Browsing by Author "Malcolm-Smith, Susan"

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    A grounded theory exploration of how young autistic adults assigned female at Birth (AFAB) make meaning of friendships
    (2025) Ovadia, Alexa; Malcolm-Smith, Susan; Spedding, Maxine
    Friendships are fundamental to human development and overall well-being. For autistic adults assigned female at birth (AFAB), navigating neurotypical norms and gendered expectations of friendship presents unique challenges, influencing how they understand, value, and experience friendships. Furthermore, autistic AFAB individuals belong to a stigmatised social group, additionally impacting their navigation of friendship. While there is increasing recognition of autistic AFAB adults' experiences, they remain underrepresented in autism due to historical diagnostic discrepancies. This study aims to address this gap by exploring how autistic AFAB individuals make meaning of their friendships, an area that is relatively unexplored. Using a constructivist grounded theory approach, nine semi-structured interviews were conducted with autistic AFAB individuals aged 19 to 28, all of whom had received a clinical autism diagnosis. Social Identity Theory (SIT) informed the analysis, emphasising how group membership as a stigmatised social identity shapes participants' sense of self. The study examined the nuanced ways autistic AFAB young adults assign meaning to friendships by exploring perceptions of friendship, their roles within these relationships, social expectations, and how their autistic identity influences these dynamics. The resulting theory reveals that autistic AFAB individuals construct meaning in their friendships through a dynamic and reciprocal interplay between their experiences of being autistic, social constructs of friendship, and their autistic identity. These elements, although distinct, are interconnected and continuously influence one another. As friendships evolve and individuals undergo personal growth, these processes intersect, shaping and reshaping the meaning and value ascribed to friendships over time. This research contributes to a more inclusive understanding of friendship by centring autistic AFAB individuals' perspectives. It offers critical insights to better support autistic AFAB young adults in fostering meaningful connections and it further challenges prevailing stereotypes about their relational capacities.
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    A Systematic Review of Interventions for Teaching Empathy in Child and Adolescent Samples
    (2023) Blacher, Ashlee; Malcolm-Smith, Susan; Pileggi Lea-Ann
    Introduction: Escalating levels of youth violence and aggression is today a major global concern and is notably apparent in South Africa. Despite the deleterious consequences associated with these acts, a long-term, efficacious intervention is still lacking. Furthermore, early onset aggression has repeatedly been linked to later aggression, which underscores the need for intervention in a younger cohort of the population. Various international studies have positioned empathy as a notable correlate of violence and aggression, associating increased empathy with a decreased risk of presenting with violent and aggressive behaviour. Research has also demonstrated the potential to enhance child and adolescent empathic behaviour using various interventions. These findings lend themselves to the possibility of using empathy enhancing interventions to counteract youth violent and aggressive behaviours. Method: To this end, a PRISMA-P compliant systematic review of randomised pre-/post-test experimental studies was conducted to assess the efficacy of interventions that have been used to enhance empathic behaviour among child and adolescent samples. Eight journal databases were searched, using key terms relating to teaching, empathy, children/adolescents, and interventions. Results: Of the 1,656 articles found, the authors reviewed the full texts of 161 articles. A total of 38 articles were included in the final analysis (ten randomised control trials, 18 cluster randomised control trials, one class randomised cross over design and nine pre-/post-test randomised experimental designs). Included interventions were classified according to eight categories: classroom-based social emotional learning (SEL) interventions (N=10), narrative/conversation-based interventions (N=8), game-based interventions (N=3), physical education (PE) interventions (N=2), mindfulnessbased interventions (MBIs; N=3), home-based, caregiver-administered interventions (N=2), role play interventions (N=1) and other (N=9). Conclusion: Evidence from the review indicates that empathic behaviour can be enhanced in children and adolescents. Notably, this review is the first of its kind to assess the efficacy of these interventions in an all-inclusive, universally applicable manner and in neurotypical child and adolescent samples. However, the review also highlights the need for a concrete, unanimously accepted definition of empathy so that future research can make more definitive conclusions and more accurate comparisons.
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    The absence of cradling bias in autism spectrum disorders: illustrating deflicits in basic empathis processes
    (2011) Pileggi, Lea-Ann; Malcolm-Smith, Susan
    Deficits in empathy are considered a defining characteristic of autism spectrum disorders (ASDs). A fundamental difficulty these individuals experience is that of relating to others. Impairments in both top-down and bottom-up processes involved in relating are implicated, as these individuals experience difficulties in relating to others on both a cognitive and a visceral level. Research focussing on their more basic difficulties with social reciprocity (i.e., bottom-up processes of relating) is, however, lacking. A well-established social phenomenon, namely cradling bias (i.e., the preference to cradle an infant to the left of the body midline) is argued to be facilitated by a capacity for empathy. Previous studies provide reason to suspect that this phenomenon taps into the innate ability to relate to another; in other words, it taps into basic bottom-up empathic processes. With the goal of drawing attention to the very basic difficulties in relating and social reciprocity pervading ASDs, I investigated whether the universal leftward cradling bias was absent in ASD children. This research consisted of a pilot and a main study. Both studies were cross-sectional comparisons of two groups: an ASD group and a Control group. For both studies, the method employed was quasi-experimental, as participants were divided into groups based on the pre-existing criterion of diagnosis (i.e., ASD and Control). The ASD groups (for both studies) included children diagnosed with low-functioning autism, high-functioning autism, Asperger's syndrome, and pervasive developmental disorder-not otherwise specified. For the pilot, the Control group consisted of only typically developing children, whereas for the main study, the Control group consisted of typically developing as well as mentally handicapped children. Direct systematic observation was employed to compare the occurrence of cradling bias across groups. In the pilot study, 20 ASD children, aged 6-14, and 20 Control children, aged 5-15, were asked to cradle a doll as if it were an infant she/he were trying to put to sleep or soothe on three separate occasions. These participants were perfectly matched on age and gender. In the main study, 53 ASD children, aged 6-16, and 40 Control children, aged 6-15, were asked to cradle a doll on four separate occasions. These participants were matched as closely as possible on age and gender. Regression analyses on both the pilot and the main study data revealed that the universal leftward bias was absent in ASD children. In contrast, a clear leftward bias was present in Control children, both typically developing and mentally handicapped. These group differences were not accounted for by differences in gender, handedness, intellectual and/or executive functioning. Moreover, differences in the quality of the child-doll (i.e., caregiver-infant) interaction in the cradling bias scenario illustrated the very basic social- emotional difficulties experienced by ASD individuals. The cradling bias scenario is one instance where impairments in primitive bottom-up processes of relating in ASDs can be illustrated. Further investigation of these bottom-up difficulties will allow for a more nuanced understanding of the empathy deficits (i.e., social- emotional deficits) by which ASDs are characterised, which in turn has implications for the management and treatment of these individuals.
