Introduction

Autism spectrum disorder (ASD), according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5),¹ or ASDs, according to the International Classification of Diseases, Tenth Edition (ICD-10),² have generally been regarded as life-long conditions. However, some questions about the nature of ASD were exposed by oxytocin studies, which have been carried out over the past decade.

Several studies with oxytocin in ASD adults demonstrated significant improvement in social cognition,^3–7although studies in ASD children and adolescents brought rather disappointing results.^8,9 If the codified concept of describing ASDs as disorders with severe, pervasive abnormalities in reciprocal social interaction and life-long impairment is unequivocally true, then the interpretation of rapid (but temporary) improvement with oxytocin is difficult at best.¹⁰ Andari et al⁴ suggested that “patients with autism might possess latent social skills, and thus oxytocin might favor social engagement behavior by suppressing fear and mistrust”. This explanation was both fair and acceptable but surprisingly has aroused negligible attention.

A central question of the concept that (at least some) people with autism may have latent social skills is how to reveal and test social skills that are hidden. In other fields of psychiatry, projective tests such as the Rorschach inkblot test proved useful in revealing hidden characteristics of the mind; however, they were not designed to uncover hidden abilities, and their contribution to the field of ASD has been generally limited.¹¹ The Theory of Mind,¹² a specific approach regarding how to test the autistic mind, relies predominantly on social abilities that the child is able and/or willing to express.

The immanent feature of hypothetical latent social skills seems to be that they are not accessible by direct observation; otherwise, they would have already been discovered during more than seven decades of autism research. Thus, we are left with indirect observation as the only viable option. An indirect approach to observation of subtle phenomena has been widely used in physics and astronomy but rather less used in medicine, eg, undetectable particles are observed through their impact on trajectories of detectable particles or invisible planetoids are observed through their impact on trajectories of visible planets. There have been, although rare, examples of using such an approach in psychiatry, eg, Nancy Andreasen discovered the negative symptoms of schizophrenia while she was studying why schizophrenic patients who had formally been in remission according to former criteria were unable to work (Andreasen, personal communication, November 1997). The indirect approach, in our case, means searching for potential nonstandard (eg, stressful or threatening) situations where hypothetical latent social skills would impact the behavior of the child, and through this behavioral impact would become detectable.

For methodological reasons, we decided to explore for our goals an existing assessment instrument with known validity and reliability, instead of creating a new assessment tool. We performed a “text” analysis of the most precise standardized interview, the Autism Diagnostic Interview – Revised (ADI-R),¹³ to determine whether any of its items were suitable for testing the latent social skills hypothesis. We identified in the third version of the ADI-R, which appeared in 1995, item number 59 “Secure Base” (Supplementary material). This item has been removed from the current version of ADI-R.¹⁴

ADI-R 59 “Secure Base,” with assessment of 4–5 year olds or to the current status in younger children, is pertinent to separation anxiety, although indirectly. A developmentally appropriate (normal) response in typically developing children involves a child that can play apart from his/her caregivers; however, he/she is able to foresee that permanent separation from parents or caregivers would have a catastrophic impact on his/her life situation. Thus, he/she regularly “checks back” to verify the proximity of parents or caregivers. In autistic children, various degrees of abnormal response are offered (Supplementary material). We suggest that a normal response to the “Secure Base” item could indicate the presence of latent social skills in autism.

The aim of our study was to test the hypothesis that ADI-R No 59 “Secure Base” could point to latent social skills in autism. For this purpose, we established two criteria for how to test whether the item is truly related to latent social skills: 1) performance on the item revealing latent social skills should correlate with expressed social skills according to the iceberg principle, ie, the extent of latent social skills should correspond with expressed social skills, and 2) performance on the item should have predictive value for further social development, ie, if the concept of latent social skills is valid, it should also represent the possibility of future social growth.Go to: