Sage Journals: Discover world-class research

Abstract

The interpersonal distance (IPD) theory provides a novel approach to studying autism spectrum disorder (ASD). In this article, we present recent findings on the neurobiological underpinnings of IPD regulation that are distinct in individuals with ASD. We also discuss the potential influence of environmental factors on IPD. We suggest that different IPD regulation may have implications for cognitive performance in experimental and diagnostic settings, may influence the effectiveness of training and therapy, and may play a role in the typical forms of social communication and leisure activities chosen by autistic individuals. We argue that reconsidering the results of ASD research through the lens of IPD would lead to a different interpretation of previous findings. Finally, we propose a methodological approach to study this phenomenon systematically.

Keywords

autism autism spectrum disorder interpersonal distance amygdala cognitive functions gamification

Imagine a situation in which people are together in an elevator. They avoid eye contact, and their movement is stiff and constrained; most of them either travel in silence or start a conversation about a superficial topic. If experts in autism diagnostics were to observe our imaginary passengers, they would notice behavioral traits that could be reminiscent of autism spectrum disorder (ASD). However, if the same group of neurotypical people were to interact in an office break room or at a cocktail party (with enough space to stand at a comfortable distance or move away if necessary), they probably would have a good time making small talk, sharing stories while gesticulating vigorously, expressing clear emotions, and making prolonged eye contact. It is unlikely that the observed individuals suddenly lost their social-communication competence in the elevator. Although many other elements of cultural norms influence whether we initiate a conversation in certain situations (e.g., people’s lack of prior acquaintance or reason to interact), which cannot be completely ruled out as explanations for this phenomenon, the preceding examples highlight the impact of interpersonal distance (IPD) on social and cognitive functioning. We believe that IPD is a simple but crucial element of social interactions in real-life situations that influences how effectively we can use our skills and strengths. The extent to which this effect is observed and the preferred size of IPD varies between individuals, and we believe that people with ASD are more affected than neurotypical people; however, a systematic examination is needed to explore the role of IPD in social interactions and how this affects people with ASD compared with neurotypical people.

Neurobiology and Neurodevelopment of Distance Regulation

IPD is modulated by many external and internal factors, and its regulation can be altered or impaired in several conditions (Candini et al., 2021; Kennedy et al., 2009). Functional brain-imaging studies revealed a different pattern of brain activity and connectivity in ASD and neurotypical individuals when measuring IPD (Massaccesi et al., 2021; Perry et al., 2015). In neurotypical people, activation of the dorsal intraparietal sulcus (DIPS), prefrontal and orbitofrontal cortices, ventral premotor and somatosensory cortices, and amygdala may play a role in IPD regulation during computerized versions of the stop-distance paradigm (in which participants are instructed to stop or tell the experimenter to stop at a preferred distance) and comfortable IPD task (in which participants are instructed to indicate the most comfortable distance as someone approaches them from the perimeter of a circle; Huang & Izumi, 2021). In addition to neural activity, functional connectivity was measured. In certain studies primarily involving neurotypical participants, significant connectivity was found during IPD tasks among the DIPS, the ventral premotor cortex, the dorsal striatum, and—in the case of social stimuli—the midbrain, the premotor cortex, and the right dorsolateral prefrontal cortex (Holt et al., 2014). In participants with ASD, Massaccesi et al. (2021) found not only reduced activity in parietal and visual regions in parallel with observed elevated discomfort in an interpersonal space task but also the dysregulation of effective connectivity between the amygdala and the DIPS and the fusiform face area (FFA). The authors argue that the dysregulation of this network might prevent information integration. The amygdala is important in signaling the motivational relevance of spatial information, and in integration with the spatial attention network, forming a salience map directing attention (Egner et al., 2008). In people with ASD, the increased effective connectivity from the amygdala to the DIPS and FFA and the decreased connectivity from the DIPS to the amygdala were associated with higher discomfort that might reflect an elevated perceived saliency. Massaccesi et al. (2021) speculate that the differential effective functional connectivity emphasizes the varying relevance of spatial (where) and visual (what) information in people with ASD, who compensate for the perceived discomfort by keeping a greater IPD.

The amygdala is a complex subcortical structure, a hub of distinct neuronal networks. It contributes not just to emotional valence, salience, and reward processing, it also plays an important role in social learning and other cognitive functions by assigning attention and coordination of top-down and bottom-up processes (Hennessey et al., 2018, Janacsek et al., 2022). In addition to its above-mentioned functions, the amygdala is a crucial area in IPD, as it is involved in emotion and face processing, and it plays a role in avoidant behavior through the regulation of arousal, both of which are essential in social situations. It is difficult to map its specific dysfunction in people with ASD. We know, however, that the amygdala and its connections with other distinct brain areas develop throughout the life span, but its development is altered in people with ASD (Stanfield et al., 2008). Studies have shown amygdala enlargement in early childhood of people with ASD, which decreased or reversed in adolescence (Barnea-Goraly et al., 2014; Schumann et al., 2009). The change in size might be a consequence of the amount of social interactions, so it could be a potential biomarker of the effectiveness of therapeutic interventions (Hennessey et al., 2018; Zalla & Sperduti, 2013). Furthermore, neuroimaging studies have found increased amygdala activation during face-processing experiments (Tottenham et al., 2014) and reduced habituation of the amygdala in people with ASD (Kleinhans et al., 2009). The overresponsivity, hyperreactivity, and consequent hyperarousal might contribute to social avoidance and support the developmental model of hyperactivity-induced excitotoxic changes (Nacewicz et al., 2006). Decreased habituation to social stimuli can lead to difficulty discriminating salient stimuli, especially in social situations (Kleinhans et al., 2009).

