Through the kinaesthetic lens: observation of social attunement during movement interactions with young participants with autism

‘...a potential cannot be given or rehearsed – a potential has to be ...found...’

(Wayne Shorter, 2013, ARTE interview [1])

Rosemarie Samaritter, 1,2,* and Helen Payne 3

1 Codarts, University of the Arts, Arts Therapies Department, NL2 Zuyd University of Applied Sciences, Arts Therapies Department, NL; e-

mail@e-mail.com3 School of Psychology, University of Hertfordshire, UK* Correspondence: rasamaritter@codarts.nl; Tel.: +xx-xxx-xxx-xxxx

Abstract:

Introduction:

Autism spectrum disorder (ASD) is a psycho-diagnostic category that describes atypical developmental features with a broad range of appearances. The diagnosis has been in use since Kanner introduced it in 1943 [2]. It is generally assumed that interactions of hereditary, neurobiological, developmental and environmental characteristics and structures play a role in the development of autism. However, a psychiatric perspective has dominated the discussion on possible causes and treatments. The classification of the Diagnostic Statistical Manual (DSM) of the American Association of Psychiatrists [3] differentiated subtypes like Asperger syndrome for high functioning individuals, pervasive developmental disorder, childhood disintegrative disorder and Rett’s syndrome. When in 2013 the DSM-5 [4] was published, the subtypes were substituted with one global diagnosis, ASD. In the diversity of individual appearances of ASD three core markers have been identified to be present over the spectrum, these are i) a diminished ability to communicate, ii) a reduced social functioning, and iii) a preference for stereotype routines [3,5]. In clinical practice, descriptive diagnoses are used to portray the specific personal traits of the condition for individual persons.

Therapeutic approaches for autism have strongly focused on the atypical development of social interactions. The development of social cognition has been considered crucial to understand another person’s mind and to participate in meaningful interpersonal interactions such as joint attention, turn taking or shared decision making [6]. Interventions in social cognition in ASD aim to support the development of interactional patterns that parallel

neuro-typical ways of social interaction [7]. Self-advocates on the contrary promote a perspective in which the behaviors of individuals with ASD are considered for their own specific quality of interactional intention, though these patterns may differ from neuro-typical interactional patterns. The challenge then would be for the neuro-typical interaction partner to learn to recognize the specific interaction patterns of the partner with autism. Recent approaches into social cognition and sense-making discuss the importance of experiential knowledge that stems from participating in intersubjective interactions [8]. This enactive perspective on social cognition has also been discussed for the development of social cognition in individuals with ASD [9] interacting.

Social attunement is a complex phenomenon that consists of a basic attention towards an interaction partner and an intentional engagement with the other, like for example during joint attention or joint actions [10]. Hence, it is the situatedness within the interaction that determines whether a movement action is attuned to another person or not. The movement characteristics of individuals with ASD seem to interfere with the spontaneous attunement towards interactions with another person, for example the timing of action responses may take longer [11,12]. This does not necessarily imply that persons with autism do not relate their actions to the interaction partner, but, due to the atypical character, it might be difficult for a neuro-typical person to develop a sense of relatedness from the interactional patterns that are used by the individual with autism [13]. The role of reciprocal embodied interactions for the development of interpersonal engagement and attunement has been described by many researchers [14-17]. As intersubjective attunement seems to develop mainly through nonverbal actions a movement perspective may be helpful to explore atypical forms of social attunement as seen in autism [13].

2. Dance Movement Therapy (DMT) in Autism

2.1 DMT general theoretical background and methodsDance movement therapy is a psychotherapeutic approach that uses dance and movement as experiential pathways to increase wellbeing and improve psychological or psychiatric conditions. A basic assumption is that dance-based activities support and develop an integrated body-mind engagement [18]. Dance as a cultural practice allows for the social engagement of participants in shared dance practices [19]. The moment of dancing generates an immediate sense of the experiential quality of the movement [20]. The potential to express and share inner states through movement with observers or other dancers define dance as a specific, bodily experienced aesthetic practice [21]. Dance movement therapists use these qualities to engage participant(s) in creative movement processes and interpersonal kinesthetic experiences. Dance-based methods in DMT may cover a broad range from structured movement activities to improvised movement processes.

2.2 DMT in ASDDMT approaches with participants with ASD have been mainly described through case studies. In recent years, the practice-based literature is complemented by research studies on the effectiveness of DMT interventions in ASD [22-24].

