Autism-Open Access
Open Access

Investigating Empathy and Alexithymia in Teenager Siblings of ASD People

Maral Besharati^* and Shahriar Gharibzadeh ^*Correspondence: Maral Besharati, Department of Neuroscience, Institute for Cognitive and Brain Sciences, Shahid Beheshti University, Tehran, Iran, Email:

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Abbreviations

TAS-20: Toronto Alexithymia Scale; ASD: Autism Spectrum Disorder; IRI: Interpersonal Reactivity Index; CANTAB: Cambridge Neuropsychological Test Automated Battery; MOT: Motor Screening Task

Introduction

Autism Spectrum Disorder (ASD) is a neurological and developmental disorder that affects how people interact with others, communicate, learn and behave. Although autism can be diagnosed at any age, it is described as a “developmental disorder” because symptoms generally appear in the first 2 years of life. Different autistic people may show different characteristics and the characteristics of this spectrum disorder may appear differently in each person at different times. Autism is considered a disorder by many sources. A spectrum disorder, a person may become a different person and each person may have some of the characteristics associated with it, but not all of them exhibit them to very different degrees. Those who have the spectrum characteristics of these problems are called autist [1].

As part of the family system, understanding the dynamics of sibling relationships is as necessary as understanding the parenting subsystem; because the relationship between siblings is often the first, most sensitive and longest relationship of the peer group. Therefore, it is possible that living with a person with special needs has long-term effects on the psychological and emotional state of his siblings. Due to having impulsive and negative behavioral characteristics, a person with autism spectrum disorder has a significant effect on all family members, including parents, siblings of the person who suffers from this. When a child in the family suffers from a disability, it affects the entire behavior and emotions of the family. It is possible that siblings of autistic individuals face different problems in interpersonal interactions and cognitive functions compared to siblings of healthy individuals. In fact, the effect of negative characteristics in the behavior of a person with autism on family relationships can also affect the quality of life and cause it to decrease. It is also clear that families and each member can be both positively strengthened and harmed by this situation. It seems that the amount of these opposing effects varies from family to family and from person to person. A meta-analysis of psychosocial functioning among siblings of children with autism showed that these siblings had lower psychosocial functioning and were at greater risk of depression and anxiety than siblings of neurotypical individuals. During a study, they found that the relationships between children with autism and their siblings are characterized by less intimacy and closeness compared to other sibling relationships. These feelings can have a negative effect on their emotional and social abilities and cause problems in establishing social interactions and understanding the emotions of others. More than 10% of siblings with autism show deficits that are associated with autistic features. In responding to social and emotional issues among siblings of people with autism, it shows the concept of broader autism phenotype [2].

The research done on the effect of autistic person's characteristics on the development of emotional and social abilities of siblings is limited. An important part of children's social and emotional development is the development of empathy and the expression and understanding of emotions. Empathy It is defined as a person's ability to understand and share the feelings and emotional experiences of others. This ability includes two major parts of cognition, which refers to the ability to understand the views and feelings of others and the emotional part, which is related to the ability to experience and respond to the feelings of others. On the other hand, autistic people show weaker empathy than normal people and may have defects in the experience of empathy, which can cause others to leave them as indifferent or unfeeling. Due to the inability to understand and respond to social cues and empathy, an autistic person may have difficulty in establishing and maintaining friendly and group relationships and this affects the family, especially siblings. According to Zhao, the empathic and social development of siblings of individuals with autism may occur either through increased genetic risk of autistic traits with related empathic and social problems or through more limited opportunities to learn and practice empathy and social behavior in the relationship. Siblings with an autistic person are affected. Campbell et al. in 2015 and 2017 and Ayioglu concluded in a study that siblings of autistic individuals scored lower in empathy compared to the control group. But on the other hand, in McDonald's research in 2017 and Shivers in 2019, they reported that the siblings of a person with autism spectrum disorder scored higher in empathy evaluations than the control group. There have been studies about empathy and concluded that they showed less empathy and prosocial behavior in siblings of individuals with autism compared to the control group [3].

On other hand, the root of many abnormalities in interpersonal interactions, including social relationships, is related to emotional disturbances. One of the emotional disorders is the inability to consciously represent and understand emotions, in other words, alexithymia. Alexithymia is a psycho-neurological disorder in which a person suffering from it has difficulty in identifying and describing individual emotions and feelings. In addition, emotional deficits in ASD are largely derived from alexithymia. Several studies have shown that siblings of autistic individuals show higher rates of alexithymia compared to the general population. For example, a meta-analysis study by Kinnard, et al. reported that the prevalence of alexithymia was significantly higher in families with an individual with autism compared to a control group. This shows that alexithymia may have a family influence by the autistic person [4].

The main issue is the experience of negative consequences and the impact of the autistic person's behavior on the social and emotional skills of his or her sibling, which should be recognized and taken into account. These feelings, such as alexithymia or lack of empathy, can negatively affect the emotional and social abilities of sibling’s autistic people and make it difficult to establish social interactions and understand the emotions of others. Recognizing the specific problems and needs of autistic siblings can help design and provide more effective support programs, and the need to conduct detailed and comprehensive research in this field is felt more than ever [5].

Materials and Methods

Study design

This quantitative study used a cross-sectional and comparative design to investigate the levels of empathy and alexithymia in siblings of adolescents with autism spectrum disorder compared to healthy siblings. Inclusion criteria for the experimental group required that siblings have a brother or sister diagnosed with autism by licensed psychologists or psychiatrists. On the other hand, the control group must have a healthy sibling. All participants and their parents provided written informed consent. In order to evaluate and enter the exam, the MOT computer test, which is part of the CANTAB test series, was taken from the experimental group of Ziafat School and from the control group at Farzangan and Marafet schools to measure speed and accuracy. The task was set up in psychopy (PsychoPy v2024.2.1) and was presented on laptops (screen dimensions: 40 × 30 cm). But we did not use its data for review and analysis and it was done only to ensure the accuracy and speed of the participants [6].

Participants

We found that using G*POWER software we could achieve 80% power to detect a medium effect (d=0.6), the sample size was determined to be 36 participants in per group. A non-random available sampling was used, focusing on teenagers from the aforementioned schools who had age and sibling criteria. The sample included equal number of male and female participants in each group. In this study, 72 siblings of teenagers aged 12 to 15 years, including 36 siblings of people with autism spectrum disorder (18 sisters) and 36 siblings of healthy people were selected. The participants were selected from the schools of Shahryar city, Tehran, including the autism school "Ziafat" for the experimental group and the "Marefat" primary school and the middle school "Farzangan" for the control group (Table 1) [7].

Table 1: Demographic information of the participants.

Materials

Following instruments were used for data collection:

TAS-20 test: This scale, developed by Taylor in 1986 and revised by Bagby, Parker and Taylor in 1994, measures difficulties in identifying and describing feelings, externally oriented thinking and reduced daydreaming. It consists of 20 items, divided into three subscales: Difficulty identifying feelings (7 items), difficulty describing feelings (5 items) and externally oriented thinking (8 items).

IRI-Short test: A questionnaire designed by Davis in 1980, which has 16 questions and 4 components and is based on a Likert scale with questions such as (I usually feel sympathy and concern for people who have a worse life than me), to it measures interpersonal reactivity. The perspective-taking scale measures the reported tendency to spontaneously adopt the psychological perspective of others in everyday life (I sometimes try to understand better by imagining how things look from their perspective). The empathic concern scale assesses the tendency to experience feelings of sympathy and compassion for others (I often have feelings of concern for people who are less fortunate than me). The personal distress scale measures the tendency to experience distress and distress in response to severe distress in others (Being in a stressful emotional situation scares me). The fantasy scale measures the tendency to imagine oneself in imaginary situations (when I am reading an interesting story or novel, I imagine how I would feel if the events of the story were happening to me) [8].

Procedure

This study received ethical approval from the Ethics Committee of Shahid Beheshti University. All participants gave their consent after reviewing all relevant information. To evaluate both groups, we first provide the participants with the TAS-20 in the form of a paper and pencil test and ask them to answer the questions honestly and accurately. We remind them to read each of the following statements and indicate how much they agree or disagree with each of them by selecting which option. To prevent mental fatigue, we give each subject a 5-minute break and then ask them to answer the Short-IRI. The total time for both tests was 15 minutes. Participants were then debriefed and thanked for their time.

Results

Data analysis was done in SPSS version 26 software. The results of this study show a statistically significant difference between the two groups in the level of empathy and ataxia. Finally, the measures of central tendency and dispersion between all these variables are provided. Our hypothesis was that the presence of an autistic person in the family has a positive or negative effect on empathy and alexithymia, siblings compared to siblings of healthy individuals. Independent t-test was used to test this hypothesis and the results were presented using statistical tables as follows:

Alexithymia between autistic and neurotypically siblings

According to the scores, the siblings of autistic people have a higher score in the scales of difficulties identifying feelings (p<0.046; r=0.67) and difficulties describing feelings (p<0.012; r=0.53) compared to the control group. But in the externally oriented thinking (p<0.051; r=0.48) scale of the control group, whose siblings are neurotypically, a higher score is observed than the siblings of people with autism spectrum disorder (Table 2) [9].