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    Afrikaans autism diagnostic observation schedule-2 : translation and cultural appropriateness for the coloured population from low-middle socioeconomic backgrounds living in the Western Cape
    (2015) Smith, Lesia; Malcolm-Smith, Susan; De Vries, P T
    One of the key needs in diagnostic practice for autism spectrum disorder (ASD) in South Africa is to generate acceptable and valid diagnostic tools for use in the official languages of the country. The Autism Diagnostic Observation Schedule-2 (ADOS-2) is the "gold standard" diagnostic tool for ASD and it is increasingly used in South Africa. However, its use is limited to English-speakers, as the tool has not been translated into any of South Africa's commonly spoken languages. Moreover, the cultural appropriateness of this tool for the local cultures of South Africa has not been explored. Consequently, this study translated the ADOS-2 into Afrikaans and assessed its cultural appropriateness for the coloured population from low-middle SES backgrounds residing in the Western Cape by using a mixed method approach. Three components associated with method bias were investigated to determine the cultural appropriateness of the tool for this population; the language used in the Afrikaans translation of the ADOS-2, the social interactions and activities in the ADOS-2, and the ADOS-2 materials. The Afrikaans ADOS-2 was pre-piloted in a clinical sample and an ethnographic investigation of play, social interaction, and social activities was conducted in a community sample. The data regarding play collected from the community sample is new to literature on this population.
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    Attachment and Emotion Regulation in Adolescents with FAS-Dysmorphism
    (2021) Kemp, Andrea; Malcolm-Smith, Susan; Jacobson, Sandra; Lindinger, Nadine
    Children with fetal alcohol spectrum disorders (FASD) are frequently reported by caregivers and teachers to have difficulties in socio-emotional functioning. It has been suggested that deficits in emotion regulation underlie these deficits in socio-emotional functioning. Children with prenatal alcohol exposure (PAE) have also been found to demonstrate higher rates of insecure attachment, as well as disorganised attachment. Previous research proposes that the attachment relationship serves as a foundation for the development of emotion regulation. However, while this association has been examined in typically developing samples, the relation between attachment and emotion regulation has yet to be examined in individuals with FASD. Previous research has also suggested that a portion of individuals who are considered heavily exposed but are non-syndromal (HE) who do not present with the full phenotype characteristic of FAS or PFAS may nevertheless present with subtle facial dysmorphism only detectable using dense surface modelling and signature analyses of 3D facial images. Furthermore, it has been shown that HE children with this subtle facial dysmorphism perform more poorly on cognitive assessments than HE children who do not present with this subtle facial dysmorphism. These findings therefore suggest that presence of even subtle dysmorphism (i.e. only detectable on signature analyses of 3D facial images) consistent with FAS can be a good indicator of cognitive performance. Given this, the aims of the current study were to examine the association between FAS-dysmorphism and insecure as well as disorganised attachment. Furthermore, the study aimed to examine the extent to which FAS-dysmorphism was associated with emotion regulation difficulties in adolescence after controlling for the effects of attachment security in infancy. Participants included 77 adolescents (M age = 17.66, SD = .7): 13 with fetal alcohol syndrome (FAS), 12 with partial FAS (PFAS), 7 HE-dysmorphic (HE+), 18 HE-nondysmorphic (HE-) and 27 non- or minimally exposed controls. At the 13-month infant assessment, the mother-infant attachment relationship was assessed using the Ainsworth Strange Situation Paradigm (Hay, Jacobson, Molteno, Viljoen, & Jacobson, 2004; Jacobson & Jacobson, 2013). At the adolescent follow-up assessment, emotion regulation was assessed using two caregiver-report measures – the Emotion Regulation Checklist (ERC; Shields & Cicchetti, 1997) and the Affect Regulation Checklist (ARC; Moretti, 2003). Results showed that infants with FASdysmorphism+ did not demonstrate significantly higher levels of insecure and disorganised attachment than those in the FAS-dysmorphism- group. In terms of emotion regulation, FASdysmorphism+ did not significantly predict any of the adaptive or maladaptive emotion regulation subscales. However, insecure attachment predicted maladaptive emotion regulation, but not adaptive emotion regulation. These results suggest that while individuals with FASD are often reported to exhibit difficulties with emotion regulation, other variables, including IQ and attachment security in infancy, may explain some of the variation in the emotion regulation difficulties observed for individuals with FASD.