Overall, altered activation of the amygdala and related functional networks in people with ASD might contribute to social dysfunction in two ways: (a) The functional connectivity differences can lead to higher discomfort at shorter IPDs, and (b) decreased habituation of the amygdala leads to the maintenance of hyperarousal and directs attention to social stimuli for longer than necessary. We argue that the effect of amygdala dysfunction on social cognition and behavior might be overwhelming for people with ASD and withdraw valuable resources from other cognitive processes during social interactions. If we measure the intellectual and cognitive performance of people with ASD while they are in person with the experimenter, there is a risk that we will get inaccurate, unreliable results.

Altered IPD Regulation as a Response to Adverse Environmental Stimuli

The phenomenon described above may be the result of atypical neurodevelopment, but we cannot rule out the possibility that environmental factors and early life experiences also have an impact on IPD regulation. Unfortunately, adverse childhood experiences or traumatic events are common in people with ASD (Kerns et al., 2015; Ng-Cordell et al., 2022). Because of difficulties in social communication, autistic children often become victims of bullying or abuse (Haruvi-Lamdan et al., 2018). Furthermore, because of sensory hypersensitivity, tactile or olfactory stimuli that are typical for other people may be unpleasant or uncomfortable for them (Wood et al., 2021). One possible coping strategy is disengaging with trauma, which can be manifested in social withdrawal, problem avoidance, self-protective behavior, emotional avoidance, learned helplessness, or wishful thinking (Ng-Cordell et al., 2022). These factors might lead to a greater preferred physical distance. However, engaging with traumatic events or maladaptive self-regulatory strategies such as emotional outbursts with aggressive behavior or sensory-seeking behavior (if touch or tactile stimuli are pleasant) might result in even closer but unwanted physical proximity. At the same time, aggressive behavior or undesirable physical contact could indirectly lead to feelings of rejection and isolation through avoiding other people in their environment. Distancing initiated by either the autistic person or the other person might lead to fewer positive interpersonal proximity experiences, which could hinder the acquisition of other social skills.

To have the appropriate attitude toward children with autism, we need to understand the origin of atypical IPD preferences. Mothers of autistic individuals often report that they had the impression that their autistic child was different, resistant, or even distant. In addition to this anecdotal evidence, a prospective study that assessed attachment style at an early age (15 months) found that infants with a high likelihood of ASD and insecure-resistant attachment were over 9 times more likely to be diagnosed later with ASD than those with a high likelihood but secure attachment (Martin et al., 2020). However, this result does not provide evidence as to whether atypical IPD was also present in autistic infants or whether it develops as a result of negative experiences. It is also possible that neurobiological and environmental factors are not independent but enhance each other’s adverse effects on IPD regulation, which would be in line with the concept of autism as a condition of generalized imbalance in adaptation (Gernert et al., 2020). To understand this relationship in more depth in terms of IPD, we need anamnestic information about traumatic experiences as well as longitudinal studies.

In this article, we highlight the importance of cross-sectional studies to measure (a) whether there is a disturbance in IPD regulation in autism and (b) how it affects performance in other areas, especially cognitive functioning. Because ASD is a highly diverse and heterogeneous condition, it is likely that individuals will be affected to different degrees. Some people with ASD may be perfectly comfortable with a closer personal distance, whereas others may prefer a greater distance. We argue that during the systematic cognitive and/or psychological assessment of autistic people, it is necessary to consider the IPD at which the study is conducted.

Results of Behavioral Measures of IPD in People With ASD

The underlying neural processes are challenging to study in ecologically valid settings at the moment. Neuroimaging and electrophysiological studies are capable of examining only the cognitive component but, unfortunately, cannot focus on the kinetic component of IPD regulation. Only a handful of studies measure the preferred IPD of people with autism in a real physical environment. Greater IPD (lower permeability of personal space) and/or altered flexibility of its regulation has been found in most of the studies (Candini et al., 2017, 2020; Farkas et al., 2023; Gessaroli et al., 2013; Kennedy & Adolphs, 2014; Perry et al., 2015). Only one study from Japan found that people with autism preferred less personal space than did neurotypical individuals (Asada et al., 2016), which raises the possibility of cultural effects on IPD regulation. In summary, not only do neuroimaging studies suggest altered neural activation in people with ASD, but also behavioral studies show that IPD preferences and/or IPD regulation are different in people with autism.

Cognitive Functions and Distancing in People With ASD

As the concept of autism has evolved over the past decades, so has the extent to which cognitive dysfunction (including executive functions) can be considered specific to it (Demetriou et al., 2019; Friedman & Sterling, 2019; Hill, 2004; Ozonoff et al., 1991, 2007; Ozonoff & McEvoy, 1994; Zhang et al., 2020). Accurate and reliable measurement of the cognitive profile of individuals with autism is critical to clinical diagnosis, treatments, and therapy as well as educational settings. However, the measurement may not be reliable and accurate without consideration of the distance between the investigator and the autistic individual. Previous studies have not reported these data, even though they might significantly affect cognitive performance. Weismer et al. (2018) found that deficits in executive functions (e.g., shifting, inhibition, working memory update) diminished after controlling for social communication characteristics; they assumed that difficulties in verbal communication and the verbal instructions might result in task impurity. Participants matching criteria are not uniform across studies (age vs. nonverbal IQ, or language level), which can be problematic, especially in studies involving children; and finally, social interaction with the experimenter might have an impact on performance, which is eliminated in computerized measurements (Weismer et al., 2018). A systematic review on executive control in ASD showed that impaired executive control, planning, or cognitive flexibility on both the Wisconsin Card Sorting Test and tower tasks are attenuated with computer administration. These findings suggest that dealing with social feedback and rules is difficult for individuals with autism (Kenworthy et al., 2008). A recent meta-analysis studied the characteristics of executive dysfunction in people with ASD. The authors found robust overall group differences between neurotypical and autistic participants across a wide range of potential mediators; however, the effect size was reduced after they excluded self-report/questionnaire data (Demetriou et al., 2018). They also found an attenuating effect on executive dysfunction of the computerized assessment format overall and on concept formation and response inhibition subdomains (Demetriou et al., 2018). Because different conditions might result in various outcomes, it is important to take results from many scenarios into account in order to accurately quantify executive functions in autism.

