- [Jeff] Welcome to "Healthy Minds."

I'm Dr.

Jeff Borenstein.

Everyone is touched by psychiatric conditions, either themselves or a loved one.

Do not suffer in silence.

With help, there is hope.

(gentle bright music) Today on "Healthy Minds."

- Initially, parents may think that there's a hearing impairment, like something that could be fixed with a hearing aid.

The pediatrician may refer the parent and the child to an audiologist where they get their hearing checked.

And often cases, hearing is okay in these kids.

And the reason they're not tuned in to voices is for another reason.

And this can often be the kind of first indicator, or one of the first indicators, that the child may have autism.

A critical component of these interventions is finding ways to naturally motivate kids with autism to interact.

Growth in the area of social communication.

- That's today on "Healthy Minds."

This program is brought to you in part by the American Psychiatric Association Foundation, the John and Polly Sparks Foundation, and the WoodNext Foundation.

(gentle bright music) Welcome to "Healthy Minds."

I'm Dr.

Jeff Borenstein.

How does our brain process voices, and how does this relate to social interactions?

And just as importantly, how does this occur in people with autism?

Today I speak with leading expert, Dr.

Dan Abrams, about these important topics.

(gentle bright music) Dan, thank you for joining us today.

- Oh, it's my pleasure.

Thanks for having me.

I appreciate the opportunity.

- I wanna jump right in and speak with you about the work that you've been doing looking at the relationship between voices, social interactions, and how this relates to autism.

So start with the big picture of how we all make use of voices, how babies begin to interact with voices.

- Voices are so important to our everyday lives.

And I guess one of the things that I like to kinda start with is to say, I think voices are so central to our everyday lives that it's easy to kinda forget what they are and how we interact with them.

Hearing voices is such a rewarding thing in our life Hearing the voices of our loved ones helps us feel immediately connected to our people, our family, our friends, and so voices play this very central role in our social lives.

For young kids, this starts, you know, all of this starts from the earliest days of development.

Our brains are wired to tune in to voices from our first days.

In fact, a baby is able to recognize their mother's voice before they're even born.

And so this tells us something really fundamental about how the brain is wired for voices and how central voices are for development and for survival.

Why else would the brain develop such a capacity to recognize a voice in utero unless it were really, really important for survival?

And so, right, so voices, they're so important.

They're central, and for kids, you know, and here, infants are able to identify their mom's voice before they're even born.

And then this obviously persists through childhood.

And kids are able to lock in, you know, infants lock in to the vocal communication going on around them from their first days of life.

Anyone who's spent any time with infants know that they'll follow a conversation, you know, kinda watching here and then watching there, back and forth, listening to two people converse.

Of course, the infants have no idea what is being said.

They have no understanding of meaning, and they're just kinda following along in this vocal game that they're observing, and they're attracted to these sounds from these first days of life.

And so we think that kind of locking in and tuning in to voices is this critical thing for development.

When we think about autism, one of the first things that parents notice before they know their child has autism is that kids often are not tuned in to voices.

And, for example, when someone calls the child's name, often the child won't respond.

And initially, parents may think that there's a hearing impairment, like something that could be fixed with a hearing aid.

And so this can lead them to, you know, discuss this with their pediatrician.

"Hey, my child isn't kind of hearing my voice when we call, you know, our child's name."

The pediatrician may refer the parent and the child to an audiologist where they get their hearing checked.

And often cases, hearing is okay in these kids.

And the reason they're not tuned in to voices is for another reason.

And this can often be the kinda first indicator or one of the first indicators that the child may have autism.

Difficulty tuning in to voices is one of the first signs that parents often have that their child may have autism.

And so, and this has been kind of documented from the very first descriptions of, you know, kinda scientific or kind of clinical descriptions of kids with autism.

These kind of difficulty tuning in to voices is one of the first observations that were kind of initially made about kids with autism.

And, you know, this continues to be the case today.

And so kind of putting this all together, you know, we have these two groups of kids, I mean, to kinda simplify things a lot, but you know, on the one hand we have neurotypical kids who are incredibly tuned in to voices from their first days of life.

They continue to lock in to voices through development.

They learn about speech sounds.

They learn about the social world through the voice because they're tuned in to the voice from these early days.

And then on the other hand, we have this group of kids whose ears work, like, their hearing is okay.

They don't need a hearing aid to improve their hearing, but they struggle to tune in to voices from these early stages of development.

And so, and we think this is kind of an important part of the broader, you know, obviously autism is associated with lots of different types of expressions of social communication.

And, you know, and so we think that the voice is one of those key elements that makes it hard for people and kids to tune in to the social world around them and learn about the social world in the same way as their typically developing peers.

- Dan, that was such an outstanding explanation of a very complicated issue.

And let me take a step back and say, do we have a sense scientifically of what's going on in the brains of a child with autism that makes this occur?