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    Attachment styles, parenting styles and theory of mind: an exploration of their relationships with social deficits in Autism Spectrum Disorder
    (2016) Bailey, Nakeeta Catherine; Malcolm-Smith, Susan
    Autism Spectrum Disorder (ASD) is fundamentally characterised by social deficits. It is thus important to understand social functioning and what contributes to social development in children on the spectrum. It is widely accepted that ASD has a neurobiological basis, however research on understanding the lack of social skills found in ASD individuals remains indefinite and controversial. In this thesis we explored attachment styles, parenting styles and ToM to discern how they relate to social deficits in ASD. The literature for typically developing children has illustrated important relationships however there is a lack of exploration in the ASD populace. This protocol was divided into two studies. Study 1 assessed social deficits, attachment and parenting styles in 46 children with ASD aged 4 – 14 years and included both verbal (n = 19) and non-verbal (n = 27) children. The ADOS-2, Attachment Style Classification Questionnaire, and Parenting Style Dimension Questionnaire were used to measure these variables. Study 2 assessed ToM capacity and its relationship with parenting styles and social deficits in verbal children with ASD. In Study 1 we found verbal and non-verbal subgroups differed on social deficits. The aims for exploring attachment and parenting styles were to discern 1) what style dominates; 2) whether attachment and parenting styles differ between verbal and non-verbal children and 3) whether these variables relate to social deficits. We found odd patterns of attachment with no clear dominant style in our full sample. Only the non-verbal subgroup showed a relationship between secure attachment and reduced social deficits. In terms of parenting, the authoritative style was reported to be mostly employed by our parents and it related to reduced social deficits in both the full sample and the verbal subgroup. In Study 2 we explored 1) the extent of ToM deficits in ASD; 2) how parenting styles relate to ToM and 3) whether better ToM and parenting in combination related to reduced social deficits. We found severe ToM deficits in our sample which suggests delayed development. Authoritative parenting was significantly related to better ToM capacities. Furthermore, a regression of positive parenting and ToM abilities in combination with social deficits indicated that only ToM and age predicted less social deficits. This current study suggests that specifically authoritative parenting and ToM skills may be important underlying mechanisms for better social abilities in ASD. Most notably, it stresses that ASD cannot be regarded as a homogenous population as a clear distinction between the verbal and non-verbal subgroups is reported herein; a currently underestimated notion. Although still in its preliminary stages, the work reported in this thesis opens up a new line of thinking that could, in principle prove to be beneficial to research in the area of ASD.
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    Attachment, Empathy and Social Ability as Correlates of Leftward Cradling in Students
    (2023) Khalfe, Faieeza; Malcolm-Smith, Susan; Pileggi Lea-Ann
    Many theories have been put forth in order to explain the emergence of leftward cradling bias - the universal phenomenon whereby humans tend to exhibit a bias for cradling to the left when trying to soothe an infant. Current research supports a cerebral laterality hypothesis, which suggests that this bias emerges because of the specialised decoding and processing of facial emotional expressions, affect, and socio-emotional stimuli, as well as non-verbal aspects of communication, all of which take place in the right cerebral hemisphere. The leftward positioning of the infant places them in the cradlers left auditory and visual fields. This placement is argued to allow for better monitoring of the infant. This has a reciprocal advantage for the infant – as they are able to perceive the more expressive side of the cradlers faces. This facilitates optimal relating and subsequent bonding, both of which contribute to developing future prosocial behaviors. Consequently, it has been recently argued that leftward cradling bias is reflective of better attachment, empathy, and social ability. It is also argued that mood-related states of depression and anxiety should disrupt leftward cradling bias, given that both disorders are associated with difficulties in socio-emotional relatedness. This study aimed to investigate the relationship between leftward cradling bias and socio-emotional relatedness. To do so, I looked at the relationship between the preferred cradling side and (1) three variables of socio-emotional relatedness - attachment, affective empathy, and social ability - and (2) mood-related states and symptoms of both depression and anxiety. The sample in this study were undergraduate male and female Psychology students (N = 677) at the University of Cape Town in South Africa. It was conducted online. Participants first placed a demographic questionnaire, after which they completed a series of self-report questionnaires between four cradling bias task trials. Despite a theoretical basis, hierarchical regression analysis indicated that none of the variables of interest predicted cradling side in this sample. Only handedness predicted cradling side, with right-handed individuals being significantly more likely to demonstrate the leftward cradling bias (β = -.11, p = .003). However, this variable only contributed 1% in explanation (R2 = .01). Future research should consider a threshold hypothesis in relation to variables of socio-emotional relatedness. An argument can be made that clinically significant deficits in socio-emotional relatedness, as seen in clinical disorders such as narcissistic personality disorder and borderline personality disorder, could disrupt the otherwise universal leftward cradling bias.
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    Autism screening in children: using the social communication questionnaire in a Western Cape population
    (2013) Bozalek, Faye; Malcolm-Smith, Susan; Hoogenhout, Michelle
    Autism spectrum disorder (ASD) has a global prevalence of approximately one percent of all new births. There is a lack of literature on autism in South Africa. South African children are waiting years for diagnoses, despite the fact that early diagnosis and subsequent intervention appear to have a positive effect on the outcomes of the intervention. A screening device to detect ASD could be used to speed up the diagnostic process. This study tested the viability of using the Social Communication Questionnaire (SCQ) in a Western Cape state-funded hospital. This thesis describes Phase 1 of a larger study. The 40 item SCQ was adapted and translated into Afrikaans and isiXhosa. The English, Afrikaans and isiXhosa versions of the SCQ were administered to parents of very young children attending the Red Cross Children?s Hospital?s developmental clinic (N = 228, age range of children = 3.00-5.97 years). Positive results were that no relationship was found between age and SCQ score, or between SCQ language version and SCQ score were found. However there was a relationship between SCQ score and socioeconomic status, indicating a possible bias in the SCQ. Internal reliability of the SCQ versions was analysed and was satisfactory. The factor structure of the English SCQ was examined. Two and four factor solutions were explored, with the two factor solution proving the best fit with good internal reliability. This two factor solution reflected the recent changes to the Diagnostic and Statistical Manual of Mental Disorders, as well as previous findings on the SCQ and the ADI-R, the diagnostic instrument on which the SCQ was based. Preliminary results of Phase 2 of the larger study were analysed. Eighteen children received an Autism Diagnostic Observation Schedule (ADOS) assessment;; the current gold standard for diagnosing ASD. SCQ scores proved to be a good predictor of ASD diagnosis, predicting 17 out of 18 individuals correctly. Further research on isiXhosa and Afrikaans versions of the SCQ as well as the predictive power, sensitivity and specificity and cut-off scores for the SCQ is recommended.
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    Blushing and gaze avoidance in social anxiety disorder : a structural neuroanatomical investigation
    (2014) Van der Merwe, Nicolina Thandiwe; Stein, Dan J; Malcolm-Smith, Susan; Brooks, Samantha J
    Background: Social anxiety disorder (SAD) is a common psychiatric condition characterised by fear and avoidance of social situations. Lifetime prevalence is 5-16% and co-morbidity with other mood and substance abuse disorders is common. Symptoms including cognitive, behavioural and physiological components vary between individuals. Of these, blushing and gaze fear and avoidance are regarded as cardinal symptoms. First line treatment of SAD involves SSRIs and cognitive behavioural therapy, while surgery may also be considered for excessive blushing. Blushing and gaze avoidance are thought to have an evolutionary adaptive advantage, promoting the display of submissive behaviour and appeasement in threatening situations. MRI research has demonstrated differences on functional and structural neuroimaging between patients with SAD and healthy controls (HCs). However, little is known about the neurocircuitry underlying gaze fear and avoidance or increased blushing propensity or how the severity of these traits correlate with the neuroimaging differences found in SAD. In this research, I explored the neuroanatomy of blushing propensity and gaze fear and avoidance in the context of SAD. Methods: 18 SAD patients and 18 HCs underwent structural MRI scans and self-report scales were administered to assess their symptom severity, blushing propensity and gaze fear and avoidance. Structural data was analysed using voxel-based morphometry (VBM). Regression and contrast analyses were used to correlate blushing propensity and gaze anxiety and avoidance symptoms with brain volumes, controlling for total grey matter volume, age and level of education. Results: Anxiety, blushing propensity and gaze fear and avoidance symptoms were all significantly higher in SAD patients (p<0.001). Brainstem volumes were increased for higher blushing scores a (p<0.01), while the volumes of left inferior parietal lobe b (p=0.04) and left occipital cortex a (p<0.01) were decreased. With increased gaze fear and avoidance, there were associated decreases in the right posterior cingulate cortex a (p<0.01), right occipital lobe b (p=0.03) and right fusiform gyrus a (p<0.01). Increased blushing and gaze symptom severity considered together, was associated with increased brainstem volume a (p<0.01) and decreased pons/cerebellum b (p=0.001), right cerebellum b (p=0.009), left cerebellum c (p<0.001) and left inferior parietal lobe a (p<0.1), volumes. Contrast analysis of SAD and HC brain volumes revealed a greater grey matter volume in HCs in the regions of left occipital cortex (p<0.01), left anterior cingulate (p<0.01) and right inferior parietal lobe (p<0.01) when compared to SAD patients. Increased symptom severity in SAD was significantly associated with higher volumes in the left premotor cortex (p<0.01), right hippocampus (p<0.01), left orbitofrontal cortex (p<0.01) and right superior temporal cortex (p<0.01). Possible areas for of interest for volume differences between SAD and HCs include total grey matter volume (d =0.83), left and right anterior cingulate cortex (d =0.68 and d =0.65), and left and right dorsolateral prefrontal cortex (d =0.55 and d =0.54), yet these differences were not significantly different. (a uncorrected peak levels b uncorrected cluster level, c corrected cluster level). Conclusion: Differences in brain volumes pertaining to blushing and gaze fear and avoidance in SAD patients may be a contributing factor or a consequence of these core symptoms, and a potential biomarker for SAD. Future studies could build on this preliminary research with increased sample sizes, and determine the possible effects of reduced symptom severity and treatment options on brain structure and function. Most importantly, an investigation of the genetic underpinnings and functional neural correlates of blushing and gaze avoidance behaviour may enhance our understanding of the complex aetiology of these cardinal SAD symptoms, thereby improving our understanding of SAD as a psychiatric disorder and facilitating better patient care and management.