The IPD theory proposes that the IPD preferred by people with ASD is a key aspect that needs to be considered. We think that the change in perceived group differences is due to not only the more predictable, standardized form and the visual instructions in computerized tests but also the greater distance from the experimenter in these situations. Because the information on this parameter is not available in most of the previous studies, it is not possible to systematically investigate the already existing studies on the effect of IPD with meta-analyses. In the future, studies with experimental distance manipulations are warranted to address this issue.

Technology-Based Interventions Provide Comfortable IPD

Cognitive training and cognitive remediation

On the basis of our IPD theory, we suggest that technology-based interventions could help improve skills in people with autism and other neurodevelopmental syndromes. In studies using computer-based remote solutions, the IPD is certainly large enough to ensure that existing competences are available to achieve the right performance. The benefits of computerized solutions are obvious in many areas, but can this approach work in situations that were previously explicitly human-assisted, such as education, skills development, and therapy? Systematic reviews and meta-analyses found that technology-based interventions (via a desktop computer, interactive DVD, shared active surface, and virtual reality) were effective overall at improving social and communication skills in people with ASD; however, the results on generalizability and maintenance of the effect or improvement on standardized tests remain controversial (DiGennaro Reed et al., 2011; Grynszpan et al., 2014; Ramdoss et al., 2011; Wainer & Ingersoll, 2011).

In a recent review, Pasqualotto et al. (2021) examined the effect of cognitive training programs on executive functions, comparing the computerized and noncomputerized interventions in people with ASD. Noncomputerized training had positive effects on executive functions (shifting, flexibility, and problem solving) when delivered at home or school (ecologically valid environments), whereas cognitive remediation contributed to the improvement of working memory and verbal fluency. In the case of computerized training, attention (divided and sustained), working memory, and inhibition control improved more among participants than in the control group. However, without human interaction, the improvement of executive functions seemed to be less generalizable to other (e.g., social and communication) skills (Pasqualotto et al., 2021). Yet the benefits of digital technology are not negligible. Computerized methods are more predictable, and they offer clearly defined and often visually supported instructions or visual or auditory feedback. The setting decreases sensory stimulation, requires less social interaction, and provides self-paced application. Moreover, in line with our theory, they provide comfortable-enough IPD. All of the above can help reduce experienced stress and arousal, providing the best learning environment and cognitive performance (D. K. C. Murray, 2011; A. Murray et al., 2022; Pasqualotto et al., 2021).

Gamification and gaming culture

In line with computerized cognitive training, IPD theory promotes gamification to support treatments by providing a large-enough IPD. Computers, computational tools, and gamification have become increasingly widespread to support treatments of a wide variety of diseases. Recently, mental health professionals have also started to contribute to the development of gamified tools for ASD. The aim of these experiments is to make certain that therapeutic or skill-training elements are playful while providing a good gaming experience. Games would provide a safe environment for facilitating collaboration and social interactions (e.g., Benton et al., 2012; Parsons et al., 2004; Whalen et al., 2010); the gamification of classical therapeutic elements, however, is not yet engaging enough (Malinverni et al., 2017), and their applicability is limited (Ben-Sasson et al., 2013; Marwecki et al., 2013). However, the development of video games and virtual reality environments to improve social communication and other skills is becoming increasingly popular (e.g., Kim et al., 2020; Terlouw et al., 2020, 2021); for a recent review, see Atherton & Cross, 2021).

Children, adolescents, and adults with ASD have a well-developed gaming culture in an extensive range of computer or video games (Mazurek & Engelhardt, 2013); however, their preferences and habits are different from those of their neurotypical peers (Craig et al., 2017; A. Murray et al., 2022). They perceive the benefits of computer-mediated communication, but they use it in specific ways (Gillespie-Lynch et al., 2014). An ethnographic case study of three children with ASD has shown that social interactions in online multiplayer games, such as sharing information; making requests; communicating rules; maintaining engagement; or using, interpreting, and mirroring gestures in virtual spaces, might support their capacity to initiate and sustain social interactions in physical spaces (Stone et al., 2019). Another interesting exploratory case study used a multiplayer online role-playing game to explore the emotional awareness and expression skills of five young adult participants with ASD. The authors suggest that advancements in virtual environments might help with the development of social skills in the future (Gallup & Serianni, 2017). A semi-structured interview with three adolescents and young adults with ASD revealed that participants perceived the virtual platform of video games as a safe environment and had an increased level of comfort and self-awareness. However, children with ASD tend to play more role-playing games than first-person shooting games, avoiding the sensory overload of fast-paced, audiovisually intense, and psychologically arousing violent games (Mazurek & Engelhardt, 2013). By avoiding the unpredictable and anxiety-provoking face-to-face interactions of the physical world, they could cooperate, develop conversations, and even maintain relationships from a distance (Gallup et al., 2016). These findings support our hypothesis that the impairments in the functioning of people with ASD are not solely due to a lack of competence but also to the overwhelming and suboptimal environment in which their performance is significantly below the best possible.

Downsides and differences of computer-mediated communication and gaming in people with ASD

Individuals with ASD might prefer computer-mediated communication because it allows interactions from a safe distance with higher control and fewer contextual and sensory distractions; however, they do not necessarily profit from it in real-life social situations (Paulus et al., 2020). Moreover, a longitudinal study has shown that although more autistic traits in general do not relate to the overuse of the Internet, gender is a risk factor: Women with more autistic traits are at higher risk for compulsive Internet use (Finkenauer et al., 2012). A recent study reported that individuals with ASD play more often by themselves rather than in multiplayer mode. In their study, they found that young participants with ASD are vulnerable to gaming disorders (Paulus et al., 2020), and a recent systematic review has confirmed that children and young adults with ASD spend more time playing video games and have a higher risk for problematic gaming (A. Murray et al., 2022).

Results so far suggest that individuals with autism prefer a safe distance; reduced sensory information load; slower, self-paced tempo; and written/visual instructions in computerized communication or gaming. Despite the presumably lower levels of stress, they cannot fully exploit the social benefits of these activities. It is possible that, in some cases, the distance is no longer safe but is so large that it leads to a permanent withdrawal, and isolation, from which it is very difficult to establish contact. However, video games are sometimes the first or only opportunity for social interaction. They provide an opportunity not only to communicate casually with other players in the game but also to build friendships between people from distant parts of the world and to use the game as a common topic to start a conversation in offline gaming-themed gatherings or in general social situations (Finke et al., 2018). To sum up, on the basis of IPD theory, computer-game-based treatment methods may be applicable to children and adults with ASD. More studies are warranted to discover and develop guidance to avoid the negative effects of computer games.

Challenging factors and counterarguments

Although the importance of IPD or even preference for larger IPD can be seen in a wide range of situations, there are two extreme scenarios in real life: when someone is at zero distance with full skin contact (e.g., sexual intercourse) or when the other person is not present at all. Social interactions are inherently complex and in addition to the spatial dimension (e.g., preferred IPD), additional factors need to be considered. The sensory preferences (e.g., hypersensitivity) and the ability to communicate them are highly relevant while having sex (Gray et al., 2021). We think that low IPD could more easily result in sensory overstimulation and that some autistic people can cope with this difficulty and enjoy sexual activity, whereas others voluntarily deprive themselves of sexual experiences, at least partly, to avoid sensory overstimulation. Furthermore, we believe that even autistic people who can cope with sensory stimulation have different preferences than neurotypical individuals considering the pace of a romantic relationship. Autistic people possibly need a longer time period to get to know a new partner, develop trust, and be ready for sexual intercourse. Moreover, communicating their preferences to their partner can also be more challenging for autistic people. In addition, these difficulties and a preference for a slower pace can also emerge in nonsexual intimate relationships, such as with close family members, friends, and peers. Further studies are warranted to investigate this topic, especially because the well-being of autistic people could benefit from the implications of such studies. However, a deeper discussion of this topic is beyond the scope of the present article.

The other extreme situation is when the other person is absent. A recent study on communication-mode preferences in people with ASD shows that they generally avoid phone calls (Howard & Sedgewick, 2021). If IPD is the only defining factor for people with ASD, this would be contradictory: During phone calls, IPD is large, so it should be pretty comfortable. But this is not the case. The narrative analysis revealed that partial information (visual metacommunicative signs are missing but difficult-to-interpret vocal signs remain), expectations of instant replies, difficulty with appropriate timing, or the unpredictability of an unknown person might be relevant as well (Howard & Sedgewick, 2021). Individuals with autism preferred face-to-face over written communication only when the setting was safe and settled for a longer time (family, friends, education, or employment). In this study, video chat and video conference platforms were not included; they became widely used during the COVID pandemic. One would assume that if IPD were the only thing that mattered, lockdown and online communication would be seen as a positive change. A recent study (Pellicano et al., 2020) highlights that a reduction in face-to-face activity (e.g., education, work, commuting, therapy sessions) is not a problem to a certain degree and for a certain type of autistic person, but it also has drawbacks and is not easy for everyone (Pellicano et al., 2020). It raises the issue that during video conferences the other person’s face on the screen may seem too close or the distance cannot be controlled, and more people can be in front of the viewer at the same time than in real-life situations.

Overall, in addition to distance, the following factors require further investigation. In terms of temporal dynamics, the social relationships in ASD can develop either extremely slowly (a lot of patience is required even in therapeutic relationships) or uncomfortably quickly. Here, again, the disruption of the adaptive capacity of approaching behavior and the diversity of ASD seem to be important factors. In the quality of relationships, factors such as trust, safety, and familiarity (caregiver, spouse, very close friend, professional helper, acquaintance, unknown person) and the number of people who can fit in each category or can be present at the same time (limited by the mentalization capacity) might also be considered relevant.

We think there may be other processes involved in fine-tuning IPD than the basic discrepancies mentioned above. For example, it should involve appropriate timing, verbal and nonverbal reciprocal communication, and mentalizing (reading and expressing nonverbal, metacommunicative cues). Difficulties in these areas are also characteristic of autism. We consider IPD as a separate, potentially atypical “symptom” dimension. In this article, we emphasize the importance of systematic measurement of IPD in a time-limited, cross-sectional setting by an unknown investigator, which is a laboratory prototype for many everyday situations.

Recommended Study Design to Test Cognitive Functions in Different Settings

Recommended study design

Given the empirical evidence discussed above, IPD seems to be an important factor to consider in people with ASD; however, systematic studies are warranted. We suggest comparing cognitive, social, and communication performance with well-established methods in five different settings: (a) in-person task administration (with a measured distance), (b) computerized versions of the same tests in the presence of the experimenter (with a measured distance), (c) the examiner at a higher distance, (d) under laboratory conditions with the participant and experimenter in separate rooms, and (e) without social interaction, by remote online participation at home (Fig. 1). The five different settings allow the following comparisons: The difference between settings (a) and (b) provides information about the effect of the human, verbal, and acoustic versus the computerized, written, and visual instructions and feedback; the (b) versus (c) comparison shows the effect of greater distance; the (c) versus (d) comparison reflects the difference between the presence (distant but physically perceptible) or absence (only a mental representation available) of the experimenter; and the (d) versus (e) comparison marks the difference between a laboratory, unfamiliar environment (including potential sensory distractors) and the natural, familiar environment.

Fig. 1.

Measuring performance in five different settings: (a) in-person task administration, (b) computerized task administration with the same measured distance between the participant and experimenter as in (a), (c) computerized task administration with a larger distance, (d) computerized task administration with the participant and experimenter in separate rooms, and (e) remote task administration (i.e., online participation from home).

Potential relevance, real-life implications

If behavioral and neuropsychological studies support the IPD theory in autism, namely, that IPD does indeed play a role in the social and cognitive performance of autistic people, it will be worth taking this into account in interactions with people with ASD in many areas of life. First, it might be necessary to provide more interpersonal space during therapy and education for people with special needs: teaching and applying the techniques needed for social interaction, first without face-to-face interaction (from an age rife with electronic device use) and then from a greater distance. However, it might be generalized even to intellectually disabled, nonverbal individuals with autism as well. To determine the comfortable distance in their case and how this information could be used properly requires further consideration. The message for them might be that caregivers and helpers should keep in mind that preferred IPD might vary in different situations, and it might affect the motivation and performance of these people, too.

It could be especially important to provide space for withdrawal after or during emotionally demanding situations, for example, at school, and at workplaces. This would be beneficial not only because it might prevent (or help manage) potential meltdowns, shutdowns, or tantrums but also because it might help use existing skills and resources or even achieve optimal performance for individuals with ASD (Fig. 2). IPD theory can be used to explore the issue of competence versus performance in neurocognitive functions in this population. Specifically, using IPD theory, we can disentangle whether a cognitive or social function in people with ASD is truly severely impaired at the level of competence or whether an overwhelming social factor, such as a preference for short IPD, is impeding their performance.

Fig. 2.

Summary of the differences between in-person and remote activities. ASD = autism spectrum disorder.

Conclusion

Here, we have described the IPD theory of ASD, which implies that autistic traits (including social difficulties and cognitive dysfunctions) might be affected by social context involving uncomfortable IPD. The IPD theory explains inconsistent empirical findings on several measures, such as executive functions or social communication, and provides a context for the typical gaming culture in people with ASD. Moreover, it provides a framework for therapeutic and educational approaches, suggesting that these processes might benefit from the adjustment of IPD.

Footnotes

Transparency

Action Editor: Tina M. Lowrey

Editor: Interim Editorial Panel

ORCID iD

Kinga Farkas

References

Asada

Tojo

Osanai

Saito

Hasegawa

Kumagaya

(2016). Reduced personal space in individuals with autism spectrum disorder. PLOS ONE, 11(1), Article e0146306. https://doi.org/10.1371/journal.pone.0146306

Atherton

Cross

(2021). The use of analog and digital games for autism interventions. Frontiers in Psychology, 12, Article 669734. https://doi.org/10.3389/fpsyg.2021.669734

Barnea-Goraly

Frazier

T. W.

Piacenza

Minshew

N. J.

Keshavan

M. S.

Reiss

A. L.

Hardan

A. Y.

(2014). A preliminary longitudinal volumetric MRI study of amygdala and hippocampal volumes in autism. Progress in Neuro-Psychopharmacology & Biological Psychiatry, 48, 124–128. https://doi.org/10.1016/j.pnpbp.2013.09.010

Ben-Sasson

Lamash

Gal

(2013). To enforce or not to enforce? The use of collaborative interfaces to promote social skills in children with high functioning autism spectrum disorder. Autism, 17(5), 608–622. https://doi.org/10.1177/1362361312451526

Benton

Johnson

Ashwin

Brosnan

Grawemeyer

(2012). Developing IDEAS: Supporting children with autism within a participatory design team. In Konstan

J. A.

Chi

E. H.

Höök

(Chairs), Proceedings of the SIGCHI conference on human factors in computing systems (pp. 2599–2608). Association for Computing Machinery. https://doi.org/10.1145/2207676.2208650

Candini

Battaglia

Benassi

Pellegrino

Frassinetti

(2021). The physiological correlates of interpersonal space. Scientific Reports, 11, Article 2611. https://doi.org/10.1038/s41598-021-82223-2

Candini

di Pellegrino

Frassinetti

(2020). The plasticity of the interpersonal space in autism spectrum disorder. Neuropsychologia, 147, Article 107589. https://doi.org/10.1016/j.neuropsychologia.2020.107589

Candini

Giuberti

Manattini

Grittani

di Pellegrino

Frassinetti

(2017). Personal space regulation in childhood autism: Effects of social interaction and person’s perspective. Autism Research, 10(1), 144–154. https://doi.org/10.1002/aur.1637

Craig

A. B.

Grossman

Krichmar

J. L.

(2017). Investigation of autistic traits through strategic decision-making in games with adaptive agents. Scientific Reports, 7(1), 5533. https://doi.org/10.1038/s41598-017-05933-6

10.

Demetriou

E. A.

DeMayo

M. M.

Guastella

A. J.

(2019). Executive function in autism spectrum disorder: History, theoretical models, empirical findings, and potential as an endophenotype. Frontiers in Psychiatry, 10, Article 753. https://doi.org/10.3389/fpsyt.2019.00753

11.

Demetriou

E. A.

Lampit

Quintana

D. S.

Naismith

S. L.

Song

Pye

J. E.

Hickie

Guastella

A. J.

(2018). Autism spectrum disorders: A meta-analysis of executive function. Molecular Psychiatry, 23(5), 1198–1204. https://doi.org/10.1038/mp.2017.75

12.

DiGennaro Reed

F. D.

Hyman

S. R.

Hirst

J. M

. (2011). Applications of technology to teach social skills to children with autism. Research in Autism Spectrum Disorders, 5(3), 1003–1010. https://doi.org/10.1016/j.rasd.2011.01.022

13.

Egner

Monti

J. M. P.

Trittschuh

E. H.

Wieneke

C. A.

Hirsch

Mesulam

M.-M.

(2008). Neural integration of top-down spatial and feature-based information in visual search. The Journal of Neuroscience, 28(24), 6141–6151. https://doi.org/10.1523/JNEUROSCI.1262-08.2008

14.

Farkas

Pesthy

Guttengéber

Weigl

A. S.

Veres

Szekely

Komoróczy

Szuromi

Janacsek

Réthelyi

J. M.

Németh

(2023). Altered interpersonal distance regulation in autism spectrum disorder. PLOS ONE, 18(3), Article e0283761. https://doi.org/10.1371/journal.pone.0283761

15.

Finke

E. H.

Hickerson

B. D.

Kremkow

J. M. D.

(2018). “To be quite honest, if it wasn’t for videogames I wouldn’t have a social life at all”: Motivations of young adults with autism spectrum disorder for playing videogames as leisure. American Journal of Speech-Language Pathology, 27(2), 672–689. https://doi.org/10.1044/2017_AJSLP-17-0073

16.

Finkenauer

Pollmann

M. M. H.

Begeer

Kerkhof

(2012). Brief report: Examining the link between autistic traits and compulsive Internet use in a non-clinical sample. Journal of Autism and Developmental Disorders, 42(10), 2252–2256. https://doi.org/10.1007/s10803-012-1465-4

17.

Friedman

Sterling

(2019). A review of language, executive function, and intervention in autism spectrum disorder. Seminars in Speech and Language, 40(4), 291–304. https://doi.org/10.1055/s-0039-1692964

18.

Gallup

Duff

Serianni

Gallup

(2016). An exploration of friendships and socialization for adolescents with autism engaged in massively multiplayer online role-playing games (MMORPG). Education and Training in Autism and Developmental Disabilities, 51, 223–237.

19.

Gallup

Serianni

(2017). Developing friendships and an awareness of emotions using video games: Perceptions of four young adults with autism. Education and Training in Autism and Developmental Disabilities, 52(2), 120–131. https://www.jstor.org/stable/26420384

20.

Gernert

Falkai

Falter-Wagner

C. M.

(2020). The generalized adaptation account of autism. Frontiers in Neuroscience, 14, Article 534218. https://doi.org/10.3389/fnins.2020.534218

21.

Gessaroli

Santelli

di Pellegrino

Frassinetti

(2013). Personal space regulation in childhood autism spectrum disorders. PLOS ONE, 8(9), Article e74959. https://doi.org/10.1371/journal.pone.0074959

22.

Gillespie-Lynch

Kapp

S. K.

Shane-Simpson

Smith

D. S.

Hutman

(2014). Intersections between the autism spectrum and the Internet: Perceived benefits and preferred functions of computer-mediated communication. Intellectual and Developmental Disabilities, 52(6), 456–469. https://doi.org/10.1352/1934-9556-52.6.456

23.

Gray

Kirby

A. V.

Graham Holmes

(2021). Autistic narratives of sensory features, sexuality, and relationships. Autism Adulthood, 3(3), 238–246. https://doi:10.1089/aut.2020.0049

24.

Grynszpan

Weiss

P. L.

Perez-Diaz

Gal

(2014). Innovative technology-based interventions for autism spectrum disorders: A meta-analysis. Autism, 18(4), 346–361. https://doi.org/10.1177/1362361313476767

25.

Haruvi-Lamdan

Horesh

Golan

(2018). PTSD and autism spectrum disorder: Co-morbidity, gaps in research, and potential shared mechanisms. Psychological Trauma: Theory, Research, Practice, and Policy, 10(3), 290–299. https://doi.org/10.1037/tra0000298

26.

Hennessey

Andari

Rainnie

D. G.

(2018). RDoC-based categorization of amygdala functions and its implications in autism. Neuroscience and Biobehavioral Reviews, 90, 115–129. https://doi.org/10.1016/j.neubiorev.2018.04.007

27.

Hill

E. L.

(2004). Executive dysfunction in autism. Trends in Cognitive Sciences, 8(1), 26–32. https://doi.org/10.1016/j.tics.2003.11.003

28.

Holt

D. J.

Cassidy

B. S.

Yue

Rauch

S. L.

Boeke

E. A.

Nasr

Tootell

R. B. H.

Coombs

(2014). Neural correlates of personal space intrusion. The Journal of Neuroscience, 34(12), 4123–4134. https://doi.org/10.1523/JNEUROSCI.0686-13.2014

29.

Howard

P. L.

Sedgewick

(2021). ‘Anything but the phone!’: Communication mode preferences in the autism community. Autism, 25(8), 2265–2278. https://doi.org/10.1177/13623613211014995

30.

Huang

Izumi

S.-I.

(2021). Neural alterations in interpersonal distance (IPD) cognition and its correlation with IPD behavior: A systematic review. Brain Sciences, 11(8), Article 1015. https://doi.org/10.3390/brainsci11081015

31.

Janacsek

Evans

T. M.

Kiss

Shah

Blumenfeld

Ullman

M. T.

(2022). Subcortical cognition: The fruit below the rind. Annual Review of Neuroscience, 45, 361–386. https://doi.org/10.1146/annurev-neuro-110920-013544

32.

Kennedy

D. P.

Adolphs

(2014). Violations of personal space by individuals with autism spectrum disorder. PLOS ONE, 9(8), Article e103369. https://doi.org/10.1371/journal.pone.0103369

33.

Kennedy

D. P.

Gläscher

Tyszka

J. M.

Adolphs

(2009). Personal space regulation by the human amygdala. Nature Neuroscience, 12(10), 1226–1227. https://doi.org/10.1038/nn.2381

34.