Table 2: Descriptive findings on the components of alexithymia in two groups of siblings of normal people and ASD.

Empathy and its level in autistic siblings and control group

As can be seen, the scales of empathic concern (p<0.006; r=0.61), perspective taking (p<0.094; r=0.46), personal anxiety (p<0.049: r=0.35) and fantasy (p<0.436; r=0.42) of the group of siblings of neurotypically people have higher scores than the siblings of autistic people (Table 3).

Table 3: Descriptive findings on the components of empathy in two groups of siblings of normal people and ASD.

Discussion

In the present study, we investigated the effect of an autistic individual on empathy and alexithymia in siblings, through emotional and social assessment. Based on the assessment, we noticed a high level of alexithymia and a low level of empathy in siblings of autistic individuals compared to the control group and the impact of autistic individuals on the emotional and social aspects of siblings was observed. According to research, alexithymia is associated with a lack and inability to empathize.

In this research, it was shown that the severity of autistic person's behavior leads to emotional and social problems and subsequently these characteristics affect the family and may face challenges. In our study, we predicted that the severity of autism spectrum disorder may increase alexithymia in siblings and in parallel, decrease empathy and its incidence. In response to this hypothesis, it can be suggested that the siblings of people with autism spectrum disorder have less opportunity to experience and practice the views of others due to the complex and stressful family environment and the special needs of their autistic siblings and this view scored lower in the adopt perspective scale. On the other hand, it is possible that because the siblings of the autistic person spend more of their time and energy supporting and caring for him, they are less involved in imaginations and daydreams and it seems that the fantasy score is lower in the group of the siblings of ASD people. But on the other hand, siblings of autistic person scored higher in the scales of personal anxiety and empathic concern than the siblings of neurotipically people, which can be stated because of the care and support of the autistic person and the increased sense of responsibility siblings of autistic people scored higher in these two scales. These results show that the characteristics of autistic people, in addition to the deficiency in some emotional and social items, strengthen other parts and the effect of an ASD person on siblings does not necessarily cause a complete deficiency like an autistic person. In other words, siblings of autism people may be at risk for psychological and social maladjustment, but they seem to show empathy and prosocial behavior in some cases compared to their peers who have healthy siblings. We hypothesized that the cause of fluctuation in empathy in the siblings of a person with autism spectrum disorder is the high score of alexithymia and the effect of the autism person's characteristic on family members. Because people with autism may be less able to understand and identify other people's feelings due to high external thinking, which can lead to a decrease in empathy and the ability to communicate emotionally with others. In fact, research shows that the lack of empathy in autism spectrum disorder is a function of insight deficits related to alexithymia instead of being a function of the autism condition itself.

These findings are consistent with previous research showing that the emotional and social needs of having an autistic sibling can significantly affect the psychological development of these siblings. The increased level of dyslexia observed in siblings of autistic people can be attributed to the increased emotional challenges and stresses they face in their daily lives. Alexithymia, characterized by difficulties in identifying and expressing emotions, may serve as a coping mechanism to manage these stressors. This finding is consistent with the work of Feldman, Dalgleish, and Mobbs, who found that alexithymia can reduce emotional involvement in social situations, possibly as a protective measure.

Conversely, the lower levels of empathy observed in these siblings may be due to the significant amount of emotional and cognitive resources required to interact with their autistic sibling. These interactions often require high levels of patience and understanding, potentially leading to emotional exhaustion and reduced empathy for others. This is supported by research showing that ongoing emotional stress can impair a person's ability to empathize. On the other hand, in the results we obtained about the level of empathy in siblings of autistic people, it is contrary to the results of Shivers in 2019 and McDonald's study in 2017. But the study's findings are consistent with Smith's 2010 research, which suggests that the difficult and often stressful environment of living with an autistic sibling may affect the development of empathy in these individuals. The constant need to adapt to the unique behaviors and needs of an autistic sibling can potentially hinder their ability to empathetically interact with others. In conclusion, this study highlights the unique emotional challenges faced by siblings of individuals with ASD and highlights the need for targeted support and interventions. Further research is necessary to examine the long-term effects of these emotional dynamics and to develop effective strategies to support these siblings throughout their development.