Despite the diversity in settings, D/MT interventions in ASD are characterized by some common features. All approaches share the premise that the participants should be met in their personal movement patterns and possibilities to interact. DMT stresses empowerment of the participants’ capacities to move and seeks to develop already present potentials towards a broader range of movement possibilities. The therapist will specifically support non-verbal interaction. Although atypical (sensori) motor features may arise during DMT with participants with ASD, these will generally not be taken as disturbances by the therapist, but instead as movement material that can be explored for their interactional potential [25].

As the basic intention of the therapist is to meet the participants with ASD in their personal movement impulses, s/he will carefully investigate occurring movement actions. It is common practice in DMT to analyze the participants’ actions with a specific movement observation system. The most frequently used observation systems are Laban Movement Analysis [26] and Kestenberg Movement Profile [27].

With so called ‘mirroring’ interventions the D/M therapist seeks to get as close as possible to the participant’s movement patterns [28]. Mirroring in this case is a flexible and playful reflection by the therapist of the participant’s movements or movement themes. Case studies conducted with mainly mirroring interventions with children on the autistic spectrum report effects on the (sensori) motor regulation of the child, as well as the expressive relating with the environment or a movement partner [29]. These outcomes have been confirmed by research studies with children [30] and young adults [31].

The DMT method used in the clinical samples that were used for this study has been described as the Shared Movement Approach (SMA) [21]. In this approach the therapist works with a single participant in dyadic DMT sessions. The movement interactions between therapist and participant are taken as improvisational dance patterns [32; 33]. The movement actions of the participant are reflected by the therapist through an immediate responsivity that takes the participants’ momentum towards shared movement activities [21]. All movement actions of the participant are answered in perspective of their interactional potential, with the intention to take them towards dialogical movement interactions. The therapist invites the participant to active regulation and co-creation of the shared movement themes. The therapeutic dyad develops throughout the improvised dance as a living dynamic system that is mutually regulated by both movers.

3. Movement observation in DMT/ASD

3.1 Movement observation in DMT

DMT faces the challenge to measure effects in a somatic experiential encounter between therapist and participant. Laban Movement Analysis (LMA) is an observation based system that categorizes movements under the aspects of use of body, space, effort and shape [34]. Within these observation categories the specific qualities of the movement patterns are captured as they are expressed in the combination of spatial, time, weight and energy aspects [26]. The strength of this system is the non-interpretative registration of movement qualities, regardless any developmental or psychological features. This allows for the therapist to invent (re) occurring movement patterns of a participant, which may serve as a reference for the movement interventions and for the evaluation of changes in the personal movement profile during therapy.

3.2 Movement observation in ASD Individuals with autism may show atypical features of (sensori) motor functionalities throughout development [35-38]. In the clinical treatment of children and adolescents the (sensori) motor maturation is examined through functional analysis with developmental test materials like Southern California Sensory Integration Test [39], Marburger Körperkoordinationstest, Entwicklungsraster Psychomotorik [40] and the PsyMot [41].

The therapist will add to the functional analysis a focus on the specific, individual movement repertoire of a participant, regardless of whether the movement development shows typical or atypical traits. Movement analysis enables dance therapists to systematically observe, describe and notate movement qualities and compose a movement profile of the client.

Case studies have described some similar movement specifics for young participants with autism [42-45]. Sossin and Loman [46], both working with KMP analysis, described participants with ASD showing a tendency to use a neutral flow of body shape, which gives the impression of lack of animation. They frequently observed a preference to move with highly localized tension, often resulting in a lack of continuity of movement and apparently unrelated adjustments of movements or clashes during movement adjustments. Partial stabilization of body parts and shaping activities, like organizing their posture around that of a partner, seemed to be less present in those with ASD [47].

The “Behavior Rating Instrument for Autistic and other Atypical Children” (BRIAC) developed by Kalish and colleagues [48] evaluates among other domains the child’s movement development.

The Laban based methods have in common that they document how the movement is performed and then describe the movement quality, but they do not necessarily capture the social components of the movement actions, nor do they provide a quantitative structure to monitor changes throughout therapy or for outcome evaluation.

With the growing need for evidence based practice, movement specific evaluation tools would be needed to cover the domain specific content of dance activities. Only a few studies were identified that used movement

behaviors for outcome evaluation of social interaction in participants with ASD [49; 50].

The purpose of this study was to monitor changes in social attunement of young people with autism during DMT and identify specific, observable movement markers that were present during these changes. The obtained interactional movement markers were expected to be useful to inventory the non-verbal aspects of the participant’s capacities for social attunement. Observation with a structured set of interactional movement markers was expected to support systematic evaluation of effects of DMT on social attunement in participants with autism.