Kenworthy

Yerys

B. E.

Anthony

L. G.

Wallace

G. L.

(2008). Understanding executive control in autism spectrum disorders in the lab and in the real world. Neuropsychology Review, 18(4), 320–338. https://doi.org/10.1007/s11065-008-9077-7

35.

Kerns

C. M.

Newschaffer

C. J.

Berkowitz

S. J.

(2015). Traumatic childhood events and autism spectrum disorder. Journal of Autism and Developmental Disorders, 45(11), 3475–3486. https://doi.org/10.1007/s10803-015-2392-y

36.

Kim

Lee

Min

Paik

Frey

Bellini

Han

Shih

P. C.

(2020). PuzzleWalk: A theory-driven iterative design inquiry of a mobile game for promoting physical activity in adults with autism spectrum disorder. PLOS ONE, 15(9), Article e0237966. https://doi.org/10.1371/journal.pone.0237966

37.

Kleinhans

N. M.

Johnson

L. C.

Richards

Mahurin

Greenson

Dawson

Aylward

(2009). Reduced neural habituation in the amygdala and social impairments in autism spectrum disorders. American Journal of Psychiatry, 166(4), 467–475. https://doi.org/10.1176/appi.ajp.2008.07101681

38.

Malinverni

Mora-Guiard

Padillo

Valero

Hervás

Pares

(2017). An inclusive design approach for developing video games for children with autism spectrum disorder. Computers in Human Behavior, 71, 535–549. https://doi.org/10.1016/j.chb.2016.01.018

39.

Martin

K. B.

Haltigan

J. D.

Ekas

Prince

E. B.

Messinger

D. S.

(2020). Attachment security differs by later autism spectrum disorder: A prospective study. Developmental Science, 23(5), Article e12953. https://doi.org/10.1111/desc.12953

40.

Marwecki

Rädle

Reiterer

(2013). Encouraging collaboration in hybrid therapy games for autistic children. In Mackay

W. E.

Brewster

Bødker

(Eds.), CHI ‘13 extended abstracts on human factors in computing systems (pp. 469–474). Association for Computing Machinery. https://doi.org/10.1145/2468356.2468439

41.

Massaccesi

Groessing

Rosenberger

L. A.

Hartmann

Candini

di Pellegrino

Frassinetti

Silani

(2021). Neural correlates of interpersonal space permeability and flexibility in autism spectrum disorder. Cerebral Cortex, 31(6), 2968–2979. https://doi.org/10.1093/cercor/bhaa404

42.

Mazurek

M. O.

Engelhardt

C. R.

(2013). Video game use in boys with autism spectrum disorder, ADHD, or typical development. Pediatrics, 132(2), 260–266. https://doi.org/10.1542/peds.2012-3956

43.

Murray

Koronczai

Király

Griffiths

M. D.

Mannion

Leader

Demetrovics

(2022). Autism, problematic Internet use and gaming disorder: A systematic review. Review Journal of Autism and Developmental Disorders, 9, 120–140. https://doi.org/10.1007/s40489-021-00243-0

44.

Murray

D. K. C.

(2011). Autism and information technology: Therapy with computers. In Powell

Jordan

(Eds.), Autism and learning: A guide to good practice (pp. 88–103). Routledge. https://doi.org/10.4324/9780203606131

45.

Nacewicz

B. M.

Dalton

K. M.

Johnstone

Long

M. T.

McAuliff

E. M.

Oakes

T. R.

Alexander

A. L.

Davidson

R. J.

(2006). Amygdala volume and nonverbal social impairment in adolescent and adult males with autism. Archives of General Psychiatry, 63(12), 1417–1428. https://doi.org/10.1001/archpsyc.63.12.1417

46.

Ng-Cordell

Rai

Peracha

Garfield

Lankenau

S. E.

Robins

D. L.

Berkowitz

S. J.

Newschaffer

Kerns

C. M.

(2022). A qualitative study of self and caregiver perspectives on how autistic individuals cope with trauma. Frontiers in Psychiatry, 13, Article 825008. https://doi.org/10.3389/fpsyt.2022.825008

47.

Ozonoff

McEvoy

R. E.

(1994). A longitudinal study of executive function and theory of mind development in autism. Development and Psychopathology, 6(3), 415–431. https://doi.org/10.1017/S0954579400006027

48.

Ozonoff

Pennington

B. F.

Rogers

S. J.

(1991). Executive function deficits in high-functioning autistic individuals: Relationship to theory of mind. Journal of Child Psychology and Psychiatry, 32(7), 1081–1105. https://doi.org/10.1111/j.1469-7610.1991.tb00351.x

49.

Ozonoff

South

Provencal

(2007). Executive functions in autism: Theory and practice. In Pérez

J. M.

González

P. M.

Llorente Comí

Nieto

(Eds.), New developments in autism: The future is today (pp. 185–213). Jessica Kingsley Publishers.

50.

Parsons

Mitchell

Leonard

(2004). The use and understanding of virtual environments by adolescents with autistic spectrum disorders. Journal of Autism and Developmental Disorders, 34(4), 449–466. https://doi.org/10.1023/B:JADD.0000037421.98517.8d

51.

Pasqualotto

Mazzoni

Bentenuto

Mulè

Benso

Venuti

(2021). Effects of cognitive training programs on executive function in children and adolescents with autism spectrum disorder: A systematic review. Brain Sciences, 11(10), Article 1280. https://doi.org/10.3390/brainsci11101280

52.

Paulus

F. W.

Sander

C. S.

Nitze

Kramatschek-Pfahler

A.-R.

