Parental Attunement, Insightfulness, and Acceptance of Child Diagnosis in Parents of Children With Autism: Clinical Implications

Abstract

Early parent–child relationships are an important factor influencing many domains of child development, even in the presence of autism. In this study, we investigated the associations between parent–child attunement during play, parental insightfulness, and parental acceptance of their child’s diagnosis of an autism spectrum disorder. A sample of 50 parents (26 mothers and 24 fathers) of 26 children aged between 24 and 58 months were videotaped during parent–child play interactions and then interviewed about what they thought had gone through their child’s head during the play interaction, and about their feelings and thoughts about their child’s diagnosis. Play interactions were evaluated using a coding protocol to assess parental attunement. The results showed that parents who were more able to accept their child’s diagnosis and to see things from their child’s perspective were more likely to also be attuned during play interactions with their children. These findings highlight the importance of studying the parental ability of insightfulness and acceptance of their child diagnosis of ASD for the implementation of intervention programs for supporting parental attunement and improving the interactions between the parents and the children with autism spectrum disorders.

Full text

fpsyg-11-01849 September 11, 2020 Time: 18:42 # 1
ORIGINAL RESEARCH
published: 07 August 2020
doi: 10.3389/fpsyg.2020.01849
Edited by:
Emma Gowen,
The University of Manchester,
United Kingdom
Reviewed by:
Giorgia Varallo,
Italian Auxological Institute (IRCCS),
Italy
Danielle Moyer,
Children’s Hospital of New Orleans,
United States
*Correspondence:
Magda Di Renzo
m.direnzo@ortofonologia.it
Specialty section:
This article was submitted to
Psychology for Clinical Settings,
a section of the journal
Frontiers in Psychology
Received: 27 March 2020
Accepted: 06 July 2020
Published: 07 August 2020
Citation:
Di Renzo M, Guerriero V,
Zavattini GC, Petrillo M, Racinaro L
and Bianchi di Castelbianco F (2020)
Parental Attunement, Insightfulness,
and Acceptance of Child Diagnosis in
Parents of Children With Autism:
Clinical Implications.
Front. Psychol. 11:1849.
doi: 10.3389/fpsyg.2020.01849
Parental Attunement, Insightfulness,
and Acceptance of Child Diagnosis
in Parents of Children With Autism:
Clinical Implications
Magda Di Renzo1*, Viviana Guerriero1,2 , Giulio Cesare Zavattini2, Massimiliano Petrillo1,
Lidia Racinaro1and Federico Bianchi di Castelbianco1
1Institute of Orthophonology (IdO), Rome, Italy, 2Department of Dynamic and Clinical Psychology, Sapienza University of
Rome, Rome, Italy
Early parent–child relationships are an important factor influencing many domains of
child development, even in the presence of autism. In this study, we investigated the
associations between parent–child attunement during play, parental insightfulness, and
parental acceptance of their child’s diagnosis of an autism spectrum disorder. A sample
of 50 parents (26 mothers and 24 fathers) of 26 children aged between 24 and 58
months were videotaped during parent–child play interactions and then interviewed
about what they thought had gone through their child’s head during the play interaction,
and about their feelings and thoughts about their child’s diagnosis. Play interactions
were evaluated using a coding protocol to assess parental attunement. The results
showed that parents who were more able to accept their child’s diagnosis and to
see things from their child’s perspective were more likely to also be attuned during
play interactions with their children. These findings highlight the importance of studying
the parental ability of insightfulness and acceptance of their child diagnosis of ASD
for the implementation of intervention programs for supporting parental attunement
and improving the interactions between the parents and the children with autism
spectrum disorders.
Keywords: parental attunement, insightfulness, acceptance of child diagnosis, autism spectrum disorders,
parent–child interaction
INTRODUCTION
Autism spectrum disorders (ASDs) are neurodevelopmental disorders characterized by deficits
in social communication, and restrictive, repetitive behavioral patterns emerging early in child
development. These children also show an intensified emotional reactivity and difficulties in
emotion regulation (Samson et al., 2012).
A recent study found a relationship between children’s alexithymia and a reduction in parent–
child interactions in the presence of a diagnosis of ASD, when compared to parents of typically
developed children (Costa et al., 2019). Moreover, a 2019 review have revealed that parental
verbal responsiveness to their children’s focus of attention predicted children’s expressive and
receptive language (Edmunds et al., 2019). In this respect, considering that children with ASD
may display poorer communicative behaviors than children with typical development, these fewer
Frontiers in Psychology | www.frontiersin.org 1August 2020 | Volume 11 | Article 1849

fpsyg-11-01849 September 11, 2020 Time: 18:42 # 2
Di Renzo et al. Parental Attunement, Insightfulness, and Acceptance of Diagnosis
social interactions may lead to reduced learning opportunities
with parents (Tager-Flusberg, 2016). Given the significance
of difficulties in social relationships for these children, many
researchers have argued for the need to better understand the
role and quality of early relationships with primary caregivers
(Crowell et al., 2019).
Research into parent–child dyads highlights the fact that social
competence is an important factor in child development (Raver
and Zigler, 1997;Vaughan Van Hecke et al., 2007;Denham
et al., 2012;Domitrovich et al., 2017). Social competence is
shaped within interactive, mutual exchanges as part of the
development of early parent–child relationships (Feldman and
Masalha, 2010), for which attuned parenting is fundamental
(Landry et al., 2006;Leerkes et al., 2009). Parental attunement is a
core dimension, defined as the parental ability to be responsive
to child signals, understand them, and respond appropriately,
while adjusting to the child’s needs (Stern et al., 1985;Stern,
1998;Schore, 2001;Zand et al., 2014). This competence emerges
during parent–child interactions, laying the foundation for a
shared and emotionally connoted experience, which represents a
precursor for the development of the child’s mind, his/her abilities
in self-regulation, and capacity to be engaged in relationships
with others.
In research investigating the role of parental attunement
in child development, little has involved samples of parents
who have children with ASD. A study of 39 parents of
children with different diagnoses (including autism) indicated
that parents showing greater knowledge of child development
were more likely to be attuned to their children. Greater
parental attunement also predicted more positive attitudes
toward child independence, which in turn predicted child social
competencies (Zand et al., 2014). A pilot study examining
parent–child physiological synchrony, that is the parent and child
electrodermal activity measured during naturalistic free play,
highlighted that higher ASD symptoms were associated with
lower levels of parental emotional attunement and synchrony
(Baker et al., 2015). In a sample of 40 preschoolers with ASD
and 40 matched typically developing (TD) peers, children’s ability
to self-regulate and mother and father parental disciplinary style
were explored (Ostfeld-Etzion et al., 2016). The study confirmed
what was already emerging in the relevant literature (Feldman
and Klein, 2003;Hirschler-Guttenberg et al., 2015), namely, that
parents of children with ASDs used the same parental disciplinary
style of parents of TD children, and that a more supportive
parental disciplinary style was associated with more child self-
regulated compliance. According to a 2017 study in an ASD
group, mother–child dyadic interactions were more engaged
in mismatched emotion-engagement states and children spent
more time exclusively with objects than the dyads in the TD
group (Guo et al., 2017). Another recent study used a narrative
methodology to study fathers’ stories of play interaction with
their children with ASD aged between 5 and 12 years old. Three
narratives emerged from the fathers’ stories (action, adjustment,
and acceptance), and among them, acceptance narratives were
more likely in fathers showing resistance to societal norms of
play, acceptance of, and attunement to their children’s play
interests (Mitchell and Lashewicz, 2018).