4. MethodologyThis study was conducted with a mixed methodology. A retrospective analyses was applied to video-materials of dyadic DMT with young participants with autism. Retrospective observation facilitates the exploration of experiential phenomena as they occur in behavioral changes over time [51] and may support construction of significant events for a domain of interest [52]. The observation of the interaction between participant and therapist was expected to allow the identification of specific interactional movement behaviors used by the participants. The domains of interest were the participants’ nonverbal intersubjective engagement and their attunement behaviors within the therapeutic dyad.

The collection and analysis of observational data was performed with a Grounded Theory Approach (GTA) [53]. This qualitative research procedure follows a systematic sequence of analysis, for example open, axial and selective coding [53] to reveal implicit structures of verbal or experiential data. GTA was applied to collect interactional movement behaviors and identify core themes and structures from these behaviors. Because the researcher had also been the therapist at the time, the observational perspective was informed by her experiences in the clinical setting. This choice was based on the understanding of the investigation as a heuristic research process, during which the effort to understand the underlying structures of a lived situation (in this case of the clinical DMT) is a complex, experientially informed, way of thinking and sense making [54].

Several steps were taken to account for the quality of contents validity of the obtained observational categories and to avoid biased interpretation during the GTA procedures.

4.1 ProceduresThe video materials used in this study were recordings from clinical DMT that had been produced for clinical outcome evaluation in an outpatient setting with young participants with ASD. All cases had been evaluated positively after termination of the therapy by parents, participants or caregivers for the development of social attunement in the participant. Therefore, it was expected that meaningful changes in social attunement would also be observable during the recorded DMT sessions.

Video vignettes were prepared for observation by anonymizing the samples and password protected usage. The annotation procedures were partly performed by hand with paper and pencil, but mainly with the free software package ELAN [55], that has initially been developed for the linguistics department of the Max Planck Institute, Nijmegen (NL) [56].

The materials were first scanned with an open coding procedure to detect and tag scenes that contained changes in the interaction from the participant towards the therapist. These scenes were analyzed for the movement actions that constituted these changes. A GTA was used to find implicit structures and themes.

The obtained movement markers were then critically annotated by external movement analysts and tested for agreement on the contents of the categories. Interrater agreement also served as a measure to decide upon the suitability of two different coding procedures.

In a last step, the movement markers were used in a selective coding procedure to analyze the changes in interactional movement profiles over four time points (TP) throughout therapy.

4.2 ParticipantsFrom the available video material four cases were selected for their similarity in duration of therapy and available video vignettes throughout therapy process. All participants had been diagnosed with ASD by a child psychiatrist and had been referred to DMT by a multidisciplinary treatment team or school-psychological service. Participants were two girls and two boys, with a mean age of 12.02 years (SD 3; 8). Participants and parents had given their informed consent for the use of the video-materials for research purposes after termination of the therapy. Ethical approval for the project was sought through the appropriate institutional procedures. All therapies were conducted as dyadic DMT with the researcher being the therapist in all cases.

Participants in the interrater procedures were six trained movement analysts (including the researcher) and one psychologist who had followed an extensive training in movement analysis. Analysts had been recruited through professional DMT in the Shared Movement Approach (SMA) networks in the Netherlands.

4.3 Data-collectionIn a first step an open coding procedure [53] was used to select scenes that contained changes in the interaction between participant and therapist. Verbal actions were not considered during these observations. The collected moments of change were taken as raw data. These data were analyzed (employing LMA) for the movement components present in the actions of the participants. In a second step, which covered an axial coding procedure [53] these actions were coded for similar structures and overarching aspects.

The obtained structural categories were used to collect data on interrater agreement regarding the contents of the movement categories and annotation procedures. The set of movement items was piloted for the

observation of interpersonal movement behavior in a small clinical study on different types of movement interventions in DMT with young ASD participants [57].

The edited movement categories were used for a selective coding procedure on vignettes from four time points for each of the four cases. Samples from the original material were selected with a randomization procedure and did not contain any information about the time point in therapy. The annotations of two raters were analyzed for interrater agreement. The observational data were then analyzed for the movement profiles for the individual participants for each TP.

4.5 Data-analysisIn the collected scenes, the occurring movement actions were analyzed for their properties with LMA based observation. After the first try outs and the first expert circle of movement analysts the categories were fine-tuned in view of their applicability during video-based movement observation.

Movement actions were grouped in the categories movement direction, facial orientation, body/body part direction, weight engagement individual, weight engagement with partner, weight regulation with partner, synchronization in rhythm, synchronization in phrasing.