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    Cortical Gyrification in Methamphetamine Associated Psychosis: A Potential Neurodevelopmental Biomarker for Risk of Psychosis
    (2024) Gribble, Amy; Malcolm-Smith, Susan
    For many years, methamphetamine associated psychosis (MAP) has been viewed as a symptomatic, genetic, and morphological blueprint for schizophrenia spectrum disorders (SSD) (Aoki et al., 2013; Grant et al., 2012; Uhlmann et al., 2016; Yang et al., 2021). MAP is currently diagnosed as a substance induced disorder; however, many researchers suggest that MAP may represent a transition into SSD following substance use (McKetin, 2018). The current study investigated global and local gyrification indices (GI) as a potential neurodevelopmental biomarker for psychosis vulnerability in three quasi-experimental groups; methamphetamine users without psychosis (n=21), individuals with MAP (n=18) and healthy controls (n=21). Gyrification indices were determined for each participant using Freesurfer 7.2 and compared across groups with age and sex as covariates in a multivariate analysis of co-variance (MANCOVA). The results demonstrate that group membership alone significantly accounts for 32% of the variation in overall gyrification (F(12, 106) = 1.87, p=.06, η²=0.16; Wilk's lambda = 0.68, p=.04). Follow-up ANCOVAs suggest that individuals who use methamphetamine have higher temporal gyrification than MAP and control participants, although this result was not statistically significant. There was also a significant effect of age on gyrification (F(6, 50) = 5.37, p<.01, η²=0.39; Wilk's lambda = .61, p<.01). Further associations between gyrification and age (r=-0.43, p<0.05), cannabis use and temporal gyrification (r=0.29, p<0.05), alcohol use and temporal (r=0.34, p<0.05) and parietal gyrification were found (r=0.26, p<0.05), as well as age of methamphetamine use onset (r=-0.40, p<0.05). These results offer more evidence on the harmful effects of drug use on brain structure, posing new questions around the developmental basis of gyrification and its status as a biomarker for disease.
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    Does mood induction elicit emotion recognition biases? : an empirical study with implications for depression research
    (2015) Harding, Steven; Malcolm-Smith, Susan
    Depression is a highly prevalent, debilitating, and sometimes-fatal mental illness. Typically, its treatment approaches are conceptualised as a dichotomy between psychological and pharmaceutical. However, a new model, in line with cogent philosophical reasoning and recent empirical evidence, integrates these approaches. The cognitive neuropsychological model places affective processing biases as central to depression aetiology and treatment-in both biological psychiatry and cognitive psychology. One affective bias, emotion recognition, is central to the tenets of this model, which, unlike some cognitive theories, places improved affective biases as temporally prior to improved mood, and as the underlying mechanism of antidepressant action. To test this account of emotion recognition bias, 103 undergraduate students participants underwent negative, positive, and neutral mood induction in a betweengroups design to assess whether mood-congruent emotion recognition biases would emerge in a multimodal (facial, vocal, musical) emotion recognition battery, while controlling for depression symptoms and assessing maladaptive cognitive schemas. Few significant emotion recognition biases resulted, but significant negative correlations between negative schemas and overall facial and musical accuracy emerged, even when controlling for depression lending some support to the cognitive neuropsychological model's premise of a bilateral relationship between schemas and emotion recognition, both of which may play a substantial role in the etiology of depression.
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    Early socioemotional development: Investigating protective factors that support resilience in a South African birth cohort study
    (2025) De Leeuw, Joannes; Malcolm-Smith, Susan
    Globally, the prevalence of mental health challenges amongst children is increasing, raising significant concerns. Despite this, there remains a limited understanding of the protective factors that support resilience in children from low- and middle-income countries (LMICs). In high-risk contexts, resilience can serve as a critical buffer against adverse effects on mental health. However, the intricate interplay between risk and protective factors in young children has been insufficiently explored, despite the foundational role of early childhood experiences in shaping an individual's positive developmental trajectory. In my thesis, I conducted a scoping review to summarise the current evidence on resilience in children aged 10 years and younger, synthesizing how resilience is conceptualised and operationalised in LMICs. I also presented a novel perspective on childhood adversity by examining both children's exposure to community violence and their emotional response. Finally, I investigated the relationship between resilience, adversity, and mental health outcomes over time in children aged 8 years and younger in the South African Drakenstein Child Health Study. The scoping review revealed that only 26 studies from 14 countries investigated childhood resilience in LMICs, highlighting a significant paucity of data, particularly in longitudinal research. In my own study of adversity, I provided a novel bifactor model, with a general adversity factor (combining violence exposure and emotional responses) and four subscales, capturing nuanced emotional responses beyond frequency and severity of adverse exposures. Importantly, higher resilience scores were consistently linked to lower mental health difficulties over time, with significant interaction effects between adversity and resilience. Moderating effects were observed at individual levels (e.g., emotion regulation, temperament), relational levels (e.g., caregiver resilience, maternal employment), and contextual levels (e.g., household income), underscoring the multifaceted nature of resilience in high-risk settings. This thesis underscores the dynamic nature of resilience in the face of ongoing adversity during childhood in high-risk contexts. By identifying several protective factors at different timepoints, it makes a significant contribution to this underexplored area and emphasises the importance of designing resilience-focused interventions to mitigate mental health difficulties in young children from LMICs.