Voran

von Gontard

(2020). Gaming disorder and computer-mediated communication in children and adolescents with autism spectrum disorder. Zeitschrift fur Kinder- und Jugendpsychiatrie und Psychotherapie, 48(2), 113–122. https://doi.org/10.1024/1422-4917/a000674

53.

Pellicano

Brett

Den Houting

Heyworth

Magiati

Steward

Urbanowicz

Stears

(2020). “I want to see my friends”: The everyday experiences of autistic people and their families during COVID-19. University of Sydney. https://www.sydney.edu.au/sydney-policy-lab/news-and-analysis/news-commentary/the-everyday-experiences-of-autistic-people-and-their-families-d.html

54.

Perry

Levy-Gigi

Richter-Levin

Shamay-Tsoory

S. G.

(2015). Interpersonal distance and social anxiety in autistic spectrum disorders: A behavioral and ERP study. Social Neuroscience, 10(4), 354–365. https://doi.org/10.1080/17470919.2015.1010740

55.

Ramdoss

Lang

Mulloy

Franco

O’Reilly

Didden

Lancioni

(2011). Use of computer-based interventions to teach communication skills to children with autism spectrum disorders: A systematic review. Journal of Behavioral Education, 20(1), 55–76. https://doi.org/10.1007/s10864-010-9112-7

56.

Schumann

C. M.

Carter Barnes

Lord

Courchesne

(2009). Amygdala enlargement in toddlers with autism related to severity of social and communication impairments. Biological Psychiatry, 66(10), 942–949. https://doi.org/10.1016/j.biopsych.2009.07.007

57.

Stanfield

A. C.

McIntosh

A. M.

Spencer

M. D.

Philip

Gaur

Lawrie

S. M.

(2008). Towards a neuroanatomy of autism: A systematic review and meta-analysis of structural magnetic resonance imaging studies. European Psychiatry, 23(4), 289–299. https://doi.org/10.1016/j.eurpsy.2007.05.006

58.

Stone

B. G.

Mills

K. A.

Saggers

(2019). Online multiplayer games for the social interactions of children with autism spectrum disorder: A resource for inclusive education. International Journal of Inclusive Education, 23(2), 209–228. https://doi.org/10.1080/13603116.2018.1426051

59.

Terlouw

Kuipers

van’t Veer

Prins

J. T.

Pierie

J. P. E. N.

(2021). The development of an escape room–based serious game to trigger social interaction and communication between high-functioning children with autism and their peers: Iterative design approach. JMIR Serious Games, 9(1), Article e19765. https://doi.org/10.2196/19765

60.

Terlouw

van ’t Veer

J. T. B.

Prins

J. T.

Kuipers

D. A.

Pierie

J.-P. E. N.

(2020). Design of a digital comic creator (It’s me) to facilitate social skills training for children with autism spectrum disorder: Design research approach. JMIR Mental Health, 7(7), Article e17260. https://doi.org/10.2196/17260

61.

Tottenham

Hertzig

M. E.

Gillespie-Lynch

Gilhooly

Millner

A. J.

Casey

B. J.

(2014). Elevated amygdala response to faces and gaze aversion in autism spectrum disorder. Social Cognitive and Affective Neuroscience, 9(1), 106–117. https://doi.org/10.1093/scan/nst050

62.

Wainer

A. L.

Ingersoll

B. R.

(2011). The use of innovative computer technology for teaching social communication to individuals with autism spectrum disorders. Research in Autism Spectrum Disorders, 5(1), 96–107. https://doi.org/10.1016/j.rasd.2010.08.002

63.

Weismer

S. E.

Kaushanskaya

Larson

Mathée

Bolt

(2018). Executive function skills in school-age children with autism spectrum disorder: Association with language abilities. Journal of Speech, Language, and Hearing Research, 61(11), 2641–2658. https://doi.org/10.1044/2018_JSLHR-L-RSAUT-18-0026

64.

Whalen

Moss

Ilan

A. B.

Vaupel

Fielding

Macdonald

Cernich

Symon

(2010). Efficacy of TeachTown: Basics computer-assisted intervention for the Intensive Comprehensive Autism Program in Los Angeles Unified School District. Autism, 14(3), 179–197. https://doi.org/10.1177/1362361310363282

65.

Wood

E. T.

Cummings

K. K.

Jung

Patterson

Okada

Guo

O’Neill

Dapretto

Bookheimer

S. Y.

Green

S. A.

(2021). Sensory over-responsivity is related to GABAergic inhibition in thalamocortical circuits. Translational Psychiatry, 11(1), Article 39. https://doi.org/10.1038/s41398-020-01154-0

66.

Zalla

Sperduti

(2013). The amygdala and the relevance detection theory of autism: An evolutionary perspective. Frontiers in Human Neuroscience, 7, Article 894. https://doi.org/10.3389/fnhum.2013.00894

67.

Zhang

Peng

Zhang

(2020). Executive function in high-functioning autism spectrum disorder: A meta-analysis of fMRI studies. Journal of Autism and Developmental Disorders, 50(11), 4022–4038. https://doi.org/10.1007/s10803-020-04461-z

Interpersonal Distance Theory of Autism and Its Implication for Cognitive Assessment,Therapy,and Daily Life

Abstract

Keywords

Neurobiology and Neurodevelopment of Distance Regulation

Altered IPD Regulation as a Response to Adverse Environmental Stimuli

Results of Behavioral Measures of IPD in People With ASD

Cognitive Functions and Distancing in People With ASD

Technology-Based Interventions Provide Comfortable IPD

Cognitive training and cognitive remediation

Gamification and gaming culture

Downsides and differences of computer-mediated communication and gaming in people with ASD

Challenging factors and counterarguments

Recommended Study Design to Test Cognitive Functions in Different Settings

Recommended study design

Potential relevance, real-life implications

Conclusion

Footnotes

Transparency

ORCID iD

References