The eight movement items were grouped under three overarching themes ‘spatial orientation’, ‘weight engagement’ and ‘synchronization in time’. The movement markers were defined to indicate spontaneous movement behaviors initiated by the participant, meaning that behaviors should be intentionally directed from the participant towards the interaction partner in contrast to behaviors that would have been predefined as social behaviors and then trained through instruction.

The single categories could cover quite a variety of appearances of a movement action. The item movement direction for example was found applicable to mark a movement of a hand directed towards the interaction partner as well as a full body movement directed towards the partner. The perspective of the social attunement of the participant with ASD was taken as guiding a conceptual frame of reference. The fact that a movement was directed towards (or away from) the interaction partner was considered of prior importance than the differentiation on body level in partial or full body involvement.

The item ‘weight engagement’ was discussed for the use of passive and active weight. For example, when the participant was leaning on the therapist, and on the other hand the use of active weight, for example, when the participant did engage strong weight while moving towards the therapist. The final categories covered active as well as passive weight. This choice was again driven by the conceptual perspective of social attunement, making the fact that the participant was engaging weight in relation to the interaction partner more important than the differentiation of separate categories for active or passive use of weight.

The final scale was tested for two different annotation procedures in a separate study [21]. An interval procedure [59] yielded a satisfactory interrater agreement, which was calculated with Cohen’s kappa [58] as k = 0,752.

The movement markers were then used in a selective observation procedure on video-vignettes that were selected from the available materials at four distributed time points (TP) of the therapy process for each case. To account for random selection of video vignettes, the middle five minutes of the video material from each session were selected for observation. For this procedure, only moments when participant and therapist were both visible in the scene were considered. The annotations were performed with an interval procedure. Analysists indicated for each minute (of the five minutes) whether a movement category was present. This yielded quantitative data on the number of minutes in which the single movement behaviors were present. From these data profiles of SEAM behaviors were composed for each TP. The profiles of each TP allowed for within subject comparison between TP’s as well as between subjects. A non-parametric procedure was applied to for a preliminary exploration of statistical trends for the development of movement behaviors over the four TP’s.

4.6 Quality issuesDuring the selection procedures journal notes were kept to conceptualise and model the experiential data in the perspective of social attunement in dance and movement and in social attunement in ASD. GTA reflective practice of memoing [53] was used to critically annotate the observational data. To apply a non-biased reflection on the obtained movement categories they were piloted by other observers than the researcher and to other materials than the vignettes used in this study.

The obtained movement items were related to the research literature on social attunement and interaction in ASD. Studies on the effect of imitation on non-verbal social behavior in participants with ASD were found to mention body-related observations items, like eye gaze, touch and proximity to another person [61-66], but did not cover a comparable spectrum of movement actions as the SEAM markers.

In the development of new observational categories validity issues are of major concern [67]. In this study interrater agreement calculation served to test for agreement between raters on the content validity of the movement categories and the construct validity of the annotation procedures [68]. During the final selective coding procedure with the SEAM scale the vignettes were presented in a random order, to blind the raters for the information on the therapy progress.

5. Results5.1 GTA procedureThe results of the GTA procedures were summarized in a movement observation scale. The term Social Engagement and Attunement Movement (SEAM) was introduced for the interpersonal movement markers. The

description of the categories and annotation procedures were described in an observation manual.

Table x here: table still to be edited!Table 1: Overview interpersonal movement behaviors

5.2 Selective observation The selective observation with the obtained markers showed in all cases an overall increase of SEAM behaviors throughout therapy. The changes occurred within single categories as well as over the number of SEAM markers involved during the observed movement actions.

All participants showed an increase of complexity of SEAM behaviors towards the end of the therapy, with all profiles showing a combination of spatial, weight and time movement aspects at TP 4, which was not the case in the profiles at TP 1. Within category analysis showed an increase for all eight markers between TP1 and TP 4.

The development of SEAM behaviors followed a similar pattern structure for all cases. The use of the categories of spatial orienting was already present at TP 1 and throughout all other TP’s for all individuals. Weight categories were less present at TP 1. None of the profiles showed ‘weight regulation towards a partner’ at TP 1. ‘Weight engagement towards a partner’ was only present in one profile at TP1. The category ‘synchronization in phrasing’ was not present in any of the profiles at TP 1, ‘synchronization in rhythm’ was only found in one profile at TP1. These categories developed throughout therapy in all cases, with two profiles showing all SEAM categories at TP 4 and two profiles showing seven of the eight SEAM behaviors present at TP 4.