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    Effortful Control, Attention and Executive Functioning in the Context of Autism Spectrum Disorder
    (2019) Page, Teneille; Malcolm-Smith, Susan; Hamilton, Katie
    Autism Spectrum Disorder (ASD) involves a broad presentation of symptoms classified along continuum of severity, with core deficits in Social Affect and Restricted, Repetitive Behaviours required for formal diagnosis (American Psychiatric Association, 2013; Lauritsen, 2013). The development of particular cognitive, behavioural and interpersonal difficulties seen in ASD is of great interest. Temperament offers particular value given that it influences the development of social behaviours, emotionality and self-regulation (Shiner et al., 2012). The self-regulatory temperament factor, effortful control, is known to be diminished in ASD (Garon et al., 2009, 2016) and is theorised to be related to attention and executive functioning (Rothbart & Rueda, 2005). This link is of particular interest, given that attention and executive function deficits are prominent in ASD (Craig et al., 2016; Lai et al., 2017; Sanders, Johnson, Garavan, Gill, & Gallagher, 2008). To date, however, a thorough literature search failed to yield a study which has investigated whether effortful control,attention and executive functioning are concurrently associated with ASD symptomatology.Moreover, the relationship between effortful control, attention and executive functioning is not as unambiguous as previously theorised in typical development, with little investigation into these relationships in ASD. To elucidate the association effortful control, attention and executive functioning have with ASD symptomatology, the relationship between effortful control and these cognitive variable needs to be better established empirically. Therefore the current investigation’s aims were twofold. Study One investigated the relationship of effortful control with attention and executive functions in neurotypical and ASD samples. Study Two explored the association between effortful control, attention, executive functions and core ASD deficits (i.e. Social Affect and Restricted, Repetitive Behaviours). A sample of 38 ASD and 38 neurotypical boys (aggregate-matched on key demographic factors), aged 6 - 15, and their primary caregivers were recruited. Study One considered both groups (n=76) and featured both quasi-experimental and relational investigations. Study Two focused only on the ASD sample (n=38) and used a purely relational design. Neurocognitive measures were used to assess two attention domains (i.e. attention span and sustained attention), and three executive functions (i.e. working memory, inhibition and switching). Effortful control was measured using a parent-report questionnaire and ASD core deficits were examined using the Autism Diagnostic Observation Schedule, Second edition (ADOS-2; Lord, Luyster, Gotham, & Guthrie, 2012). Results of Study One revealed effortful control was a significant predictor of attention span, working memory and inhibition, with ASD participants performing significantly more poorly on these cognitive domains and rated significantly more poorly on effortful control. Study Two’s results indicated that Social Affect was significantly correlated with inhibition and the interaction effect between effortful control and working memory. Furthermore, only effortful control, attention span and their interaction effect were significantly associated with Restricted Repetitive Behaviours. Specifically, effortful control was found to moderate this relationship. At high levels of effortful control, increased attention span was associated with less Restricted, Repetitive Behaviours. These findings may aid efforts to establish a predictive model for ASD core deficits on the basis of temperament and cognitive difficulties. Keywords: Autism Spectrum Disorder (ASD), Effortful Control, Attention, Executive Functions, Social Affect, Restricted Repetitive Behaviours
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    Empathy in autism spectrum disorder: Predictions from child/adolescent temperament, parenting styles, and parenting stress
    (2019) Ross, Toni Carmen Faith; Malcolm-Smith, Susan; Hamilton, Katie
    Individuals with autism spectrum disorder (ASD) exhibit definitional impairments in social relatedness; a phenomenon that can be explained, in part, by their deficits in empathy. Despite the extent of these deficits, relatively little is known about which factors promote or impede empathic functioning within this group. To date, studies of neurotypical children and adolescents suggest the explanatory power of temperament, parenting style, and parenting stress; associations which have yet to be adequately explored with ASD. Thus, the overarching aim of this investigation was to test whether the aforementioned intra- and interindividual features would predict empathy amongst children and adolescents with ASD. To account for some of the heterogeneity in ASD, two groups of parent-child dyads were recruited: one comprising male children and adolescents with intact receptive and expressive language (n = 40, M = 7.68 years); the other, males with little to no language use in either domain (n = 40, M = 9.09 years). A third group of parent-child pairs comprising male neurotypical children and adolescents with age-appropriate language functioning was included as a comparison sample (n = 40, M = 9.53 years). Parents completed wellestablished questionnaires pertaining to child/adolescent temperament and empathy, as well as parenting style and parenting stress, primarily via telephonic interviews. Results showed that temperamental regulation and negative affectivity were linked to empathy within the neurotypical group in positive and inverse directions, respectively. Only regulatory processes were positively associated with empathy within the non-verbal ASD group, whilst only negative affectivity was inversely associated to empathy within the verbal ASD group. Further, warm, responsive, autonomy-promoting parenting was positively associated with empathy within the neurotypical group, whilst punitive and lax parenting were inversely associated with empathy. Positive forms of parenting were also found to predict empathy within both ASD groups – though somewhat less so within the verbal ASD group. Perhaps a consequence of the severity of their empathic deficits, lax and permissive parenting techniques were not tied to empathy within the ASD groups. Finally, parenting stress was inversely linked to empathy within the non-verbal ASD and neurotypical groups only. Results highlight that findings obtained within neurotypical samples cannot always be extrapolated to ASD. Results further underscore the need for ASD interventions to adopt a family systems perspective, teaching parents how to perceive and respond to their children in adaptive ways.
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    Epistemic action and language : a cross-linguistic study
    (2008) King, Warren; Malcolm-Smith, Susan; Nunez, David
    Epistemic actions are physical actions which increase the speed, accuracy, and/or robustness of internal computation by allowing cognitive work to be off-loaded to the environment, thus simplifying internal computation. Previous studies on epistemic action are limited in that they demonstrate that epistemic actions may only improve task performance within tasks which are inherently spatial in nature. In this regard, a cross-linguistic replication of an experiment by Maglio et al. (1999) which required participants to produce as many words as possible within five minutes from a string of seven random letters was performed in order to investigate epistemic actions in a verbal task domain.
