The Thorn in the Dyad: A Vision on Parent-Child Relationship in Autism Spectrum Disorder

Parents and children form a family: their characteristics balance personal and family well-being with healthy levels of stress. Research on parents of children with Autism Spectrum Disorder (ASD) demonstrated that higher levels of parental stress are associated with communication impairment, a core symptom of ASD. The aim of this article is to discuss the connection between non-verbal communication impairment and parental psychological distress, in families with children with ASD. The interaction between atypical communication and distress of parents likely determines a cascade effect on the parent-child dyad; in fact, it decreases the quality and frequency of interactions, preventing the establishment of a healthy parent-child relationship and leading to a series of collateral problems. To this perspective, guiding the parents to reframe their children’s atypical communicative behaviour can relieve parental stress and re-program the interactional routine. This observation stresses the importance of interventions centred on the dyad, especially during early development and soon after the diagnosis, when the communicative impairment may be extremely severe.

Children with ASD show less conventional-interactive gestures, compared to children with Down Syndrome and typical development (Mastrogiuseppe, Capirci, Cuva, & Venuti, 2015), and respond less to communicative gestures, such as lateral gaze and pointing (Falck-Ytter, Fernell, Hedvall, von Hofsten, & Gillberg, 2012). Cognitive functioning, as well as the severity of the symptoms, are specifically associated with the expression through gestures, rendering this behaviour a relevant marker of the evolution and outcome of the condition (Mastrogiuseppe, Capirci, Cuva, & Venuti, 2015). Besides, patients with ASD scarcely integrate different kinds of expressive behaviours, such as gaze and gestures, and barely coordinate with their social partner (Rozga et al., 2011). In this particular study, the authors reported significant differences in responding to pointing gestures, pointing and handling objects to initiate an interaction already at 12 months. Further details on early, non-verbal communicative impairment in ASD are provided in Table 1.
The atypical emergence and development of non-verbal communicative abilities may prevent parents from being aware of the child's needs. In the next section, we will highlight the relationships between parental stress and characteristics of ASD and the specificity of preverbal communication impairment as a child-related stressful factor.

Communication Difficulties in ASD
Parents of children with ASD are the first people to recognize the difficulties and differences in their children and are responsible for their education and treatments. Hence, besides the study of individuals with ASD, the impact of the difficulties in communication on the well-being of parents is of greatest importance. The challenge of being parents of children with ASD has been addressed by several studies that report that parents of children with ASD experience elevated levels of stress related to parenting a child with ASD (Ingersoll & Hambrick, 2011;Ozturk, Riccadonna, & Venuti, 2014). Compared to parents of typically developing children and with others developmental disabilities, parents of children with ASD report more psychological distress and mental issues, such as depression (Eisenhower, Baker, & Blacher, 2005;Estes, Munson, Dawson, & Koehler, 2009;Ingersoll & Hambrick, 2011;McStay, Trembath, & Dissanayake, 2014). In one study, a striking percentage of parental distress (85%) resulted related to the parent's role (Ingersoll & Hambrick, 2011). The characteristics of a child and a family are associated with parenting distress (Bishop, Richler, Cain, & Lord, 2007;Hastings et al., 2005;Lecavalier, Leone, & Wiltz, 2006). The child's ability in communication has a determining impact on parents' well-being (Bebko, Konstantareas, & Springer, 1987;Ekas & Whitman, 2010) and parents of children with ASD (Lecavalier et al., 2006) and intellectual disability (Hassall, Rose, & McDonald, 2005) with better communi-Del Bianco,Ozturk,Basadonne et al. 697 cation skills report lower levels of stress. In fact, parents' behaviour can be significantly modified by the child's condition: difficulties in communication makes the parents anxious and worried (Marcus, Kunce, & Schopler, 2005)