Table x about here

Table 2: To show a graphical summary of differences in the average group SEAM profile between start and end of DMT. The SEAM categories are presented in columns the height of the columns indicates the average number of minutes that a SEAM behavior was present during the observed five minutes’ samples.

All profiles showed a trend over the four TP’s for the orienting actions to occur prior to actions of weight engagement and regulation towards partner. The synchronizing actions occurred only after weight engagement and weight regulation had appeared in the participant’s interpersonal movement behavior. (see for individual profiles over the four TP’s supplement 1)

This structure was particularly visible in the comparison of the group averages of TP 1 and TP 4. Due to the small number of cases involved in this study, the statistical analysis was limited to a preliminary analysis with non-parametric measures. A Friedman test was applied to the group’s averages of the four TP’s. With a Chi-square value χ² = 7.95, it yielded with a significance level at .05 a p-value of p = .0028. A Wilcoxon Signed-Rank test indicated with Z= -2.527 and with a significance level at .05 a p-value of p= .012 a significant increase for the group averages of SEAM behaviors between TP 1 and TP 4.

6. Discussion

The analysis of interpersonal movement patterns presents a movement informed perspective on social attunement in ASD. From a movement perspective, interpersonal attunement can be understood as the interplay of several directly observable behavioral components. The interactional intention may show in the active orienting toward the other (attention) together with active engagement and regulation of impulses towards the other.

The successive emergence of spatial orienting, weight engagement, weight regulation, synchronization in timing may be considered developmental steps that together bring the individual with ASD towards a higher complexity of interpersonal engagement and attunement during shared movement actions. This contributes to (new) experiences of interpersonal actions and to (new) experiences of mutual corporeal responsiveness in the interpersonal relation.

In view of enactive social learning these processes may add to the autistic participant’s experiential means to responsively move with a partner. The co-regulation of the shared movement situation is experienced through kinesthetic perceptions. The embodied quality of these experiences may facilitate transfer to other contexts than therapy [70].

For the therapist, the SEAM markers help to closely observe and analyze the development of interpersonal attunement behaviors of the participant throughout the therapy process and to tailor the interventions during shared movement improvisations accurately.

In the starting phase of the therapy participants SEAM behaviors showed lower complexity in the sense that not all movement categories were present during the interactions. The initial presence of spatial orienting seemed to fit with the fact that all participants were at a functional level that allowed them to attend therapy in an outpatient setting. The integrated used of social orienting, engaging and synchronizing qualities during the final phase of the therapy were understood as fully attuned interpersonal movement actions. These actions can be related to interactional patterns that develop in the early dyad between young children and caregivers [69].

With the increased complexity in the SEAM patterns, the participants seemed to gain more agency and regulation in the movement interaction with the partner. The increase of SEAM patterns also delivered more cues for interpersonal responsive movement interventions for the therapist. These results match with the therapy outcome evaluations of parents and other caregivers who reported their children to be better attuned during interactions with peers and adults.

LimitationsSatisfactory agreement between movement analysts points towards contents validity of the SEAM categories, however, the construct validity of the SEAM markers as observational scale for social attunement behaviors would need further testing against standardized instruments [56]. Further validity tests for the SEAM observation scale would be needed to investigate the robustness of the scale as a quantitative research tool [75].

The small number of cases involved in this study demands a prudent interpretation of the results. Further studies with a larger cohort would be needed to confirm these results.All sessions observed for this study had been conducted by one therapist. Replication between therapists and over more cases would strengthen the results. Further research might also show if observations with the SEAM

markers throughout therapy would also influence the effectiveness of the DMT intervention.

7. Conclusion

From an experientially informed selection of interpersonal interactions, movement markers and clusters were found for the theoretical construct of attunement [72-74]. Retrospective movement observation with the SEAM scale revealed capacities of social engagement and attunement rather than pathologies. The observation of movement behaviors that are intentionally directed towards the movement partner may contribute to the therapist’s understanding of the potential developmental pathways of social attunement in participants with autism. In this study the development of interpersonal movement behaviors showed a specific sequence from orienting, via engagement towards synchronization. Further research may investigate if this developmental sequence of attunement behaviors is specific for the autistic population.

From the current study, we may conclude that the SEAM observation scale is adequate to track changes in nonverbal interpersonal relating for the monitoring of therapy process and evaluation. A movement based observation tool may be well suited to capture the experiential perspective to interpersonal relating and to indicate the potential cues for the development of social attunement with individuals with autism.

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