- I'm sure whatever I'm gonna say about the brain is a wild oversimplification of what's actually happening in the brain.

But the way we conceptualize what's different in the brain is that there are some fundamental differences in neural connections that link the hearing parts of our brain with other parts of our brain that kind of help us make sense of those vocal signals.

I'll kinda break this down into two types of brain system.

On the one hand, you have kind of what we consider, like, the hearing brain, and these are parts of the brain that help us process all kinds of sounds.

And so we kind of think about this as kind of our sound processing part of our brain.

This is what we call auditory cortex.

And in auditory cortex, the way that this works, and again, this is a wild oversimplification, but sound comes into our ears.

Sound are these, you know, sound pressure waves that travel through the air, and our ear turns these sound pressure waves, which are vibrations, into neural impulses that reflect the acoustic characteristics of the sounds.

And these neural impulses get propagated up to our brain.

And the first stop in our cortex, the big kind of wrinkly outer structure in our brain, the first stop at the level of cortex for processing sounds is a part of the brain called auditory cortex.

And auditory cortex, part of auditory cortex doesn't care what sound it is.

It could be a door slamming, a bird chirping, someone talking, music playing.

It doesn't care what the sound is.

Part of auditory cortex just processes all different kinds of sounds.

Part of auditory cortex is specialized for voices though.

And this is a different part of auditory cortex called superior temporal gyrus and sulcus.

And this part of auditory cortex is particularly sensitive for voices compared to all other sounds.

And so, this is a key part of the voice processing network.

It's still part of auditory cortex, or is often considered part of auditory cortex, our hearing brain.

But it's very specific for processing voices.

Okay, so that's on the one hand, that's our kind of hearing brain, as we think about it.

On the other hand, we have a whole rest of our brain here, right?

There's a lot of other brain structures that do all kinds of important work for us to make sense of our world.

And some of those brain systems, these other brain networks that we call them, they're kind of in different parts of the brain.

And a few of the networks that are particularly important in the context of voice processing include the reward system.

The reason I bring up the reward system is because we know that certain voices, that there's an important connection between our hearing brain and the reward system.

And so for example, when a child hears their mother's voice, the reward system becomes active.

And so that's one brain system that's also kind of associated with voice processing.

Another is part of our brain that helps us kind of navigate the social world.

Part of our brain is able to understand the social meaning of vocal information, and we use these subtle vocal cues to help us understand how someone is feeling.

And so the reason I'm saying all this is that we have a different set of brain regions to help us understand social meaning.

What we're seeing is that in kids with autism, there are different connection profiles between these hearing parts of our brain and these other brain systems, like the reward system and our social evaluative systems that appear to have kind of different connection types.

And in this case, I'm not talking about physical connections, although that may be the case.

What, at the moment, we're talking about are kind of activity-related connections.

And it's kind of a complex idea.

The idea is what we call functional connectivity.

This is when two different brain regions correlate and show similar activity patterns over time, which, to us, kind of signals that these two brain systems are communicating with one another.

- So I just wanna ask a clarification, make a clarification point, which is that in people with autism, there is something different in how those sounds are then processed in the brain and go to the different parts of the brain versus people who don't have autism.

And that can all come together to bring about some of the differences in social interactions that a person with autism may experience.

- This is our current hypothesis.

Yes.

I mean, this is what the data point to, is that hearing brain regions appear, you know, and again, we're we're using these coarse methods of measuring the brain, you know, in living, breathing human beings.

But, you know, using these coarse methods, the evidence largely points to the hearing brain is intact and performing in ways that we would expect it to do and kind of commensurate with neurotypical individuals.

And the thing that distinguishes individuals with autism in how they process voices is related to how these hearing brain regions connect to these other downstream brain systems that help us process reward and social information.

So that's the kind of, that's what the evidence points to.

And we've seen this across several different studies.

And so that's kind of how we conceptualize the difference in sound processing and voice processing in individuals with autism.

- Given those differences, are there steps that we can take, that parents can take, professionals can take, to help a child who is beginning to experience those differences at a young age?

What can be done to help that child?

- That's a great question, and I guess I always like to start answering a question like that by saying, you know, these are relatively early days in understanding these voice processing brain systems.

And so I wanna always be cautious about making really specific kind of blanket statements about how parents should think about their child's treatment based on these neural results.

However, I mean, with that said, are there clinical interventions that help motivate kids with autism to tune in to the vocal world?

And, in fact, there is a class of interventions for kids with autism called Naturalistic Developmental Behavioral Interventions.

It's kind of a mouthful, NDBI.

A critical component of these interventions is finding ways to naturally motivate kids with autism to interact and to build on their personal interests, on the child's personal interests and goals, to foster growth in the area of social communication.

Well, the idea with NDBIs is to focus on these areas of interest and to use it as a scaffold to build social communication in kids with autism.