Parent-Child Relationship
Conspicuous evidence connect perceived parental stress and maladaptive parenting strategies with specific characteristics of ASD. Factors of the Parental Stress Index (PSI; Abidin, 1995) has been found to correlate At 6 months, EC facilitates gaze-following (Senju & Csibra, 2008).
GF scores at 10.5 months predict the use of mental-state words at 2.5. years At 12 months, GF establishes affective referencing to objects (Itier & Batty, 2009) GF skills at 12 months predict later productive vocabulary (Tenenbaum et al., 2015) Less allocation of attention to gazed-at- At 9 months, infants focus on objects out of field of view, after the parent looks and points at it (Flom, Deák, Phill, & Pick, 2004) Gestures prefigure referential labeling, before language is developed (Liszkowski, 2008) At 24 (Nackaerts et al., 2012) The Thorn in the Dyad: Parent-Child Relationship in ASD 698 with child's problematic characteristics that relate to the communicative domain: scores estimating general and parenting-related distress strongly correlate with the Social Responsiveness Scale (Zaidman-Zait et al., 2011) and the Communication Scale of the ADOS-G (Ozturk et al., 2014). The perception of issues related to the child, estimated by the subscale Difficult Child, correlates with scores on the Vineland Adaptive Behaviour Scale, including Communication (Hassall et al., 2005) and communication as a problematic behaviour predicts PSI variance over one year of observation (Lecavalier et al., 2006). Communication impairment affects perceived parenting difficulty and the levels of stress of parents. Furthermore, communicative competence has the long-term predictive power of parents' well-being. Keen and colleagues (2010) reported that scores of the Communication and Symbolic Behaviour Scales -Developmental Profile (CSBS-DP), a caregiver questionnaire about parent's perception of child's communicative behaviour, showed a significant amelioration when the family was supported by a short-term, intensive intervention mediated by a trained professional. This intervention resulted efficacious in reducing child-related parental stress (Keen et al., 2010), but the follow-up, standard assessment did not detect a significant degree of improvement. Thus, it is possible that the intervention promoted

Problems and Food Selectivity
Gastrointestinal problems are common in children with ASD but difficult to detect, given the deficit in communication that complicates the description of symptoms and/or the expression of pain even through intentional nonverbal communication (Buie et al., 2010). In fact, behaviour that parents usually report as "unexplained" can actually express gastrointestinal discomfort: vocalizations (i.e. frequent clearing of the throat, screaming, groan- food selectivity tend to show higher levels of parenting stress (Postorino et al., 2015) and even spousal stress (Curtin et al., 2015). Problems in communication might contribute to this situation. For example, parents might unintentionally force the child to eat something that he/she has problems to digest properly and they cannot intervene promptly to prevent the extension of selectivity to other foods of the same category. In conclusion, a defective non-verbal communication, exemplified by discomfort and symptom expression, can heavily contribute to frustrate the parents' attempts to manage the everyday life with their child with ASD.