An important contribution to understanding the roles played
by the parents of children with ASD has been made by
Oppenheim and Koren-Karie (Oppenheim et al., 2001;Koren-
Karie and Oppenheim, 2018) with the introduction of the concept
of parental insightfulness. This refers to the parental ability to
see things from the child’s point of view. Previous studies have
shown that insightful mothers were more sensitive within their
interactions with their children, and these mothers are also more
likely to have children with secure attachments (Koren-Karie
et al., 2002). Furthermore, insightful mothers were found to
display higher levels of positive parenting during interactions
with their children, regardless of the number of stressful life
events experienced by the mother (Martinez-Torteya et al., 2018)
when compared to non-insightful mothers. Higher levels of
cooperation and co-parenting in triadic interactions when both
parents were insightful were also identified, and no differences
were found between mothers and fathers in their ability to
see things from the child’s point of view (Marcu et al., 2016).
A recent study (Feniger-Schaal et al., 2019) on 38 mothers
of children with intellectual disabilities found that 41% of the
mothers showed positive insightfulness and that better capacity
for insightfulness was associated with better maternal sensitivity1
behavior during mother–child interactions when compared to
non−insightful mothers.
When comparing a group of clinically depressed vs. non-
depressed mothers, Ramsauer et al. (2014) showed lower
sensitivity and insightfulness toward their child, in depressed
mothers. Based on clinical theorizing, in the presence of a mental
illness, parental ability to display attunement/sensitivity and
insightfulness toward a child may be somewhat impaired, which
may negatively influence parent–child relationship (Oppenheim
and Koren-Karie, 2009;Carter and DelCarmen-Wiggins, 2020).
However, to our knowledge, there are no studies investigating
these variables in a sample of children with ASD.
Within the population of children with ASD, a 2008 study
showed that maternal insightfulness did not depend on the
severity of ASD or the level of child functioning. Overall,
42% of mothers were found to be insightful and 58% were
found to be non-insightful, regardless of the severity of ASD
(Oppenheim et al., 2008). Furthermore, in a sample of 39 children
with ASD and their mothers, maternal insightfulness and child
secure attachment at preschool age predicted better adaptation to
developmental tasks, such as school, 4 and 8 years later (Dolev
et al., 2014). Consistent with this, a recent systematic review
1In this context with sensitivity, we mean “the caregiver’s ability to understand
and recognize child’s signals. In particular, this term refers not only to the parental
ability to interpret the emotional and physical states expressed from the early
hours of life, but also to the willingness to provide a sufficiently adequate response
in terms of timing and contents” (Di Folco et al., 2016, p. 72). We are aware
that the debate on attunement is still open. Specifically, the terms attunement
and sensitivity, which have been carefully described within different theoretical
paradigms, not without facing some confusion, were proposed with different
conceptual terms (Mesman and Emmen, 2013;Di Folco et al., 2016). Maternal
sensitivity appeared initially thanks to the observations conducted by Ainsworth
(1967) and is generally used within attachment researchers to describe an ability
that emerges within the parent–child relationship. However, the term attunement
was first described by the psychiatrist and psychoanalyst Daniel Stern (Stern et al.,
1985) and refers to individual’s ability to share affect, empathize, and appropriately
respond to another person, not necessarily the child.
Frontiers in Psychology | www.frontiersin.org 2August 2020 | Volume 11 | Article 1849

fpsyg-11-01849 September 11, 2020 Time: 18:42 # 3
Di Renzo et al. Parental Attunement, Insightfulness, and Acceptance of Diagnosis
on autism and attachment showed that maternal sensitivity and
insightfulness support the development of secure attachment in
children with ASD (Kahane and El-Tahir, 2015).
As stated by Oppenheim et al. (2009), in cases of the diagnosis
of severe pathology, the study of the parental state of mind
should include not only insightfulness but also the acceptance
or resolution of the diagnosis as “seeing things from the child’s
point of view must also include understanding and accepting
the challenges associated with the child’s diagnosis” (Oppenheim
et al., 2009, p. 519). Resolution is the process of the integration
of this information/emotion [about their child diagnosis] within
the parents’ representational systems of themselves as parents,
of their child, and of the relationship with their child (Pianta
and Marvin, 1993, p. 3). Receiving a diagnosis may cause
disruption or damage to normal maternal fantasies about a
child (Pouillaude, 2018) and negatively interfere with a parent’s
acceptance of the child’s diagnosis and their investment in
the child–parent relationship. Lack of acceptance can interfere
with the parental ability to integrate the representations of a
“healthy” and “ill” child, and with the possibility of focusing
their attention on the present and their relationship with the
actual child (Marvin and Pianta, 1996;Pianta et al., 1999;
Zavattini, 2016).
In studies with children with different diagnoses, the
proportion of parents with acceptance of the child’s diagnosis
varies from 36 to 81% (Lord et al., 2008;Milshtein et al., 2010;
Barak-Levy and Atzaba-Poria, 2013;Yirmiya et al., 2015;Dolev
et al., 2016;Baiocco et al., 2017). Parental acceptance of the child’s
diagnosis does not seem to depend on the time passed since
receiving the diagnosis (Pianta et al., 1996;Lord et al., 2008;
Hutman et al., 2009;Oppenheim et al., 2009;Milshtein et al.,
2010;Kearney et al., 2011;Lecciso et al., 2013;Popp et al., 2014),
the child’s gender (Marvin and Pianta, 1996;Schuengel et al.,
2009;Kearney et al., 2011;Yirmiya et al., 2015;Krsti´
c et al.,
2016), or parental gender (Lord et al., 2008;Schuengel et al.,
2009;Milshtein et al., 2010;Barak-Levy and Atzaba-Poria, 2013;
Yirmiya et al., 2015). Instead, it has been found that maternal
acceptance of the child’s diagnosis relates to more sensitive
caregiving during social play (Dolev et al., 2016) and a better
maternal perception of their physical health (Reed and Osborne,
2019). Failure in accepting the child diagnosis is linked to higher
maternal distress (Lord et al., 2008;Kearney et al., 2011;Krsti´
c
et al., 2015), parental depression (Kearney et al., 2011;Krsti´
c
et al., 2015), lower levels of emotional support (Sheeran et al.,
1997), greater use of avoidance strategies (Freda et al., 2016),
and lower maternal sensitivity (Dolev et al., 2016). Few studies
have investigated both paternal and maternal acceptance of child
diagnosis, but those have found significant gender differences.
Mothers low in acceptance, but not fathers, reported more
parental negative feelings and more negative impacts of the child’s
disease on their social life and marriage (Milshtein et al., 2010).
Fathers reported higher levels of couple satisfaction if mothers
were able to accept their child diagnosis (Sheeran et al., 1997) and
mothers were more prone to use an emotional coping style while
fathers tended to use a cognitive coping style when they talked
about the experience of receiving the diagnosis of the child’s
illness (Barak-Levy and Atzaba-Poria, 2013).
As for research on the parents of children with ASD, Milshtein
et al. (2010) studied 60 fathers and 61 mothers and found that
almost 43% were classified as acceptance of the child diagnosis
and that for mothers, the acceptance of the diagnosis was
associated with a better perception of the child and the impact
of raising a child with a disability on family life. Another study
(Lecciso et al., 2013) with a sample of 21 mother–child dyads
with high-functioning autism showed that accepting mothers
of their child diagnosis were better able to see themselves
and their children as mental agents, to think of themselves as
a secure base, and to not avoid the negative aspects of the
relationship. The maternal ability to accept the child diagnosis
was associated with the type of diagnosis: in contrast to the results
by Milshtein et al. (2010), the researchers found that mothers
of children with high-functioning autism were more likely to be
accepting of their child diagnosis than mothers of children with
Asperger’s syndrome.
Seventy-seven parents of recently diagnosed children with
ASD were the participants of a study (Poslawsky et al., 2014)
that found that parental acceptance of the child diagnosis
(also known as Resolution) was associated with less severe
autistic symptoms, and demonstrated a substantial stability of
the resolution classification relating to the child’s diagnosis after
7 months from the first evaluation. Yirmiya et al. (2015) also
examined the stability of resolution classification over time
(3 years after the first evaluation) among 78 mothers and
fathers of children with ASD. At time 2 (3 years after the
first evaluation), mothers’ acceptance of the child diagnosis
was significantly predicted by an increase in maternal anxiety,
an increase in the children severity of symptoms, and a
longer duration of time since they received the diagnosis.
A 2016 paper presented data from a sample of 46 mothers of
children with ASD aged between 2 and 8 years, demonstrating
that accepting mothers were more likely to be sensitive to
their children during play and reported less psychological
parental distress and fewer child symptoms compared to
mothers low in acceptance (Dolev et al., 2016). A recent
study on 84 mothers of children newly diagnosed with ASD
showed that mothers low in acceptance had a worsening of
maternal health status (in terms of their perception of their
symptoms) after 1 year from the time of their child diagnosis,
and they perceived to have a poorer health status when
compared to mothers more able to accept their child diagnosis
(Reed and Osborne, 2019).
Finally, some studies have investigated both parental
insightfulness and the acceptance of child diagnosis. A 2009
study of 67 mothers and their children with ASD did not identify
a significant association between these two variables, highlighting
instead that insightful mothers were more synchronous than
non-insightful mothers during play, while mothers able or
not able to accept their child’s diagnosis did not significantly
differ from each other in synchronous behavior during play
(Hutman et al., 2009). The maternal ability to accept child
diagnosis and maternal insightfulness were both associated
with a secure attachment classification in children with ASD
(Oppenheim et al., 2009). A further paper also demonstrated
that maternal sensitivity mediated the association between
Frontiers in Psychology | www.frontiersin.org 3August 2020 | Volume 11 | Article 1849

fpsyg-11-01849 September 11, 2020 Time: 18:42 # 4
Di Renzo et al. Parental Attunement, Insightfulness, and Acceptance of Diagnosis
insightfulness/maternal acceptance of the diagnosis and child
attachment in a sample of 45 preschool children with ASD
(Oppenheim et al., 2012).
The studies discussed above show that, to our knowledge, only
one study investigated the relationships between attunement,
insightfulness, and acceptance of the child diagnosis, in the
presence of a diagnosis of autism for children, focusing
exclusively on mothers. The aim of the present study was
therefore to examine the relationships between these three
aspects of parental functioning, on both mothers and fathers.
We hypothesized that the parents of children with ASD who are
insightful and able to accept their child diagnosis are more likely
to be attuned with their children during play interaction than
parents low in their ability to accept their child diagnosis and
insightfulness.
MATERIALS AND METHODS
Sample
Participants in this study were 50 parents (24 fathers and 26
mothers) of 26 children who had been diagnosed within the past
3 months of study participation with ASD or being at risk for
autism due to a diagnosis of global developmental delay. Children
ranged in age from 24 to 58 months (M= 34.36, SD = 8.65)
and the total sample comprised 23 (88%) males and 3 (12%)
females. Autistic risk was calculated for children under 30 months
using the Toddler Module of the Autism Diagnostic Observation
Schedule-2 (ADOS-2; Lord et al., 2012a,b). The children with
a diagnosis of ASD were 8 (Module 1 Pre-verbal of ADOS-2)
and the children with a diagnosis of Global Developmental Delay
(GDD) with a risk for autism were 18 (Toddler Module of ADOS-
2). Before participating in this study, parents and children have
received from 0 to 3 months of intervention. Only one parent
refused to participate in the study. The average age of mothers
was 38.20 years (SD = 5.51) and the average age of the fathers
was 41.38 years (SD = 9.09). Of the parents, 80% were Italian
and the remaining 20% were from other countries. Concerning
educational level, 14.3% of parents obtained a middle school
diploma or lower grade, 46.9% a high school diploma, and 38.8%
a university degree or higher (Table 1).
Procedure
The parents were recruited at the Institute of -Blinded for
Peer Review- between 2017 and 2018. Parent–child dyads were
videotaped during play interactions lasting 15 min. The play
TABLE 1 | Descriptive statistics.
N(%) MDS
Females Males
Parents’ gender 26 (52%) 24 (48%)
Children’s gender 3 (12%) 23 (88%)
Parents’ age 39.755 (Years) 7.570
Children’s age 34.360 (Months) 8.651
Length of treatment 1.040 (Months) 1,228
Educational level#
Middle school diploma or lower 7 (14.3%)
High school diploma 23 (46.9%)
University degree or higher 19 (38.8%)
Severity of the symptoms
Mild 5 (19.2%)
Moderate 10 (38.5%)
Severe 11 (42.3%)
Acceptance of child diagnosis
Resolved 24 (48%)
Unresolved 26 (52%)
Insightfulness
Insightful 27 (54%)
Non-insightful 23 (46%)
Attunement
Attuned 26 (52%)
Unattuned 24 (48%)
Acceptance of diagnosis/Insightfulness
(A) Resolved/Insightful 21 (42%)
(B) Unresolved/Non-insightful 20 (40%)
(C) Unresolved/Insightful or Resolved/Non-insightful 9 (18%)
#One missing data.
Frontiers in Psychology | www.frontiersin.org 4August 2020 | Volume 11 | Article 1849

fpsyg-11-01849 September 11, 2020 Time: 18:42 # 5
Di Renzo et al. Parental Attunement, Insightfulness, and Acceptance of Diagnosis
interactions used for coding the DAOS were the same for
assessing parental AI. Parents were then asked to complete
a questionnaire and to respond to a videotaped interview
lasting about 30–45 min. The clinicians who communicated
the diagnosis to the families were different from the team of
psychologists in the present study. One of the authors of this
study is the clinician who administered the ADOS-2, during the
assessment for the diagnosis of autism. No children had received
a diagnosis before the assessment at our center. The “at-risk
group” was made only by toddlers under 30 months of age and
that is why there was no diagnosis of ASD.
Parents were recruited after they have received a diagnosis
of ASD or Global Developmental Delay (GDD) with a risk for
autism for their children. The child diagnosis was communicated
to parents after the diagnostic process carried out at the Institute
of Orthophonology (IdO) of Rome (Di Renzo et al., 2015). The
Reaction to Diagnosis Interview was administered with regard
to the actual diagnosis they had (ASD or GDD with a risk for
autism). At the moment of participating in this study, parents and
children have received from 0 to 3 months of intervention at our
clinical institute. The intervention consisted of 10 h of treatment
per week including 6 h of child individual/group therapy, 2 h
of school observation and counseling, and 2 h of parental
psychological support, carried out by different clinicians than
those who conducted the present study (Di Renzo et al., 2020b).
This study was not submitted to an Ethical Committee for
ethical review and approval because it is suggested but not
mandatory in our legislation. In accordance with articles 5, 7,
and 9 of the Italian Ethical Code for Psychologist, a written
informed consent to participate in this study was provided by
the participants’ legal guardian of children. Before participating
in the study, parents were asked to sign an informed consent
indicating the methods, possible risks, and purpose of the study,
as well as being given the possibility of refusing to participate
further at any time, in accordance with the Helsinki Declaration
(World Medical Association, 2013).
Instruments
The Autism Diagnostic Observation Schedule, Second Edition
(ADOS-2; Lord et al., 2012a,b;Colombi et al., 2013) is a semi-
structured, standardized assessment of communication, social
interaction, play, and restricted and repetitive behaviors for
children aged between 12 months to adulthood. It presents
various activities that elicit behaviors directly related to a
diagnosis of ASD. By observing and coding these behaviors, we
obtained information relating to two areas: Social Affect (AS) and
Restricted and Repetitive Behaviors (RRBs). Critical behaviors
in the area of Social Affect, quantified in the coding algorithm,
receives a score ranging from 0 to 2, where 0 indicates normotypic
behavior, 1 indicates a behavior that is present but atypical and/or
not very flexible, and 2 indicates an anomaly or an absence of
such behaviors. The RRBs follow a progressive numerical coding
based on their frequency and intensity increasing from 0 to 2. The
overall score is given by summing AS and RRBs. The ADOS-2
includes five modules: the Toddler Module, for children between
12 and 30 months of age who do not have language or who do
not consistently use phrase speech; Module 1, for children from
31 months and older who do not consistently use phrase speech;
Module 2: for children of any age who use phrase speech but are
not verbally fluent; Module 3, for verbally fluent children and
young adolescents; Module 4, for verbally fluent older adolescents
and adults. The ADOS-2 has good psychometric properties
confirming its usefulness in distinguishing individuals with ASD
from other clinical groups (Mazefsky and Oswald, 2006;Gotham
et al., 2007, 2009;Lord et al., 2012a,b;Hus and Lord, 2014;
Esler et al., 2015).
The Reaction to Diagnosis Interview (RDI) (Pianta and
Marvin, 1993) is a brief, 15 min interview, aimed at examining
parental resolution of the loss/trauma associated with the
experience of receiving a child diagnosis of disability or chronic
illness. The RDI assesses this acceptance (or lack of acceptance)
through videotaping and then coding an individual parent’s
responses to six standardized questions with specific probes
investigating beliefs, memories, and emotional reactions of
parents to the news of the child’s illness and any changes that have
occurred over time. The coding yields the major classifications
of Resolved or Unresolved, plus several sub-classifications
within each major classification (Pianta and Marvin, 1993).
The Resolved parents are those accepting the diagnosis of their
child and can describe with balance the changes that may have
occurred following the communication of the diagnosis, without
continuing to look into the past or to question the possible
causes of what happened (Marvin and Pianta, 1996). They show
greater acceptance of the situation over time and can describe
the difficulties of the disease and the specific characteristics of
their child. Unresolved parents provide inconsistent descriptions
of the diagnosis experience. They may produce distorted stories,
which highlights an inability to describe the reality of the
situation, or the story appears confused and it is difficult for
the encoder to follow the thread of the discourse. Parents can
also experience difficulty in managing their feelings related to the
memory of the diagnosis experience and show themselves to be
emotionally overwhelmed by anger or pain, or depressed and/or
lost in their memories.
The Insightful Assessment (IA) (Koren-Karie and Oppenheim,
2004) is a video replay procedure for assessing parental
insightfulness. The procedure involves an initial phase in which
the parent and the child are videotaped during three different
moments of interaction. Then, the parent is invited to watch brief
video clips and interviewed regarding his/her child’s thoughts and
feelings. The evaluation allows each parent to be assigned one of
the following categories: Positively Insightful (PI) in which the
parent shows that he can describe the child in a complex way
and can focus on his internal world; One-sided (Os) in which
the parent has a one-dimensional view – positive or negative –
of the child and the relationship; Disengaged (De) in which the
parent shows a lack of emotional involvement in the description
of the child and the relationship; and Mixed (Mx) in which
no single, coherent parent strategy emerges (Koren-Karie and
Oppenheim, 2018). In our study, parents were divided according
to whether they fell into the broad Insightful and Non-insightful
classifications (which includes the Os, De, and Mx classifications).
The Dyadic Attunement Observation Schedule (DAOS;
under validation) is an observational measure of parent–child
interaction during play. The DAOS observation schedule was
used for scoring parent–child dyads videotaped during play
Frontiers in Psychology | www.frontiersin.org 5August 2020 | Volume 11 | Article 1849

fpsyg-11-01849 September 11, 2020 Time: 18:42 # 6
Di Renzo et al. Parental Attunement, Insightfulness, and Acceptance of Diagnosis
interactions. Parents were invited to play with their children as if
they were at home. The clinician gave the parents the instructions
of creating three different circumstances lasting about 5–10 min
each: a time of free play and two structured playtimes (i.e.,
blocks and sponge ball). This observational assessment consists
of eight scales: 1. joint attention, 2. body, 3. interaction, 4. space
sharing, 5. play sharing, 6. authonomy, 7. emotional regulation,
8. understanding child mental states. Each scale has a score
ranging from 0 to 3 and the final coding allows parents to be
assigned one of two categories: Attuned or Unattuned. Attuned
parents can adapt their bodies to respond to their child’s signals
with combined and alternating use of their space (remaining
close to/far, next to/face to face). They are generally able to play
with their child by activating a body dialog made up of gestures,
sounds, and eye gazing, supporting an interactive exchange
in which they organize role switching and involving the child
with sufficient participation (without intrusiveness). Attuned
parents are also able to facilitate their child’s actions without
overlap with the child, with the aim of increasing his autonomy
and supporting his skills so that the child may experience new
actions. They can offer their emotional availability to the child
by co-regulating emotions when the child is not able to regulate
these by himself. They are also able to recognize and repair
moments of failed attunement. Unattuned parents, on the other
hand, do not play with their children by activating body dialog
(they sometimes look like clumsy or inhibited), and they are
not very proactive in involving their child in play. They show
little or no shared and alternative use of space, remaining close
to/far, next to/face to face), tending to overpower the child or to
withdraw following demands for play. These parents may show
a strongly passive role, feeling inadequate, and unable to contain
and regulate their child’s emotions during difficult periods in
the interaction. They are powerless to repair moments of failed
attunement.
At present, the DAOS has currently been used with children
with typical development, learning disabilities, speech disorders,
anxiety disorders, and emotion regulation problems. The
measure is under validation.