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    Euphoria in multiple sclerosis: an investigation of constructs and symptons
    (2014) Duncan, Amy Louise; Solms, Mark; Malcolm-Smith, Susan
    In multiple sclerosis (MS), some patients are said to present with unawareness of deficit, and positive mood and optimism that is out of place or incongruous given the patient's circumstances. The history of these symptoms, collectively known as euphoria, however, is characterised by marked inconsistencies regarding a number of aspects of these symptoms. This research attempted to investigate both the constructs, and the symptoms themselves, with the aim of better defining and broadening our understanding of euphoria. Results revealed that a change in the definition of euphoria appears to have occurred since the concept was introduced by Cottrell and Wilson. Different operational definitions appear to be partly responsible for the very different incidence rates reported throughout the literature. Instead of the classical three types of euphoria identified by the classical authors, or the single type utilised in the contemporary literature, the current research revealed two types of euphoria in MS (viz. positivity and unawareness). Positivity appears to be a subjective mood/outlook experienced by the patient and not an outward façade projected by the euphoric individual, and was defined in fairly subtle terms. Unawareness appears to relate to a number of domains (including physical, cognitive and mood or behavioural deficits), and was measured via participant/informant discrepancies on self-report questionnaires. Both positivity and unawareness were represented on a continuum and appeared to have different demographic, disease and cognitive correlates. Positivity was significantly predicted by a medical history of conditions that can affect neuropsychological functioning. Unawareness of physical deficits was associated with a female gender, a younger age, a lower income, relapsing-remitting course, a current disease state of relapse or exacerbation, a shorter disease duration, but a greater disease severity in terms of physical disability. Severity of the disease and the cognitive composite representing cognitive functions sub-served by the orbitobasal frontal cortex were also significant individual predictors of unawareness of physical deficits. Visuospatial ability significantly predicted unawareness of cognitive deficits. No demographic, disease or cognitive correlates of unawareness of mood or behavioural deficits were identified. Finally, no indisputable single cause underlying the two types of euphoria in MS identified by this research was isolated by the exploratory investigations undertaken; however interesting preliminary findings that may tentatively implicate executive dysfunction as well as, possibly, immunological disease processes in the etiology of euphoria in MS were revealed. These results have broadened our understanding of euphoria in MS and may shape both the research and clinical work with euphoric patients going forward.
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    Examining empathy in Autism Spectrum Disorders: cognitive, subjective and physiological correlates of the perception of pain
    (2017) Hoogenhout, Michelle; Malcolm-Smith, Susan; Weyers, Peter; Schulz, Stefan
    Social-communication impairments in autism spectrum disorder (ASD) are often ascribed to deficits in empathy. I argue that social-communicative deficits in ASD stem from impairments in specific aspects of empathy, rather than a general empathy impairment. Empathy is defined as the sharing of another's emotion (affective empathy), understanding others' mental states (cognitive empathy), and regulation of one's own emotional state (self-regulation). Empathy can also lead to muscle mimicry and empathic concern for another's wellbeing. I argue that empathy should be measured on multiple levels: cognitive, subjective and physiological. Particularly, measurement of autonomic regulation can contribute to characterising the empathy profile in ASD. Furthermore, confounding factors such as lack of understanding of one's own emotions, or alexithymia, must be accounted for when measuring empathy. I measured subjective trait empathy ratings in people with varying levels of autism traits (N₁ = 519 & N₂ = 98, ages 14 - 45). I also investigated the association between physiological arousal, trait empathy, and empathic concern for (1) sensory pain and (2) facial pain expressions, controlling for alexithymia (N = 98); and examined the evidence for atypical autonomic arousal at rest and during empathy-induction in individuals with ASD. Autism traits were negatively correlated with cognitive empathy and self-regulation, but were not associated with atypical affective empathy per se. However, individuals with poor self-regulation showed heightened subjective affective states, whereas alexithymic individuals showed reduced affective empathy to facial pain expressions. Regarding the autonomic regulation of empathy, there was a significant association between autonomic arousal and affect regulation: Low sympathetic arousal and concurrent high parasympathetic arousal at rest predicted smaller changes in personal distress during pain observation than did autonomic co-inhibition. However, resting state arousal did not predict absolute affective state levels or dispositional empathy, and was not associated with amount of autism traits. In conclusion, the findings do not support the hypothesis of global empathy deficits in ASD. The results suggest that interventions focusing on own-emotion identification and self-regulation skills are important, but caution against the over-hasty adoption of interventions targeting resting state autonomic arousal, which was not related to either ASD or dispositional empathy.
