**5. What are the improvements of social impairments in the treatments of patients with ASD?**

Social impairments in ASD have fundamentally different meanings from personality characteristics, such as introversion, interpersonal tension, or aloofness. Infants or preschool children with ASD may indicate very unique and impressive behaviors in the social context, which substantially reflect the disparity between typically developing children and children with ASD in social interaction. Here, we will describe pointing behaviors as an illustration.

When one points at something, others are invariably around. When one points at something, one invariably attempts to convey any information to others around. A toddler pulls his/her mother's sleeve, points to a miniature car on a shelf, and then looks at his/her mother's face (requesting pointing). When a preschool child sees a rainbow in the sky after rain, he/she runs up to his/her mother, takes her to the garden, and points to the rainbow while looking at her (declarative pointing). Liszkowski et al. found that twelve-month-old infants show different attitudes according to experimenter's reactions when infants point declaratively [47]. When experimenters responded to infants' declarative pointing but attended an incorrect referent with positive attitude, infants repeated pointing to redirect the experimenters' attention. When experimenters identified the correct referent with negative attitude, infants did not repeat pointing. When experimenters identified the correct referent and shared interest in it, infants appeared satisfied. Pointing is a prototypical behavior of interpersonal exchange, i.e., sociality.

102 Neuroendocrinology and Behavior

impairments [46].

**patients with ASD?** 

behaviors as an illustration.

The Social Responsiveness Scale provides quantitative measurements of social impairments in ASD by assessing domain of sociality such as social awareness and social information processing [37], and has been used as an outcome measure for interventions [38, 39]. The Reading the Mind in the Eyes Test [36] measures an aspect of social cognition by having the subjects assess emotion through the look of an actor's eye in photographs and has been adopted in many experimental trials [35, 40]. The Diagnostic Analysis of Nonverbal Accuracy Scale measures receptive and expressive abilities for receiving and sending emotions in faces, gestures, postures, and prosody [41], and has been used in the researches of not only ASD [42] but also of other mental disorders [43]. The Childhood Autism Rating Scale helps to identify subjects with ASD and determine symptom severity and has been commonly used in research and clinical settings. The scale assesses various domains of symptoms in ASD, including social impairments. The Autism Diagnostic Observation Schedule is a tool for assessment of symptoms of ASD through structured and semistructured activities with subjects and provides scores in communication, social, and restricted and repetitive domains [44]. This tool has been regarded as the gold standard for assessing and diagnosing ASD. The Interaction Rating Scale Advanced assesses a practical index of social skills using five-minute video recorded interaction session [45]. It is interesting to note that this new tool may provide a validated measure of social impairments of ASD. The evaluations mentioned above provide quantitative values of social impairments

At present, there is no commonly used assessment of symptoms in ASD, especially social and communication domains, for any interventions in contrast to the Positive and Negative Symptom Scale in schizophrenia and Hamilton Rating Scale for Depression in major depressive disorder, which are widely used as almost definitive measures. In the wellknown research in which risperidone, a second-generation antipsychotic, was shown to be effective for reduction of irritability in subjects with ASD, the authors stated that they were unable to identify a validated measure for the core symptoms of ASD, i.e., social

A key question is whether these outcome measures could be used to sensitively assess improvements in sociality, which may only be subtle changes. This question remains

**5. What are the improvements of social impairments in the treatments of** 

Social impairments in ASD have fundamentally different meanings from personality characteristics, such as introversion, interpersonal tension, or aloofness. Infants or preschool children with ASD may indicate very unique and impressive behaviors in the social context, which substantially reflect the disparity between typically developing children and children with ASD in social interaction. Here, we will describe pointing

of ASD based on caregivers' self-reports or behavioral observations.

unanswered before publication of the results of these trials.

Toddlers with ASD display a reduced incidence of declarative pointing compared to typically developing toddlers [48]. Declarative pointing constitutes a significantly diagnostic sign as well as social interest and joint attention for early detection of ASD [49]. Individuals with ASD have an innate disability in the social domain.

We consider that it would be essential to refer to one's own self and others if social impairments in ASD are discussed, because our own selves are embedded in a society full of others [20]. Individuals with ASD may be unable to mentalize the inner states of typically developing individuals, and this raises the question of whether typically developing individuals can mentalize the inner states of individuals with ASD. "Theory of mind" tasks would be regarded as tasks in ASD with "altered" self-consciousness proposed by individuals with "intact" self-consciousness.

According to the standpoint of traditional German psychopathology, self-consciousness (Ichbesstsein in German) is formally comprised of four prototypical representations. First, one's own self is identical at all times. Second, one's own self is always consistent. Third, all of one's own acts belong to one's own self. Finally, one's own self differs from others' own self. These representations deeply embedded in social interactions are intrinsically selfevident and underlie interpersonal exchange of sociality. While one exists almost without reflection on these representations in daily life, severe disruption of self-consciousness would have fairly serious consequences, such as dissociative identity crisis, doppelganger, xenopathic experiences and delusions of possession. Interestingly, children with ASD performed significantly less well on the self-test question than the other-person test question using tasks in which participants have to reflect an awareness of one's own prior belief [50]. These results suggest that individuals with ASD represent altered self-consciousness as mentioned above: "all of one's own acts belong to one's own self."

Although self-consciousness have been investigated using functional magnetic resonance imaging in ASD and healthy individuals [22, 23], the effects of OT on self-consciousness in humans have not been examined.

It is essential but difficult to answer questions regarding improvements of social impairments associated with treatment of patients with ASD. However, it may be useful to

assess self-consciousness, although there is as yet no suitable test to examine representations of self-consciousness available in ASD research.

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