NDBIs take these principles of learning, and they're able to apply them in ways that motivate the child, surrounding the child's natural interests in their natural setting, for example, at home versus in a clinician's office.

And so, often there's a lot of parent training that goes around NDBIs because a parent is able to help deliver the intervention throughout the day with their child, rather than just waiting for a clinician, waiting for their clinic visit.

Drawing kids in, using their natural interests and motivation, to bring them into the vocal conversation, to draw them into vocal discourse, and to get them to tune in a little bit more to voices, to help them strengthen their relationships, to help them build community and build their vocal abilities.

- So it's really making use of that child's strengths and interests in a particular area, and engaging them, and using that to build upon that engagement to other engagement with social interactions.

- That's exactly right, Jeff.

That's a great way of summarizing that.

- I wanna jump from the young children that we're talking about to an older age child, adolescents.

And some of the work that you've done in terms of interventions for adolescents in social interactions.

Could you speak a little bit about that as well?

- Yeah, sure.

So, you know, many interventions, and I would say most interventions, are really focused on young kids.

The reason for this is that, you know, the thinking is that young kids' brains are particularly plastic.

They're able to change their behavior.

They're kind of still in a formative state.

And so there's a lot of focus on young kids in the autism intervention literature and in clinics in general.

And as parents learn, it can be quite disappointing for lots of parents as kids kind of age out from this earlier stages into tweens and then being a teenager.

There often aren't very good intervention options for adolescents.

And our group, working with Dr.

Lynn Cagle who, in concert with her husband, Robert Cagle, developed Pivotal Response Treatment, we've worked with them, and they've developed a intervention for adolescents with autism.

These are typically more verbal adolescents with autism.

The idea is that adolescence, even though there aren't many interventions focused on this particular age range, adolescence represents a really beautiful time to continue to strengthen social skills for kids with autism.

You know, many kids with autism, as they become adolescents, they want to make friends and are motivated to have friends, maybe in ways that they were less focused on as younger kids.

And so, let me take a quick step back, and just kind of talk about adolescence more generally.

In neurotypicals, adolescence is considered this really critical period for social development.

You know, as many parents are aware, adolescent kids start to really tune in to their peers and new social partners, and their social awareness and, you know, their understanding of social complexities and nuance become enormously strengthened during the adolescent years.

For many kids, the adolescent years, you know, it's this crucial time for social development.

In fact, some researchers have considered it a critical period for social development.

And so, and this is also the case for kids with autism in the sense that they're going through the same hormonal changes as their neurotypical peers.

And they're similarly driven, or often driven in similar ways, to engage socially during adolescence.

So all of this is just kind of a long way of saying adolescence remains an important period for kids with autism to develop social skills.

And so we've, and there's this gap, there's this need for more intervention options for these kids.

So far, we're still in the process of running this study.

And my interest in it, in addition to the clinical part, is to understand if we can strengthen these vocal reward connections in our brain following a successful intervention.

You know, this is an important question because we'd like to learn whether these neural connections are plastic, whether drawing kids into the vocal world through successful intervention that's tailored to the kids' interest and that can be delivered in their everyday lives, whether this can help strengthen the brain and the particular connections of interest, which include these voice reward circuits in the brain that we've studied.

And so, you know, we're still kind of in process with this intervention for adolescents.

But there is this kind of important and general need for more intervention options for adolescents.

And we, again, feel that integrating motivation and reward into the intervention, even for adolescents, or could be at any stage of development, is gonna be critical to help build social skills, and kind of strengthen a child's interest in kind of tuning in to the voices around them.

- I think part of what I find exciting about the work that you're doing is it can help people down the road in the future by better understanding these mechanisms, developing potential methods of prevention and better treatments.

But also in the here and now, for people currently living with autism, there are things that could be done to help those people right now.

And I think that combination in research is very, very exciting.

- As a neuroscientist, you know, I think about the brain all the time, and then to have the opportunity to work with kids, and help kids, and see them improve in their vocal communication and their social communication more broadly, has been amazing.

And so that's been a really, incredibly rewarding thing for me.

I guess there's always the question about how much our particular contributions to brain understanding will help, but knowing that we've helped this handful of kids is enormously satisfying, and really might be the most rewarding thing I've been able to lead.

- Dan, I wanna thank you for joining us today, for the work that you've done and continue to do.

And your passion for this comes across so clearly, I wanna thank you for that.

- Thank you so much for the opportunity to talk about our work and for this great interview.

I appreciate it.

(gentle bright music) - As we learn more about autism, we're able to develop new and better interventions to help people.

Remember, with help, there is hope.

(gentle bright music) Do not suffer in silence.

With help, there is hope.

(gentle bright music) This program is brought to you in part by the American Psychiatric Association Foundation, the John and Polly Sparks Foundation, and the WoodNext Foundation.

(gentle bright music) (gentle bright music continues) (gentle bright music continues) (gentle bright music continues) (gentle bright music continues) (gentle bright music fades)