1. SpecificAims:
The purpose of our proposed study is twofold:1) To investigate the role of the affiliativeneuropeptide oxytocinin
unhealthy interactions in families of patients with autism, and 2) to investigate whether manipulation of this
oxytocinergic system positively influences these family interactions.
Autism is a neurodevelopmental disorder associated with significant communication, social, and behavioral
deficits including impairments in verbal and nonverbal communication and excessive attachments to routine.
These deficits can impede parent-child bonding, increase parental stress, and lead to dysfunctionalparent-child
interactions. One measure of impaired parent-child interactions is high negative expressed emotion (EE),whichis
characterized by parental criticism, hostility,and lack of warmth high negative EE is the strongest psychosocial
risk factor forrelapse in schizophrenia, and although less wellresearched, high negative EE is both prevalent and
predictive of worse clinical outcomes in families with a child with autism. Currently there are no pharmacological
treatments to improve dysfunctional parent-child interactions or improve parent-child warmth and attunement in
families witha child with autism. A safe and cost-effectivepharmacologicalintervention that could be given to non-
affectedfamily members that decreases high negative EE and improves parent-child communication might
augment current psychosocialtherapies, improve the functioning of the family, decrease parental stress and lead
to better clinicaloutcomes for the patient with autism.
Endogenous oxytocin(OT)is a neuropeptide associated with attachment, parenting, and social cognition in
both humans and animals. Exogenous OTcan be administered intranasally in humans, enters the brain in high
concentrations, is welltolerated, increases positive interpersonal and parenting interactions, promotes
cooperation and trust, decreases hostility and reduces stress-induced physiology. Due to OT’s involvement in
processes associated withhigh negative EE (e.g. hostility, parenting) and attachment, we hypothesize that the OT
system represents a highly promising focus of research into the biological underpinnings of EE,as well as a
promising target for biological interventions aimed at reducing high negative EE and improving communication
between parents and their autistic children. If so, this would represent the first demonstration of a neurobiological
factorin the family functioning of persons with autism, and wouldrepresent the first biological intervention
applied to the family members of persons with autism, rather than to the individual with autism. Our proof-of-
conceptstudy willtake a criticalstep towards this goal by investigating this promising and novel pharmacologic
intervention with families of autistic patients in a laboratory setting.
Aim1: Toexamine the effectsof exogenous and endogenous OT on EE and nonverbal prosocial behavior in fathers
of patients withautism during a laboratory conflicttask
Hypotheses:
1A: Fathers will demonstrate lower EE and higher quantity of nonverbal prosocial behaviors when administered
intranasal OTcompared to placebo.
1B: Fathers’ baseline levels of OTwill predict EE and quantity of nonverbal prosocial behaviors during a laboratory
conflicttask, such that higher baseline levels of OTwill be associated with lowerlevels of EE and greater quantities
of nonverbal prosocial behaviors.
1C (Exploratory):Low peripheral levels of OT will be associated withgreater changes in fathers' EE and
nonverbal prosocial behavior in response to intranasal OT administration.
Aim2: To examine the effectsof intranasal OTadministration to fathers on their child's behavior, feelings of
closeness and stress physiology
Hypotheses:
2A: Children willhave reductions in negative affect,disruptive behaviors, and conflictual statements during a
laboratory conflicttask when their fathers receiveintranasal OTcompared to placebo
2B: Children willdemonstrate increased feelings of closeness with their fathers after a laboratory conflicttask
when their father receives intranasal OT compared to
placebo.
2C:Father and child willdemonstrate increased
behavioral synchrony during the conflicttask when the
father receives intranasal OTcompared to placebo.
Experimental Design:
We will recruit 20 verbal, transitional age (age: 14-24)
patients with autism spectrum disorder (ASD)(autism or Asperger’s disorder, not Pervasive Developmental

2. Disorder) with normal range IQ(IQ>75) and their fathers (lacking psychopathology) fromthe UCSF Autism and
Neurodevelopment Program. Because OT may have sexually dimorphic effects,only male caregivers will be
included to minimize inter-subject variability in this pilot study.
BloodTests:Onthe day beforethe first interaction task, fathers will have their blood drawn to determine OT
levels using an enzyme immunoassay.
