What is Virtual Autism? – Occupational Therapy Practice

One of my viewers brought my attention to the topic of ‘virtual autism’. I was not familiar with this exact term, but I was familiar with the association between the negative effects of screen time and decreased psychological well-being. So I conducted more research into this topic.

Related post: Digital Play vs. Traditional Play for Children

This topic was brought up as it was related to my recent video about how early video feedback parent-based intervention was able to decrease the symptoms and likelihood of children being diagnosed with autism spectrum disorder (ASD). This intervention, Video-feedback Intervention to promote Positive Parenting, or VIPP is based on attachment theory between the parents and children and how they interact in the environment may influence symptoms such as those seen in ASD.

Much is still not known about the link between screen time and autism. Then there’s the issue between cause and effect – like the chicken and the egg. Did the child already have or was predisposed to autism and consumed a lot of screen time or the other way around? Does too much screen time cause increased autism symptoms and/or an autism diagnosis?

I briefly scanned a Psychology Today post about virtual autism and looked at the references. The first reference was an editorial.

The second reference was titled ‘Association of Early-Life Social and Digital Media Experiences With Development of Autism Spectrum Disorder-Like Symptoms’. This cohort studied of 2152 children involved caregivers reporting viewing habits at 12 months, 18 months, as well as time spent reading got the child and playing with the child. The study found that greater screen exposure time AND less caregiver-child play early in life was associated with later ASD-like symptoms.((Heffler KF, Sienko DM, Subedi K, et al. (2020). Association of early-life social and digital media experiences with development of autism spectrum disorder–like symptoms. JAMA Pediatrics, April 20. doi:10.1001/jamapediatrics.2020.0230))

What this study tells me is that screen time alone is not necessarily associated with increased ASD-like symptoms later in children. Two variables are involved: increased screen-time AND decreased parent-child interaction. This is an important distinction to make because I think it will be naturally difficult to design a research study that ONLY looks at screen-time. Naturally, the child will be exposed to their caregivers to some extent and its nearly impossible to look at these variables in isolation. It would  of course be unethical to isolate children from human interaction altogether and only look at screen time. Then there’s the issue of whether the child would have developed ASD-like symptoms “anyways” without increased screen-time.

But the implications from this study actually correspond with my points in the video about VIPP. Personally, I don’t think the issue is so much the screen-time as it is as much the interactions between the parent-child.

The 3rd reference was a case study that described a similar phenomenon and called it ‘early media overexposure syndrome’. A 25-month-old boy was found to have ASD-like symptoms as well as language delays and sleeping disturbances. Environmentally, he was exposed to a lot of screen time. The parents stopped screen time AND replaced it with more play and social interaction with similar-aged peers [scaffolding]. Following this intervention, the child became more stable, focused, less agitated, and had increased language abilities.((Dieu-Osika, S., Bossière, M. C., & Osika, E. (2020). Early Media Overexposure Syndrome Must Be Suspected in Toddlers Who Display Speech Delay With Autism-Like Symptoms. Global Pediatric Health 7: 2333794X20925939.)) So a similar thing is happening with this case study: decreased screen time and increased socialization and play. It would have been interesting to see the outcome if this child was still exposed to some screen time and more social interaction and play if he would have had a decreased or delayed positive outcome.

The 4th reference was a systematic review titled ‘Screen Media and Autism Spectrum Disorder’.((Slobodin, O., Heffler, K. F., & Davidovitch, M. (2019). Screen media and autism spectrum disorder: A systematic literature review. Journal of Developmental & Behavioral Pediatrics, 40: 303-311.)) Results conclude that “Correlates and long-term consequences of early screen exposure (before the age of 3 years) remain largely unexamined.” Again, it is important to also consider as the author’s mentioned, other environmental factors such as SES and parent-child relationships. The authors bring up a good point and it does not necessarily need to be black and white. What may be more appropriate is finding out “how much-exposure is detrimental and allow appropriate recommendations and interventions related to screen time among children with ASD” or suspected of having ASD.