Data Analysis
We used chi-squared tests to examine differences in parental
attunement, acceptance of diagnosis, insightfulness, parental
gender, parental educational level, and child severity of
symptoms. The variable “severity of symptoms” ranging from 1
to 5 (1 = no evidence, 2 = minimum, 3 = mild, 4 = moderate,
5 = severe symptomatology), was created on the basis of the
scores from ADOS-2 and clinical observations of the deficits in
the quality of communication and relational behaviors calibrated
upon children’s age.
We used t-tests to determine any significant differences
between Attuned/Unattuned, Resolved/Unresolved, and
Insightful/Non-insightful parents with respect to the
variables “children age” and “length of the treatment.” In
order to investigate our hypothesis that both Resolved and
Insightful parents were more attuned with their children
with ASD during play interactions, we created a combined
variable Resolution/Insightfulness, similar to the approach
used by Oppenheim et al. (2009). Three groups of (A)
Resolved/Insightful (21), (B) Unresolved/Non-Insightful
(20), and (C) Unresolved/Insightful or Resolved/Non-Insightful
(9) parents were formed.
A 3 ×2 cross-tabulation was performed to examine
differences between this new variable and parental attunement.
We used the likelihood ratio (LR) when our data did not meet the
assumption of having at least 80% of the cells with an expected
count of over 5 for the chi-squared tests.
The differences between the two groups of children with ASD
and autistic risk were calculated for the study variables, showing
no statistically significant differences between the two groups
(χ2= 1.923, p= 0.166 for attunement; χ2= 1.087, p= 0.297 for
insightfulness; χ2= 0.855, p= 0.355 for the reaction to diagnosis).
We therefore considered the entire sample in further analyses
without distinguishing between the two groups.
In line with Rosner (2010), reported by Dogan and Dogan
(2015), ICC <0.4 indicates poor dyadic relationship, so we
assumed our dyads had poor relationships for the three main
variables of our study (acceptance of diagnosis, insightfulness,
and attunement), and we considered mothers and fathers
separately for statistical analysis.
RESULTS
Descriptive Analysis
As shown in Table 1, 26 parents were classified as Unresolved
(15 fathers and 11 mothers); 23 parents were Non-Insightful
(16 fathers and 7 mothers), and 24 parents were Unattuned (13
fathers and 11 mothers). Children were assigned to a group
according to the severity of symptoms as follows: 3 = mild
(19.2%), 4 = moderate (38.5%), and 5 = severe (42.3%). No
children were assigned to the groups 1 = no evidence or
2 = minimum.
We examined the associations between insightfulness,
acceptance of the diagnosis, and parental attunement with the
study variables: parental gender, severity of the child’s symptoms,
and level of parental education. No differences emerged between
mothers and fathers for parental acceptance of the diagnosis
(p= 0.153) or parental attunement (p= 0.402). Significant
differences emerged between mothers and fathers relating to
insightfulness (p= 0.005), with mothers being more insightful
than fathers. No significant association was found between
the severity of the child’s symptoms and RDI classification
p= 0.055), parental insightfulness (p= 0.869), or parental
attunement (p= 0.942). No significant association emerged
between parental educational level and RDI (p= 0.051), or
parental attunement (p= 0.145). The association between
parental educational level and parental insightfulness was
statistically significant (p= 0.006), with insightful parents
more likely to have a university degree or higher and non-
insightfulness parents more likely to have a high school
diploma (Table 2).
Furthermore, no significant differences emerged between
Resolved/Unresolved (p= 0.389), Insightful/Non-insightful
(p= 0.462), and Attuned/Unattuned (p= 0.707) parents
Frontiers in Psychology | www.frontiersin.org 6August 2020 | Volume 11 | Article 1849

fpsyg-11-01849 September 11, 2020 Time: 18:42 # 7
Di Renzo et al. Parental Attunement, Insightfulness, and Acceptance of Diagnosis
TABLE 2 | Descriptive statistics, associations, and group differences with acceptance of the child diagnosis, insightfulness, and attunement.
Acceptance of child diagnosis (RDI) χ2Insightfulness (IA) χ2Attunement (DAOS) χ2
Resolved (%
of the total)
Unresolved (% of
the total)
Insightful (%
of the total)
Non-insightful (%
of the total)
Attuned (% of
the total)
Unattuned (% of
the total)
Mothers 15 (30%) 11 (22%) 2.039 19 (38%) 7 (14%) 7.936* 15 (30%) 11 (22%) 0.703
Fathers 9 (18%) 15 (30%) 8 (16%) 16 (32%) 11 (22%) 13 (26%)
LR LR LR
Middle school diploma or lower#2 (4%) 5 (10%) 5.950 4 (8%) 3 (6%) 10.360* 3 (6%) 4(8%) 3.859
High school diploma 8 (16%) 15 (31%) 7 (14%) 16 (33%) 9 (18%) 14 (29%)
University degree or higher 13 (27%) 6 (12%) 15 (31%) 4 (8%) 13 (27%) 6 (12%)
LR LR LR
Mild 8 (16%) 2 (4%) 5.803 6 (12%) 4 (8%) 0.283 5 (10%) 5 (10%) 0.120
Moderate 7 (14%) 13 (26%) 10 (20%) 10 (20%) 11 (22%) 9 (18%)
Severe 9 (18%) 11 (22%) 11(22%) 9 (18%) 10 (20%) 10 (20%)
M (DS) M (DS) tM (DS) M (DS) tM (DS) M (DS) t
Children’s age 33.250 (7.320) 35.385 (9.753) 0.869 33.518 (7.029) 35.348 (10.316) 0.742 34.808 (7.408) 33.875 (9.966) 0.378
Length of treatment 1.083 (1.380) 1.308 (1.436) 0.678 1.259 (1.534) 1.130 (1.254) 0.247 1.269 (1.538) 1.125 (1.262) 0.219
*p <0.01. #One missing data. LR, Likelihood Ratio.
Frontiers in Psychology | www.frontiersin.org 7August 2020 | Volume 11 | Article 1849

fpsyg-11-01849 September 11, 2020 Time: 18:42 # 8
Di Renzo et al. Parental Attunement, Insightfulness, and Acceptance of Diagnosis
according to child age. No significant differences emerged
between Resolved/Unresolved (p= 0.501), Insightful/Non-
Insightful (p= 0.806), and Attuned/Unattuned (p= 0.828)
parents according to the length of the treatment (Table 2).
Associations Between Parental
Acceptance of the Child
Diagnosis/Insightfulness and
Attunement
We checked the associations between the variable
Resolution/Insightfulness and the study variables that were
significantly associated with Insightfulness: level of education
and gender of the parents. The association with the educational
level was statistically significant (LR = 10.269, df = 4, p<0.05)
with Resolved/Insightful parents more likely to have a university
degree or higher, and Unresolved/Non-insightful parents more
likely to have a high school diploma. The association with the
parental gender was not statistically significant (LR = 5.844;
df =2;p= 0.054) for parental gender.
A 3 ×2 Resolution/Insightful ×Attuned crosstab (Table 3)
showed a significant association between the variables
(LR = 10.157, df =2,p<0.01). Parents classified as both
Insightful and Resolved were more likely to be Attuned during
the play interaction with their children than parents in the
other two groups, and parents classified as both Non-Insightful
and Unresolved were more likely to be Unattuned during the
play interaction with their children than parents in the other
two groups.
DISCUSSION
These findings support our hypothesis that parents high in
acceptance of their child diagnosis and insightful are more likely
to be attuned to children with ASD during play interactions
than those low in acceptance and insightful. Parental abilities
include understanding their child’s point of view and accepting
the experience of having received a child’s diagnosis of ASD. In
addition, being able to focus attention on the present and their
relationship with the child, together with the ability to understand
the child’s perspective taking into consideration his/her mental
states, wishes, and difficulties, all appear to be associated with
being responsive to a child’s signals and responding to these while
appropriately adjusting for their needs.
TABLE 3 | Parental acceptance/insightfulness categories and attunement as
percentages of the total sample.
Attuned
(% of the
total)
Unattuned
(% of the
total)
LR
(A) Resolved/Insightful 15 (30%) 6 (12%)
(B) Unresolved/Non-insightful 5 (10%) 15 (30%) 10.157*
(C) Unresolved/Insightful or
Resolved/Non-Insightful
6 (12%) 3 (6%)
*p <0.01.
From our clinical experience, we can assume that the parents
able to accept their child diagnosis may better contrast the desires
associated to the fantasies about his or her child as “healthy”
(Pouillaude, 2018), protecting the child from the projection of
unreal desires associated with him/her, or the parent manages to
overcome the image of himself as the “parent of an autistic child”
and that of the child as an “autistic child,” allowing both of them
to access a process of individuation and psychic growth. Non-
insightful parents are likely to have a rigid and unidimensional
(positive or negative) perception of their child’s behavior and
motivations, may show a lack of emotional involvement or
interest providing only short and limited descriptions of the child,
or may be very hostile, angry, and concerned about the child
(Koren-Karie and Oppenheim, 2018).
Our data lay in the findings from the studies that, within
the attachment framework, have shown that in mother–child
dyads with the presence of a diagnosis of ASD, the ability to
accept and elaborate the experiences of the diagnosis together
with the capacity of insightfulness was associated with a secure
attachment in children (Oppenheim et al., 2009). Furthermore,
the relationship between insightfulness, acceptance of the
diagnosis, and child’s attachment was mediated by maternal
sensitivity (Kahane and El-Tahir, 2015). The acceptance of the
child diagnosis along with insightfulness may favor parental
ability to be responsive to child signals because they allow the
parents to establish a relationship with the “real child,” that is, the
one whom the parent meets and experiences in terms of strengths
and weaknesses and the potential for his/her development.
In cases of a severe diagnosis of the child, the parents may
become frustrated and disappointed once confronted the “real
child” with the “imaginary child,” that is the one dreamed of
during pregnancy.
Thus, attunement ability can be proposed to promote a secure
attachment allowing “the infant to perceive a sense of being
accepted and recognized, which facilitates social adjustment
and a positive psychological functioning” (Manini et al., 2013).
Furthermore, as suggested in the Introduction, children’s social
competence may be positively influenced by attuned parenting,
supporting an aspect usually inadequate in children with ASD.
This hypothesis should be verified in future research through
longitudinal studies. Another interesting finding is that parents
low in acceptance or in insightfulness are more likely to be
attuned during play interactions with their children, suggesting
a possible protective factor of at least one of the two parental
abilities to understand child’s point of view or to accept the
child diagnosis.
The percentage of parents who have accepted the child
diagnosis experience and those demonstrating parental
insightfulness are consistent with what emerges in other
studies with parents of children with ASD (Hutman et al., 2009;
Oppenheim et al., 2009;Milshtein et al., 2010;Lecciso et al.,
2013;Yirmiya et al., 2015;Dolev et al., 2016). However, some
differences to the published findings also emerged in the current
study. In our study, the parental acceptance of child diagnosis
was not associated with parental gender, child age, or parental
educational level. No significant differences emerged for the
severity of the children symptoms, in contrast to previous studies
Frontiers in Psychology | www.frontiersin.org 8August 2020 | Volume 11 | Article 1849

fpsyg-11-01849 September 11, 2020 Time: 18:42 # 9
Di Renzo et al. Parental Attunement, Insightfulness, and Acceptance of Diagnosis
that found that a worsening of the ASD levels of functioning,
along with other variables, predicted maternal acceptance of the
child diagnosis (Yirmiya et al., 2015) and that the severity of the
ASD diagnosis was associated with parental acceptance of the
diagnosis (Poslawsky et al., 2014). A possible explanation for
these differences concerns the selection of measures that are used
to identify the level of severity, such as questionnaires, interviews,
or observational tools. The use of different tools can make it
difficult to compare the results obtained in different studies.
However, we assume that parental acceptance of the diagnosis
is associated with parental resilience and previous emotional
stability rather than the severity of the child’s symptoms, allowing
parents to find creative solutions even in the face of serious
clinical scenarios.
We found that maternal insightfulness did not depend
on the severity of symptoms or child age as ascertained in
other studies (Oppenheim et al., 2008). However, our data
showed a statistically significant association between parental
educational level and parental insightfulness in the direction of
higher educational level for insightful parents. This is consistent
with findings from the study by Oppenheim et al. (2009)
in a sample of mothers of children with ASD, indicating
that mothers classified as insightful had a higher level of
education than mothers classified as non-insightful. However,
this pattern has not been confirmed in samples of mothers
of children with typical development patterns (Oppenheim
et al., 2001;Koren-Karie et al., 2002), suggesting that this
relationship may be specific to samples of children with
ASD (Oppenheim et al., 2009). We assume that a higher
level of education could function as a protective factor in
understanding the child’s internal world when it seems that
the child deviates from typical functioning, or that a broad
cultural background could help parents adapt their resources
to the needs of the child. Moreover, a statistically significant
association emerged between educational level and the combined
variable Resolution/Insightful, with parents both accepting the
child diagnosis and insightful more likely to have a university
degree or higher, and parents both less able to accept the
child diagnosis and less insightful more likely to have a high
school diploma.
Finally, significant differences emerged between the
insightfulness of mothers and fathers, suggesting that mothers
are more insightful. This finding is in contrast with that from
another study that tested whether mothers and fathers differ in
insightful ability using a low-risk sample of parents of young
children with typical development (Marcu et al., 2016). This
probably highlights a specific aspect of our sample that should be
explored further in future work. It is possible that some fathers
may experience greater difficulties than mothers since, in general,
they spend less time caring for children (Dyer et al., 2009;Hartley
et al., 2014). Some research indicates that many fathers want to
increase their levels of involvement in child care if supported on
this path (Rankin et al., 2019), which may lead to them feeling
frustrated if having less chance of developing an understanding
of their child.
This study has several methodological strengths given that
narratological and observational measures are less vulnerable
to the willingness of participants to provide information or to
provide a personal view of the information collected as compared
to questionnaires. A further strength is that the literature has
often failed to consider the role of fathers whereas we directly
tested this. Nonetheless, this study has also some limitations
that should be taken into account as they could reduce the
generalization of the results. These include the small number of
parents who participated, the specific diagnosis of the children
involved (risk for autism relating to global developmental
delay and autism spectrum disorder), and the use of one
measure that is not yet validated in the literature (the Dyadic
Parent–Child Attunement Observation Schedule). Literature
provides several observational instruments to measure parental
attunement, especially within attachment theory researchers.