OT/Placebo administration:40IU of intranasal OT and placebo will be administered to fathers of patients with
autism immediately before undergoing the Family Interaction Task (FIT) in a randomized, double-blind,
counterbalanced order witha cross-overdesign, one week apart. The FITwill follow drug administration aftera
waiting period of 35 minutes and willlast for no longer than 45 minutes. This dosage of OThas been used
successfully and safely in previous studies.1
FamilyInteractionTask:Fathers and their autistic child willparticipate in a 45-minute interaction task that will
be videotaped. A psychologist will assist the patient-father pairs to discuss a problem that has created a high
degree of conflictbetweenthe twoparticipants and attempt to resolve it within ten minutes. There will be two
more ten-minute conditions that will include a neutral and positive topic for discussion.
The psychologist and one research assistant, both of whom willbe blind to the OT/placebocondition, will code
each videotape for parental criticalversus constructivecomments, hostility (generalized criticismand rejecting
comments), and warmth, patient odd and disruptive verbal behaviors, self-stimulation, and disengagement as well
as nonverbal prosocial behaviors in both the parent and the child including affect,affectivetouchand eye-contact2
PowerAnalysis:Thefollowingpower analysis is based on a double blind, placebo controlled, within-subjectstudy
3 of the effectsof intranasal OT administration on fathers’ behavior during play with their toddler. The effectof OT
on fathers' behavior was large (eta-squared = 0.33). These considerations lead to the followingsample size
estimate for our study: An N of 20 dyads will provide 83% power to detect an effectof intranasal OTon fathers' EE
during the FIT,at an alpha level of 0.05.
Data AnalysisPlan:Fordata reduction purposes, a composite parental EE score will be calculated from quantities
of hostility, criticism, and warmth and a composite patient negative behavior score will be calculated from
quantities of odd and disruptive verbal behaviors, self-stimulation, and disengagement.
Similarly, a composite score of nonverbal prosocial behavior willbe calculated forboth parent and child
from quantities of affect,affectivetouch and eye-contact.In order to test our first hypothesis, that fathers will
demonstrate lower negative EE and more nonverbal prosocial behaviors (Hypothesis 1A) when administered
intranasal OTcompared with placebo, tworepeated measures analyses of variance willbe conductedwith drug. as
a within-subject factor.Post-hoc univariate analyses willbe conductedto determine differences in the outcome
measures (EE and nonverbal prosocial behavior) in the OTcondition compared to the placebo condition. In order
to test forbias due to order effects,a preliminary multivariate repeated analysis of variance will be performed with
order of OTadministration as a between-subjects factor.Should the result be significant, the order of
administration willbe used as a covariatein all analyses.
In order to test our second hypothesis, that high peripheral OTlevels predict low EE and greater nonverbal
prosocial behavior in fathers (Hypothesis 1B) during the FIT,we will run twomultiple regression models, one
examining the relationship between peripheral OTlevels and EE and the other examining the relationship between
peripheral OT levels and the quantity of nonverbal prosocial behaviors. Because the interaction between
peripheral levels of OT and responsiveness to exogenous OT is unknown, these analyses willutilize data only from
the session during whichsubjects were administered placebo. In exploratory analyses, we will additionally
examine the relationship between peripheral levels of OT and responsiveness to exogenous OT (Hypothesis 1C)
using a multiple regression model.
In order to test our fourth hypothesis, that patient negative behaviors will decrease and nonverbal
prosocial behavior will increase in response to their father receiving intranasal OT (Hypothesis 2A), two repeated
measures analyses of variance analysis willbe conducted withdrug as a within-subject factor.Post-hoc univariate
analyses will be conducted to determine differences in the outcomemeasures (negative behaviors or nonverbal
prosocial behavior) in the OTcondition compared to the placebo condition.

3. To test our fifthhypothesis, that child feelings of closeness to their father willincrease when their fathers
receive intranasal OT compared to placebo (Hypothesis 2B), a paired T-test willbe used. In order to test our sixth
hypothesis, that child stress/threat responses willdecrease when their fathers receive intranasal OTcompared to
placebo (Hypothesis 2C), separate models and multivariate analysis of variance will be considered for
cardiovascular outcomes foreach individual. Statistical tests will be two-tailed and conducted at the .05 level of
significance. Higher levels of peripheral OT lead to higher vagal control, more benign stress reactivity (reduced blood
pressures,cardiovascular response patterns characterized by increased ventricular contractility, heart rate,and cardiac
output, but decreased total peripheral resistance),higher anabolic balance, and reduced subjective distress, by comparing
the change in responses before and after stress across the oxytocin and placebo control groups.4
Timeline:Because wealready have experience withadministering OT to humans and already have FDA and
CHR approval forseveral similar studies, we believe that wewill be able to start the proposed study within two
months after receiving funding. Given the number of father-patient dyads that we see at our research center, we
anticipate that we willrecruit approximately 2 families a month, thereby completing this pilot study in 10 months.