The 5th reference was titled ‘Intensive early screen exposure as a causal factor for symptoms of autistic spectrum disorder: The case for «Virtual autism»’. This was an opinion paper that by an author that highlighted how several cases studies similar to the others. Screen time removal and increased parent-child interaction resulted in decreased ASD-like symptoms.((Harlé, B. (2019). Intensive early screen exposure as a causal factor for symptoms of autistic spectrum disorder: The case for “virtual autism.” Trends in Neuroscience and Education, 17:100119.))

Another study documented the extent of cellular phone usage by parents during the child’s diagnostic developmental assessment. The rate of language and motor delays were found to be twice more common among children of cell phone users than among non-users (p=0.04).((Davidovitch, M. et al., (2018) The role of cellular phone usage by parents in the increase in ASD occurrence: A hypothetical framework. Medical Hypotheses 117:33-36 DOI: 10.1016/j.mehy.2018.06.007)) This paper is very insightful as it provides additional support in how a small glimpse of parent’s behaviors and habits is telling of how they may be interacting with their children throughout the course of the day. Another point they bring up is joint attention: when one person purposefully coordinates his or her focus of attention with that of another person.((Eggebrecht AT, Elison JT, Feczko E, et al. Joint attention and brain functional connectivity in infants and toddlers. Cereb Cortex 2017;27(3):1709–20.))
((Tomasello M, Carpenter M. Shared intentionality. Dev Sci 2007;10(1):121–5.))

According to this study, twelve-month-olds respond to joint attention and 18-month-olds initiate joint attention, which is a predictor of language abilities at 24 months. Joint attention is associated with the visual network and attention network, which is related to the attention problems in ASD. Parents that shift their eyes towards their phones interrupt the joint attention cascade and the potential problem here is that repeated joint attention interruptions will interfere with the development of joint attention in infants.

Now for a personal example. I was filming using the selfie-cam on my smartphone as my 10-month-old was falling asleep. I noticed he was about to dose off, so I wanted to film this for my wife. But as the screen naturally has a light, I noticed that my little one kept his eyes on the screen much longer than I anticipated. It was not until I moved it off from the visual field that he immediately closed his eyes. If my child was fixated on the screen for an extended amount of time, it is likely his sleeping patterns would have been disrupted. This was a personal reminder to be mindful of my own screen time in front of my child when I should be instead spending time interacting with him. Or at the very least, wait until he is asleep to be staring at a screen.

Just like how insects are drawn to light, I believe so are humans – developing infants and children can become so fixed at these glass lightboxes we call screens that it may decrease their development of visual systems: saccades, accommodation, scanning, reading non-verbal expression (my hypothesis), and now, joint attention.

I think more of what is happening is parents are so consumed by their screens and they either co-watch with their children or give their children their own screen that overall, there is decreased social skill development between children and their environment.

Personally, I plan to not expose my child to screen time for as long as possible. My 10-month-old has not watched TV at all and only seen glimpses of our smartphone and laptop screens. But I hope to make it a point when I notice him staring at my screen to put my device away and engage with him socially: first promoting joint attention such as through making eye contact, speaking with him, playing with him, and responding with him daily.

What parents may find helpful is scheduled play time or scheduled ‘bonding’ time to counteract the screentime that we all engage in because our lives are so intertwined with technology.

Occupational Therapy Practice Suggestions

  • Educate families about screen effects and case studies and the potential combination link/causation of screen time AND parent-child interactions.
  • Assess parents’ and children’s screen time with questionnaires.
  • Consider parent and child’s routines, roles, culture, and occupations.
  • Help devise a plan to replace or limit screen time with play and social interaction.
  • Use tools like screen time timers to help decrease screen time.
  • Promote joint attention, eye contact, speaking in full sentences, and exposing the child to different environments.
  • Find and use clear outcome measures for ASD symptoms.
  • Integrate sensory integration and other approaches if indicated to promote engagement in play, eating, school, and socialization.
  • Refer to MD, SLP as appropriate.
  • Stay up to date on virtual autism research.