As mentioned above, the debate on attunement is still open
and the authors vary in their formulation of this construct
(Mesman and Emmen, 2013). The tool we used for the
assessment of the parental attunement, which is currently
being validated, was specifically built for assessing interaction
within parent and child with autism, guided by our theoretical
basis and specific therapeutic intervention, focused on children
body and sensory processing to promote the ability to be
responsive to others’ signals, understanding them and replying
to them appropriately (Di Renzo, 2017). To overcome these
limitations, future studies should involve a larger and less
heterogeneous sample and include additional measurements of
parental attunement. Furthermore, given the lack of information
on the child’s level of development and the physical and
mental health of the parents in this study, future research
should investigate the relationship between these variables and
the acceptance of the child’s diagnosis, insightfulness, and
attunement. Finally, we want to report the cross-sectional design,
the use of categorial rather than continuous variables, and the
use of parents of the same children as further limitations of
our study.
CONCLUSION
The results presented in this study provide some insights into
potential clinical work with the mothers and fathers of children
with ASD. Studying the parental ability of insightfulness and
acceptance of a child diagnosis of ASD has enriched our
understanding of the processes underlying the interactions of
these parents with their children. These aspects should be
addressed through intervention programs for parents. At the
Institute of Orthophonology (IdO) support for parents has been
incorporated into the D.E.R.B.B.I. intervention (known in full
as the Developmental, Emotional Regulation and Body-Based
Intervention) within the Turtle Project (Di Renzo et al., 2016).
The project combines various interventions offered to children
and parents including child assessment (Di Renzo et al., 2019),
counseling for parents, clinical sessions with the professionals
who work with the child, thematic seminars and experiential
workshops, mothers/fathers–child in care settings, and groups of
parents (Di Renzo et al., 2020a).
The importance of starting and supporting a process
of acceptance relating to the child diagnosis (Guerriero
et al., 2017a,b;Guerriero and Di Folco, 2017;Freda
et al., 2019;Waizbard-Bartov et al., 2019) and parental
Frontiers in Psychology | www.frontiersin.org 9August 2020 | Volume 11 | Article 1849

fpsyg-11-01849 September 11, 2020 Time: 18:42 # 10
Di Renzo et al. Parental Attunement, Insightfulness, and Acceptance of Diagnosis
insightfulness could support the relational experiences that
determine the child “way of being” that is strongly connected
to the non-verbal aspects of parental communication,
especially parental attunement (Di Renzo, 2017). According
to Trevarthen and Delafield-Butt (2013), responsive and
attuned communication and a pattern of timed and sensitive
actions can compensate for children experiencing repetition of
uncertain and anxious attempts, when psychomotor attunement
with perceptive and motor experiences become confused
(LaGasse and Hardy, 2013). The basis of this hypothesis is the
importance of considering the close interaction between dyadic
function and specific parenting abilities in the formation of the
psychic structure and the self-regulating abilities of the child
(Beebe et al., 1999).
The results of this study also help us to better understand
some of the discrepancies between mothers and fathers, which
could give useful indications in planning group interventions for
parents of different genders.
To date, only a few studies have investigated the needs of
parents of children with ASD while paying particular attention
to fathers, their involvement in child therapy, and direct
involvement in an intervention (Hartley and Schultz, 2015;
Rankin et al., 2019). In the present study, we documented that,
in our sample at least, mothers are more insightful than fathers,
making it understandable that when children show behaviors
that are difficult to manage and understand, as in the case of
children with ASD, paternal insight may be inadequate. This
aspect should, therefore, be considered as the main goal of
group therapy aimed at fathers, while monitoring over time the
usefulness of such an approach in supporting fathers’ ability to
“see things from their child’s point of view” (Koren-Karie and
Oppenheim, 2018, p. 223).
DATA AVAILABILITY STATEMENT
The raw data supporting the conclusions of this article will be
made available by the authors, without undue reservation, to any
qualified researcher.
ETHICS STATEMENT
Ethical review and approval was not required for the study
on human participants in accordance with the local legislation
and institutional requirements. Written informed consent to
participate in this study was provided by the participants’ legal
guardian/next of kin.
AUTHOR CONTRIBUTIONS
MD and VG conceived the study concept. GZ and VG designed
the model and developed the theory. MP and LR recruited
the sample and administered the assessments. VG coded the
interviews and analyzed the data. FB helped in supervise the
project and with MD they provided critical revisions of the
findings. All authors discussed the results and contributed to the
final manuscript.
ACKNOWLEDGMENTS
We thank all the parents and children who participated in this
research project.
REFERENCES
Ainsworth, M. D. S. (1967). Infancy in Uganda: Infant Care and the Growth of Love.
Baltimore, MD: Johns Hopkins University Press.
Baiocco, R., Gattinara, P. C., Cioccetti, G., and Ioverno, S. (2017). Parents’
reactions to the diagnosis of Duchenne muscular dystrophy: associations
between resolution, family functioning, and child behavior problems. J. Nurs.
Res. 25, 455–463. doi: 10.1097/JNR.0000000000000186
Baker, J. K., Fenning, R. M., Howland, M. A., Baucom, B. R., Moffitt, J., and
Erath, S. A. (2015). Brief report: a pilot study of parent–child biobehavioral
synchrony in autism spectrum disorder. J. Autism Dev. Disord. 45, 4140–4146.
doi: 10.1007/s10803-015- 2528-0
Barak-Levy, Y., and Atzaba-Poria, N. A. (2013). Paternal versus maternal coping
styles with child diagnosis of developmental delay. Res. Dev. Disabil. 34, 2040–
2046. doi: 10.1016/j.ridd.2013.02.026
Beebe, B., Lachman, F., and Jaffe, J. (1999). Le strutture d’interazione madre-
bambino e le rappresentazioni presimboliche del sé e dell’oggetto. Ricerca
Psicoanalitica 10, 9–63.
Carter, A. S., and DelCarmen-Wiggins, R. (Eds.). (2020). The Oxford Handbook
of Infant, Toddler, and Preschool Mental Health Assessment. Oxford Library of
Psychology.
Colombi, C., Tancredi, R., Persico, A., and Faggioli, R. (2013). ADOS-2 –Autism
Diagnostic Observation Schedule, 2nd Edn. Florence: Hogrefe.
Costa, A. P., Steffgen, G., and Vögele, C. (2019). The role of alexithymia in parent–
child interaction and in the emotional ability of children with autism spectrum
disorder. Autism Res. 12, 458–468. doi: 10.1002/aur.2061
Crowell, J. A., Keluskar, J., and Gorecki, A. (2019). Parenting behavior and the
development of children with autism spectrum disorder. Compr. Psychiatry 90,
21–29. doi: 10.1016/j.comppsych.2018.11.007
Denham, S. A., Bassett, H. H., Thayer, S. K., Mincic, M. S., Sirotkin, Y. S.,
and Zinsser, K. (2012). Observing preschoolers’ social–emotional behavior:
structure, foundations, and prediction of early school success. J. Genet. Psychol.
173, 246–278. doi: 10.1080/00221325.2011.597457
Di Folco, S., de Campora, G., and Zavattini, G. C. (2016). Sintonie e dissintonie nei
legami precoci: traiettorie di valutazione e considerazioni cliniche nei contesti
ad alto rischio per lo sviluppo infantile. [Attunement and dis-attunement in
early interactions: directions for the assessment and clinical implications in
high-risk settings for infant development]. Maltrattamento e abuso all’infanzia
2, 71–93. doi: 10.3280/MAL2016-002005
Di Renzo, M. (2017). The theoretical principles of the body-centered therapy to
promote affective attunement in children with autism spectrum disorder. J.