Conclusion

Our study is a cross-sectional study. Although the sample size of the present study is statistically adequate, a larger sample set may enable researchers to examine the lens through which problems of emotional and social competence are more challenging. In addition, the fact that the age groups of siblings in each variable were in the age range of 12 to 15 years in the studied sample, caused the problems that these siblings of autistic individuals will experience in the second period of adolescence and adulthood will not consider in this study that there may be an effect of age on the intensity and incidence of these abilities.

Therefore, examining these age periods in future studies will enable us to understand the problems of families of autistic people with regard to past experiences and future challenges. On the other hand, in eastern cultures, we need more research in this field to achieve comprehensive and integrated results. The reliance on self-report measures, such as the TAS-20 and the IRI, may introduce response biases, such as social desirability or inaccuracies in self-assessment. Incorporating multiple methods of data collection, including parent or teacher reports and behavioral observations, could provide a more comprehensive assessment of empathy and alexithymia. The study did not control for potential confounding variables such as the severity of the ASD symptoms in the sibling, family socioeconomic status and the presence of other psychological conditions in the participants. These factors could influence the levels of empathy and alexithymia and should be considered in future research. Cultural differences in emotional expression and socialization practices were not accounted for in this study. Cultural context can significantly affect the development and expression of empathy and alexithymia. Future studies should consider cultural factors and include participants from diverse backgrounds to understand better how these constructs manifest in different cultural settings. Future research suggestions included exploring emotional intelligence and empathy in siblings of other types of children with disabilities to identify differences and similarities, as well as providing insights for professionals working with siblings of children with disabilities. In conclusion, while this study provides valuable insights into the emotional experiences of siblings of individuals with ASD, these limitations highlight the need for further research to build on these findings and address the gaps identified. Understanding the emotional and social competencies, specifically empathy and alexithymia, in siblings of individuals with autism spectrum disorder has significant implications for both clinical practice and familial support systems. Firstly, recognizing the unique challenges faced by these siblings can guide the development of targeted psychological interventions aimed at enhancing their emotional intelligence and coping strategies. Such interventions could help mitigate the potential negative psychological impacts associated with living with a sibling who has ASD, such as increased stress, anxiety and social isolation. Recognizing the specific problems and needs of autistic siblings can help design and provide more effective support programs.

Moreover, this understanding can inform educational programs and support groups tailored for siblings of autistic individuals, providing them with resources and peer support to navigate their unique familial dynamics. Educators and counselors could be trained to recognize signs of emotional distress or alexithymia in these siblings, enabling early intervention and support. Additionally, research in this area underscores the need for holistic family-centered approaches in treating and supporting families affected by ASD. By acknowledging and addressing the emotional needs of siblings, clinicians can foster a more supportive and nurturing home environment, which is crucial for the overall well-being of all family members. This not only helps to improve the psychological and social condition of these people, but also leads to the overall development of the quality of life of their families. Emotional and social abilities in adolescence are considered as one of the key factors in determining social and academic success in the future. Adolescent siblings of autistic people who face emotional and social challenges may have more problems in facing and interacting with academic and social environments. Investigating and researching to improve these capabilities can prevent future problems and help academic success.

In other words, research that examines the emotional and social capabilities of adolescent siblings of people with autism spectrum disorder can help increase society's awareness of the challenges and needs of this group of people. This awareness can lead to the improvement of social relations, increasing empathy and social support for families with autistic individuals. Finally, these findings highlight the importance of further research into the long-term impacts of growing up with an autistic sibling, which can contribute to broader societal understanding and acceptance, potentially reducing stigma and fostering more inclusive communities.

Acknowledgements

Not applicable.

Author Contributions

Shahriar Gharibzadeh participated in the design of this study and the review process and Maral Besharati collected data, wrote the article and performed statistical analysis. All authors have read and approved the final version.

Funding

Not applicable.

Data Availability

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

Ethical Approval and Consent to Participate

All procedures performed in this study were approved by the Shahid Beheshti University Ethics Committee and was conducted with the ethics ID IR.SBU.REC.1403.046 and was carried out in accordance with the ethical principles established by the Declaration of Helsinki.

Consent for Publication

Not applicable.

Informed Consent

Informed consent obtained from the caregivers of children with autism for their participation in the study.

Competing Interests

The authors have no conflicts of interest to declare.

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