We will then spend the followingtwomonths analyzing data and preparing manuscripts forpublication.
Significance
High negative EE has consistently been linked to worse clinical outcomes in patients with schizophrenia and a
variety of other psychiatric illnesses, including depression, bipolar disorder, and eating disorders.5 Most parents
experience difficultiescommunicating with their autistic child6 and 28.7% of families with an autistic child reach
criteria for high negative EE.7 High negative EE and the behaviors this conceptencompasses have been repeatedly
linked to worse clinical outcomes for patients with autism including increased rates of asocial maladaptive and
repetitive behaviors, and increased behavioral problems.8,9 Conversely, low-EE behaviors,such as greater positive
parental involvement and warmth are associated with greater improvements in children's social development8 and
reductions in behavioral problems, social reciprocity impairments and repetitive behaviors.10 Early interventions
aimed at promoting physical affection,praise, and talking with children reduce noncompliant and oppositional
behavior but are time consuming and costly.11 A safe and cost-effectivepharmacologicalintervention that
improves interactions between parents and children withautism is a promising approach to improve symptoms of
autism.
When administered intranasally in humans, OThas anxiolytic and prosocial effectsand is extremely well
tolerated12. In healthy individuals, intranasal OTpromotes trusting behavior, improves memory forfaces,
facilitates emotional empathy13 and increases the ability toinfer the mental states of others.12 Subjects tend to rate
faces as more trustworthy followingOT administration,.12,14 intranasal OT reduces physiological and
psychologicalresponses to social stressors14 and increases fathers’ attentiveness and decreases their hostility
towards their toddlers.3 Parental OT levels predict affectivetouchand social gaze in triadic family interactions15,
and intranasal OT promotes longer eye gaze14 and improves "mind-reading" for individuals withsocial deficits14.
Finally, administration of OTto romantic heterosexual couples increases positive communication and decreases
cortisol levels (a marker of stress) during a standardized laboratory conflictprotocol.14 Taken together, this data
indicates that intranasal OTpromotes social behaviors, such as positive touch and communication, increases the
ratio of positive to negative interactions, and decreases social anxiety and fear, all qualities highly relevant to EE.
Therefore, administering intranasal OT to family members of patients withautism may decrease negative EE and
promote healthier family interactions. If so, this would significantly broaden our knowledge of the neurobiological
factorsthat contribute to deleterious interaction patterns in families of patients with autism, and it would
demonstrate that intervening in the OTsystem couldfavorably impact those social interactions, decreasing high
negative EE,and thereby improving outcomes for patients and their families.
Impact
Our study is a first, proof-of conceptstudy, and is particularly novelin being focusedon the neurobiology of non-
affectedfamily members of patients withautism. If successful, our results will lead to larger clinical trials of OTto
improve clinical outcomes in autism such as studies to test whether short-term OTadministration can heighten the
effectivenessof established family psychosocialinterventions. Furthermore, our study will provide high-impact
human data on the neurobiological factors that underlie social affectivefunctioning in family groups. Finally, our
study may lead to a novel intervention that helps parents feel more connected to their children and improves
clinical outcomes forpatients with autism.
References:

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Psychol 2006, 45 (Pt 2), 205-16. 6. Osborne, L. A., Research ASDs 2010, 4 (3), 405-414. 7. Greenberg, J. S., AJMR 2006, 111 (4),
229-49. 8. Kurani, D., JOID 2009, 13 (4), 269-89. 9. Orsmond, G. I., AJMR 2006, 111 (2), 121-37. 10. Smith, L. E., AJMR 2008, 113
(5), 387-402. 11. Sanders, M. R., J Consult Clin Psychol 2000, 68 (4), 624-40. 12. Heinrichs, M., Front Neuroendocrinol 2009, 30
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