With ASD
For a successful management of a child with ASD, intervention should support parenthood and deal with the psychological distress of parents. As we previously explained, the child's difficult predisposition to communicate significantly influence the relationship with the parents, that in turn feel high levels of stress connected to the child and their role. Parents should be trained by professionals to use their knowledge about their special child in various situations, such as during lunchtime or in the playground. Empowered parenting skills can significantly improve caregiver-child interactions, which is the basis of the several situations parents experience with their child diagnosed with ASD.
The interaction between a child and his/her parents is important and crucial in the daily life of the family. However, atypical child development significantly alters the modalities of interaction between parent and child (Venuti, Bentenuto, & Villotti, 2011). In a broader sense, activities of children with ASD can stress parents' attempts to frame and build interactive behaviour (Mundy, Sullivan, & Mastergeorge, 2009). The question arises about how atypical development has such specific consequences on parenting strategies. Coming back to the first communication media, the properties of cry have been linked to the quality of the first interactions: for instance, atypical cry episodes prevent the caregiver from efficaciously responding to the infant's distress (Venuti, 2003;Venuti & Esposito, 2007). The pace is short towards feelings of inadequateness and disruption of parenting practices. Qualitative differences have been observed in the interactive style of parents with their children with ASD, compared with parents of typical children and other disabilities, such as Down Syndrome (Venuti et al., 2011). Namely, parents of children with ASD display more behavioural attempts of control, physical contact, and similarity between mother's and father's parenting style (Venuti et al., 2008;Venuti et al., 2011). It is worth noticing that these parents often show sufficient levels of "intuitive parenting" (Papoušek & Papoušek, 2002), though their behaviour becomes maladaptive due to the modified interaction they are exposed to. The good quality of a caregiver-child relationship can be measured, for instance, considering the levels of synchronization. The level of synchrony during natural, unstructured social exchanges, like joint play, is a measure of one's own behavioural and mental plasticity in front of a social partner. The ability to understand others' attitude and react contingently makes the interaction synchronized, accessible and fluid. If the child with ASD needs support in understanding his or her partner in this context, so does the parent. A high skilled parent could render the interaction less effortful and facilitate the child's development in several domains. In fact, a more efficient paren- The Thorn in the Dyad: Parent-Child Relationship in ASD 700 tal style, with normative levels of synchronization, has a positive impact on the developing child, influencing, for instance, language development (Siller & Sigman, 2002;Siller & Sigman, 2008). Therefore, parents' adequate sensitiveness has to be considered an incontrovertible aspect of a successful therapeutic approach. The same principle is valid for many situations of everyday life that take place out of the clinic: lunch and dinner, eating meals, with the problems that we described before. If the parents are able to read the signs of their child, they will be ready to interpret the source of distress and make correct choices. It is reasonable to think that parents should be educated to use their knowledge about their special child in various situations, and not only in predefined therapeutic settings. Therefore, the support for parents of a trained professional should be, if not continuous, constant in time and set on the new challenges along the child's development.
The therapeutic approach should not impose specific response to parents but offer a safe standpoint for reframing the child's behaviour (Bornstein & Venuti, 2013;Fava et al., 2011;Venuti, 2012). A reasonable option is that parents observe the child's communicative modalities during an interaction with a therapist. From this neutral position, a parent can observe what behaviour conducts to failure, intuitively guess and develop a knowledgeable perspective. This process is natural and devoid of negative consequences on the emotive sphere of the parent, avoiding additional disruption of his or her self-efficacy. The mediation of parent-child interaction by the therapist is the next step. During this phase, difficulties and worries can be verbalized and new approaches to a resolution discovered. Direct observation is only one aspect of a complex and complete series of interventions: through colloquia, deferred observation of recordings of therapeutic sessions, and the participation to groups for sharing experiences, a satisfying level of parenting competence can be achieved. Clearly, one of the goals of this kind of intervention is to support parenthood. As it has been recently shown, better communications skills of the child significantly affect parents' psychological distress (Ozturk et al., 2016); moreover, parents' expertise in the child's special way of communicating possibly improves after a number of cycles of treatment.

Future Directions
We took on this theme and highlighted some connection with the clinical picture of ASD; however, in order to really face this topic, it is necessary to take into account also differences among parents. For instance, gender specificity of parental reactions should be evaluated: the majority of studies included mothers, but not fathers.
Recent findings showed that levels of general stress related to parenting a child with ASD are not different between fathers and mothers (Ozturk et al., 2014). However, a specific scale of the Autism Diagnostic Observation Schedule-Generic (ADOS-G), the Communication scale, resulted positively correlated with fathers' perceived stress related to the child and with mothers' scores of general stress (Ozturk et al., 2014). Therefore, an open question is if distress related to non-verbal communication impairment in ASD differs between mothers and fathers since a difference in terms of parental attitude is present. The scores associated with social exchanges have been reported higher in mothers of children with ASD (Ozturk et al., 2014); social exchanges involve face-to-face interaction and a closer physical contact, factors that could modulate differently the impact of an impaired non-verbal communication. This could be a starting point for conceiving future research projects and differentiated intervention programs.

Conclusion
In this paper, we illustrated the importance of nonverbal communication impairment -including cry, social gaze, and movement execution and comprehension -in modulating the parent-child relation. Through a relevant issue for families of children with ASD -the detection and management of gastrointestinal problems and food selectivity -we described an example of the negative consequences of non-verbal communicative impairment in the everyday life. In addition, we discussed how parental distress relates to different degrees of functioning in communication between parent and child. Finally, we presented an intervention strategy that may help parents to overcome the communication difficulties.
To conclude, the intervention with the child on early communication channels is crucial soon after the diagnosis, and parents should be instructed about the atypical communication attempts. A better communicative attitude in the child and an empowered sensitivity of parents to atypical attempts of communication has the potential to improve the quality of the parent-child relationship, reducing parental stress and ameliorating the life of families.
Further research is needed in order to find out the best way to work on non-verbal communication aspects as well as how to adapt these kinds of interventions to the child and parents' needs.

Funding
The authors have no funding to report.