaire (AICQ). Results indicate that Interpersonal competence is associate with higher WM integrity in several major tracts of the right hemisphere, in specific the uncinate fasciculus, the cingulum, the forceps minor, the infero-fronto occipital fasciculus, the inferior longitudinal fasciculus, and the superior longitudinal fasciculus. These results provide the first direct analysis of the neuroanatomical basis of interpersonal competencies and young adult self-reported skills in social contexts. In the second work we used the same paradigm to test one of the main assumption of the attachment theory which states that social skills highly depends on the quality of attachment relationship. Results show higher integrity in four white matter association fibers in the left hemisphere: Uncinate Fasciculus, Cingulum, Superior Longitudinal Fasciculus and Inferior Fronto Occipital Fasciculus. This result supports the idea that the quality of the attachment relationship influences the emotional and social life of the individual from childhood to adulthood. Furthermore, the research represents an explorative approach to the study of mother-child relationship in healthy population, demonstrating the feasibility of using neuroimaging tools coupled with clinical investigations. Together those studies show that efficient structural connectivity is linked with secure attachment, improved social cognition and cognitive ability. Similarities and differences emerged in these studies will be discussed at the end of Chapter 3 in particular regarding left and right hemisphere specialization. In the second part of the thesis we switched the focus on parenting behaviour. Evidence from the literature suggest an association between Axonal Integrity measured with FA and functional connectivity measured with TMS in two region involved in preparing ad executing actions: premotor and motor cortex. Moreover neuroimaging reveals that infant cries activate parts of the premotor cortical system. In line with this evidence we linked parenting and brain functional connectivity conducting a study on motor cortex excitability in response of infant cries. We used event-related transcranial magnetic stimulation (TMS) to investigated the presence and the time course of modulation of motor cortex excitability in young adults who listened to infant cries. TMS was delivered from 0 to 250 ms from sound onset in six steps of 50 ms in 10 females and 10 males. Motor Evoked Potentials (MEPs) were recorded from the biceps brachii (BB) and interosseus dorsalis primus (ID1) muscles. Results indicate an excitatory modulation of MEPs at 100 ms from the onset of the infant cry specific to females and to the ID1 muscle. This modulation is considered as automatic response to natural cry as it was not present in response of control sounds and the effect is found at 100-ms latency which make this modulation not compatible with a voluntary reaction to the stimulus but suggests an automatic, bottom-up audiomotor association. These results indicate that the brains of adult females appear to be tuned to respond to infant cries with automatic motor excitation. This effect may reflect the greater and longstanding burden on females in caregiving infants. The second part of the thesis continue with a study addressing the natural condition in which baby cries arise when the parent is not attending for infant stimulation. In this study we investigated how infant crying, compared to control sounds, captures adults’ attentive resources. Participants were all nulliparous women and men, we investigated the effects of different sounds on cerebral activation of the default mode network (DMN) while listeners engaged in two different kind of tasks: one designed to activate the DMN ( self-referential decision task) and one designed to deactivate the DMN (syllabic counting tasks). We found a strong deactivation of DMN in woman during baby cry which suggest a shift of attention from self-referential thinking toward the baby cry stimuli. In men we found instead a weaker deactivation of DMN during woman cry while their attention was directed toward an external task and simultaneously a sudden woman crying arise. Gender differences found in our studies and in the literature will be discussed. In the third part of the thesis we investigated the ability to discriminate synchrony and asynchrony during interaction between mother and child with typical or atypical development. We tested two kind of population: in the first study we compared parents of children with Autism Spectrum Disorder (ASD) to parents of children with Typical Development (TD). In the second study we used the Autistic Quotient questionnaire to divide the sample in two groups according with their autistic traits. The relevance of this task is due to the extreme importance to promptly individuate cues of abnormal social behavior in those cases in which the child might shows deficit in the social development. We hypothesized that individual related with a child with ASD or an individual with high autistic traits, might show similar social difficulties as the individual with ASD finding more challenging to detect cue of appropriate or unappropriated social behavior. To test this hypothesis we asked parents of children with ASD and parents of children with TD to judge video of interactions between mothers and child with ASD and mothers and child with TD. Each video were 20s long and depicted either a synchrony or asynchrony interaction, as categorized by an expert clinician. Contrary to our initial hypothesis results indicate that parents of children with ASD are as accurate as parents of children with TD in discriminating synchrony and asynchrony interaction with ASD, however they are less accurate than parents of children with TD in judging interaction with TD. In the second study by testing individual with higher autistic traits (HAQ group) versus lower autistic traits (LAQ group) we confirmed this trend. Using the same paradigm we found that both groups were less accurate during asynchrony interaction. However HAQ was more accurate in judging synchrony interaction with ASD while LAQ was more accurate in judging synchrony interaction with TD. This result indicate a facilitation effects in understanding interaction which include people that share similar characteristic with the observer disconfirming the hypothesis that people with higher autistic traits would have more difficulties in understanding social interactions and pointing the attention on other factors which might contribute during this process. A discussion on the need of further investigation using neuroimaging techniques to understand similarities and differences on neural processing of social interactions is provided at the end of Chapter 4.