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    An exploration of the relationship between autism spectrum disorders, theory of mind and the serotonin transporter promoter length polymorphism
    (2014) Hamilton, Katie; Malcolm-Smith, Susan
    Autism Spectrum Disorder (ASD) is a highly heritable prevalent pervasive developmental disorder. All cases have deficits in social communication and interaction and in restricted and repetitive behaviours and interests. The mechanisms underlying different clinical presentations remain elusive. Deficits in Theory of Mind (ToM), the ability to understand that others have mental states independent of one's own, have been suggested as a possibly underlying the socia l deficits in ASD. The serotonin transporter promoter length polymorphism (5 - HTTLPR) has been implicated in ASD, and as serotonin is implicated in social functioning more generally, it is possible that 5 - HTTLPR could underlie social functioning in ASD. As such, ToM and 5 - HTTLPR have been implicated in ASD, and specifically as underlying the social deficits typical of this disorder. This protocol assessed core ASD symptoms (i.e. deficits in social communication and interaction, and impairment in restricted and repetitive behaviours and interests) in 69 children with ASD between the ages of 7 and 14 years. The Autism Social Skills Profile, Social Communication Questionnaire, and Repetitive Behavior Scale - Revised assessed these symptoms. 5 - HTTLPR genotypes were established for 55 of these children. ToM was comprehensively assessed in 57 of the children using the University of Cape Town Autism Research Group's Theory of Mind Battery. This protocol is the first is a series of studies assessing the biological bases for social deficits in ASD. One of the main aims was to pilot the use of ASD scales in a local sample. The preliminary analyses assessed the performance of these scales. This data was also used to assess whether the new DSM - 5's merging of social communication and social interaction into a single domain was supported. Study One then assessed for possible relationships between 5 - HTTLPR and cores ASD symptoms, and hypothesised that the 5 - HTTLPR genotype with the most reduced serotonergic transmission woul d relate to increased deficits in social communication and interaction. Study Two explored possible relationships between core ASD symptoms and ToM, and between 5 - HTTLPR and ToM. It was expected that impairment in social communication and interaction would correlation with reduced ToM ability, and that ToM would be most impaired in children with the genotype with the most reduced serotonergic transmission. Preliminary analyses found the scales did not perform well in a local sample. This was likely due to cultural, socio - economic, and educational factors. The bluntness of the scales 13 and broad nature of ASD characteristics likely also contributed. The DSM - 5's diagnostic criteria were supported. Study One and Study Two found no relationships between core ASD symptoms, ToM, and 5 - HTTLPR. Core ASD symptoms were assessed very broadly and it was not possible to establish clear phenotypes for the participants, which likely undermined analyses. At most this protocol showed that broad assessment of core ASD symptoms is not specific enough to reveal relationships to underlying mechanisms, and that ToM and 5 - HTTLPR are not implicated when board measures are used. We emphasise the need for better measures in ASD. We also believe the serotonin system needs to be investigated beyond 5 - HTTLPR in ASD
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    Exploring the relationships between gender, affective and cognitive empathy, and aggressive behaviour in young Western Cape children
    (2019) Mayosvi, Panashe Agatha; Malcolm-Smith, Susan
    Aggression among children and adolescents has been a major area of focus for many researchers across the world. In South Africa, specifically, aggressive behaviour has increasingly become problematic. Aggression can be regarded as antisocial or offending behaviour. Aggressive behaviour usually results in unfavorable consequences for both the victim and the assaulter. Although aggression usually manifests itself physically, it also has underpinning psychological factors. One of the factors that most research has looked at in relation to aggressive behaviour is empathy. Most studies have, however not looked at how the different components of empathy separately affect or predict aggressive behaviour. Females have generally been found to be more empathic and less aggressive; however the relationships between the variables have not been adequately simultaneously investigated. This project therefore assessed the effect of both affective empathy and cognitive empathy on the manifestation of aggressive behaviour in young Western Cape children. The study focused specifically on externalized aggressive behaviour. The study further aimed to investigate if the association between these two components of empathy and externalized aggressive behaviour differed across gender. The study made use of quantitative measures to examine the relationships between the above-mentioned variables. The study recruited a total of 249 Colored, English speaking learners aged 3 to 12 and their parent or caregiver. The sample had approximately equivalent numbers of boys and girls and an approximately equal number of children from low, middle and high SES to ensure that each demographic stratum was represented sufficiently. Statistical analyses of the data indicated that in general the children in the sample had low levels of aggressive behaviour. No statistically significant gender difference in aggression was found. A non-significant relationship was found between affective empathy and aggressive behaviour. A significant negative relationship was however found between cognitive empathy and aggressive behaviour. The correlation between cognitive empathy and aggressive behaviour was significantly evident only among boys; boys who scored low in cognitive empathy scored high on the externalized subscale of CBCL. The study also investigated the effect of potential covariates, Age, SES and IQ on aggressive behaviour; none of these covariates seemed to influence aggressive behaviour. The results of this study provide vital inferences regarding prevention of aggressive behaviour in children. There were however some disparities from what literature reports and that require further exploration. Keywords: affective empathy, cognitive empathy, externalized aggressive behaviour, gender
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    Investigating correlates of aggressive behaviour in South African children and young adolescents living in the Western Cape: the role of empathy
    (2018) Pileggi, Lea-Ann; Malcolm-Smith, Susan; Decety, Jean
    Escalating rates of aggression in South African schools, particularly in the Western Cape, are disconcerting. The early childhood through adolescent years is therefore an important platform for investigations to inform strategies to reduce and prevent aggressive behaviour. Studies conducted outside of South Africa have identified numerous correlates of aggressive behaviour; investigation in South Africa has, however, been sparse. The role of empathy, in specific, has been limited to one prior investigation. Furthermore, while empathy is considered an important construct in explanations of aggressive behaviour internationally, theoretical and methodological issues have undermined findings to date. Our understanding of the relationship between empathy and aggressive behaviour needs refining. I investigated the role of empathy, while simultaneously investigating the role of several known correlates of empathy and aggressive behaviour in typically developing young adolescents (N = 160, ages 11-13; Study 1) and children (N = 76, ages 6-8; Study 2) living in the Western Cape of South Africa. To improve on previous investigations, I employed a framework informed by both neurobiological and behavioural approaches. I conceptualised empathy as comprising affective and cognitive components, as well as a self-regulation component concerned with regulation of affective states. Employing a contextual approach, I argued that the interaction between these empathy components along with multiple contextual factors would provide a more nuanced understanding of the relationship between empathy and aggressive behaviour. I used hierarchical regression and structural equation models to investigate the correlates of aggressive behaviour. Empathy was significantly correlated with Aggressive Behaviour in young adolescents, but not in children. Furthermore, as expected, contextual factors were also significantly correlated with Aggressive Behaviour: Household Income, Parenting Style, and Parent Empathy were correlated with Aggressive Behaviour in young adolescents, while among the measures taken only Parenting Style was correlated with Aggressive Behaviour in children. Future investigations should, as in the current dissertation, work towards articulating the complex web of relationships between correlates of aggressive behaviour and their changes across development.