La capacità di esprimere adeguatamente le emozioni attraverso l’uso di strategie adattive di regolazione delle emozioni è cruciale per il sano sviluppo dei bambini. Secondo la teoria dell'attaccamento di Bowlby, la reattività e la regolazione emotiva dei bambini sono correlate ai loro stili di attaccamento. Il presente studio mira ad indagare se l'interazione tra la classificazione di attaccamento e l’espressione emotiva può predire i cambiamenti nella reattività fisiologica dei bambini durante un compito stressante. In un primo momento (T1), le rappresentazioni di attaccamento di N = 59 bambini in età scolare sono state misurate utilizzando la Child Attachment Interview. In un secondo momento (T2), i bambini hanno sostenuto un’impegnativa procedura di laboratorio standardizzata in cui dovevano cercare di risolvere una serie di puzzles risolvibili e irrisolvibili. I livelli di conduttanza cutanea (SCL), l'aritmia sinusale respiratoria (RSA) ed i livelli di cortisolo sono stati registrati come indici fisiologici durante l’intero compito. Le espressioni emotive facciali dei bambini (tristezza e vergogna) sono state codificate durante il quarto puzzle irrisolvibile. I risultati hanno evidenziato che l'espressione dell'emozione modera la relazione tra l'attaccamento evitante e le risposte fisiologiche: in alcuni compiti sono stati mostrati una RSA più bassa e dei SCL più alti; inoltre, l'interazione tra attaccamento ed espressione emotiva di ritiro era associata ad un aumento quasi significativo dei livelli di cortisolo durante l’intera esecuzione dei puzzles. I risultati rivelano che la presenza di attaccamento evitante modulata dall'espressione emotiva di ritiro induce uno stress fisiologico più elevato nei bambini. Comprendere i fattori che influenzano la reattività allo stress nei bambini è essenziale nello sviluppo di interventi che promuovano un adattamento funzionale in risposta al disagio.

Clinical and research practice in the context of Autism rapidly evolved in the last decades. Finer diagnostic procedures, evidence-based models of intervention and higher social inclusivity significantly improved the possibility for autistic children to participate in the fabric of social life. In terms of health best practices, gold-standard procedures still need to be improved, and bridging research and clinical practice still presents several challenges. From the clinical standpoint, the role of process variables, predictors, mechanisms, and timing of change still requires extensive investigation in order to explain response variability and design optimized interventions, tailored to individual needs and maximally effective. Observational techniques represent the elective research methods in child development, especially in clinical contexts, due to their non-invasiveness. However, they still suffer from limited objectivity and poor quantification. Further, their main disadvantage is that they are highly time-consuming and labor-intensive. The aim of this thesis was moving forward to promote translational research in clinical practice of Autism intervention with preschool children. At first, we tried to design and apply quantitative observational techniques to longitudinally study treatment response trajectories during developmental intervention. We tried to characterize different response profiles, and which baseline predictors were able to predict the response over time. Secondly, we investigated mechanisms of change. In particular, we focused on the role of the child-therapist interaction dynamics as a possible active mediator of the process of intervention, especially in the developmental framework that stresses the importance of interpersonal aspects. We also aimed at understanding whether certain time-windows during the intervention were particularly predictive of the response, as well as which specific interaction aspects played a role. Finally, to promote the translational application of observational methods and to improve objective quantification, we proposed and validated an Artificial Intelligence (AI) system to automate data annotation in unconstrained clinical contexts, remaining completely non-invasive and dealing with the specific noisy data that characterize them, for the analysis of the child-therapist acoustic interaction. This effort represents a base building block enabling to employ downstream computational techniques greatly reducing the need for human annotation that usually prevents the application of observational research to large amounts of data . We discuss our findings stressing the importance of assuming a developmental framework in Autism, the key role of the interpersonal experience also in the clinical context, the importance of focusing on trajectories of change and the important need to promote the acquisition of large amounts of quantitative data from the clinical contexts exploiting AI-based systems to assist clinicians, improving objectivity, enabling treatment monitoring, and producing precious data-driven knowledge on treatment efficacy.