Behav. Brain Sci. 7, 545–556. doi: 10.4236/jbbs.2017.712039
Di Renzo, M., Bianchi di Castelbianco, F., Vanadia, E., Petrillo, M., Racinaro,
L., and Rea, M. (2016). From the emotional integration to the cognitive
construction: the developmental approach of Turtle Project in children with
Autism Spectrum Disorder. Autism 6, 1–9. doi: 10.4172/2165-7890.1000160
Di Renzo, M., Di Castelbianco, F. B., Petrillo, M., Racinaro, L., and Rea, M.
(2015). Assessment of a long-term developmental relationship-based approach
in children with autism spectrum disorder. Psychol. Rep. 117, 26–49. doi: 10.
2466/15.10.PR0.117c15z8
Di Renzo, M., Guerriero, V., Mammarella, V., and Bianchi di Castelbianco, F.
(2020a). “Developmental interventions for children with Autism Spectrum
Frontiers in Psychology | www.frontiersin.org 10 August 2020 | Volume 11 | Article 1849

fpsyg-11-01849 September 11, 2020 Time: 18:42 # 11
Di Renzo et al. Parental Attunement, Insightfulness, and Acceptance of Diagnosis
Disorders: a literature review,” in Understanding Children with Autism Spectrum
Disorders, ed. B. Anne (Nova Book Publisher), 57–105.
Di Renzo, M., Guerriero, V., Petrillo, M., Racinaro, L., Vanadia, E., and Bianchi di
Castelbianco, F. (2019). A comprehensive assessment process for children with
autism spectrum disorders. Advances in Autism 6, 95–108. doi: 10.1108/AIA-
09-2018-0031
Di Renzo, M., Vanadia, E., Petrillo, M., Trapolino, D., Racinaro, L., Rea, M.,
et al. (2020b). A therapeutic approach for ASD: method and outcome of the
DERBBI–developmental, emotional regulation and body-based intervention.
Int. J. Psychoanal. Edu. 12, 59–75.
Dogan, Ý, and Dogan, N. (2015). Usage of the intraclass correlation coefficient
as a measure of dependence in dyadic data. Turk. Klin. J. Biostat. 7, 119–125.
doi: 10.5336/biostatic.2015-46361
Dolev, S., Oppenheim, D., Koren-Karie, N., and Yirmiya, N. (2014). Early
attachment and maternal insightfulness predict educational placement of
children with autism. Res. Autism Spectr. Disord. 8, 958–967. doi: 10.1016/j.rasd.
2014.04.012
Dolev, S., Sher-Censor, E., Baransi, N., Amara, K., and Said, M. (2016). Resolution
of the child’s ASD diagnosis among Arab–Israeli mothers: associations with
maternal sensitivity and wellbeing. Res. Autism Spectr. Disord. 21, 73–83. doi:
10.1016/j.rasd.2015.09.004
Domitrovich, C. E., Durlak, J. A., Staley, K. C., and Weissberg, R. P. (2017). Social-
emotional competence: an essential factor for promoting positive adjustment
and reducing risk in school children. Child Dev. 88, 408–416. doi: 10.1111/cdev.
12739
Dyer, W. J., McBride, B. A., and Jeans, L. M. (2009). A longitudinal examination
of father involvement with children with developmental delays: Does timing
of diagnosis matter? J. Early Interv. 31, 265–281. doi: 10.1177/0192513X0934
0386
Edmunds, S. R., Kover, S. T., and Stone, W. L. (2019). The relation between parent
verbal responsiveness and child communication in young children with or
at risk for autism spectrum disorder: a systematic review and meta-analysis.
Autism Res. 12, 715–731. doi: 10.1002/aur.2100
Esler, A. N., Bal, V. H., Guthrie, W., Wetherby, A., Weismer, S. E., and
Lord, C. (2015). The autism diagnostic observation schedule, toddler module:
standardized severity scores. J. Autism Dev. Disord. 45, 2704–2720. doi: 10.1007/
s10803-015-2432-7
Feldman, R., and Klein, P. S. (2003). Toddlers’ self-regulated compliance to
mothers, caregivers, and fathers: implications for theories of socialization. Dev.
Psychol. 39, 680–692. doi: 10.1037/0012-1649.39.4.680
Feldman, R., and Masalha, S. (2010). Parent–child and triadic antecedents of
children’s social competence: cultural specificity, shared process. Dev. Psychol.
46, 455–467. doi: 10.1037/a0017415
Feniger-Schaal, R., Oppenheim, D., and Koren-Karie, N. (2019). Parenting children
with intellectual disability: linking maternal insightfulness to sensitivity.
J. Intell. Disabil. Res. 63, 1285–1289. doi: 10.1111/jir.12614
Freda, M. F., Dicé, F., Auricchio, M., Salerno, M., and Valerio, P. (2016). Suspended
sorrow: the crisis in understanding the diagnosis for the mothers of children
with a Disorder of Sex Development. Int. J. Sex. Health 27, 186–198. doi:
10.1080/19317611.2014.957793
Freda, M. F., Savarese, L., Dolce, P., and De Luca Picione, R. (2019). Caregivers’
sensemaking of children’sHereditary Angioedema: a semiotic narrative analysis
of the Sense of Grip on the Disease. Front. Psychol. 10:2304. doi: 10.3389/fpsyg.
2019.02609
Gotham, K., Pickles, A., and Lord, C. (2009). Standardizing ADOS scores for a
measure of severity in autism spectrum disorders. J. Autism Dev. Disord. 39,
693–705. doi: 10.1007/s10803-008- 0674-3
Gotham, K., Risi, S., Pickles, A., and Lord, C. (2007). The Autism Diagnostic
Observation Schedule: revised algorithms for improved diagnostic validity.
J. Autism Dev. Disord. 37:613. doi: 10.1007/s10803-006- 0280-1
Guerriero, V., de Campora, G., Gnazzo, A., Vegni, E., and Zavattini, G. C. (2017a).
“Parents facing their child’s disease: Insights from attachment theory,” in
Advances in Psychology Research,ed. A. M. Columbus (Nova S cience Publisher),
137–158.
Guerriero, V., de Campora, G., Gnazzo, A., Vegni, E., and Zavattini, G. C.
(2017b). “Parents facing their child’s disease: Insights from attachment theory,”
in Advances in Psychology Research,Vol. 126, ed. A. M. Columbus (Nova S cience
Publisher), 137–158.
Guerriero, V., and Di Folco, S. (2017). La reazione materna alla diagnosi di
epilessia del bambino: due esperienze a confronto. [The maternal reaction to the
diagnosis of infantile epilepsy: comparing two experiences]. Psicol. Clin. dello
Svilupp. 21, 183–191. doi: 10.1449/86193
Guo, Y., Garfin, D. R., Ly, A., and Goldberg, W. A. (2017). Emotion coregulation
in mother-child dyads: a dynamic systems analysis of children with and without
autism spectrum disorder. J. Abnorm. Child Psychol. 45, 1369–1383. doi: 10.
1007/s10802-016-0234-9
Hartley, S. L., Mihaila, I., Otalora-Fadner, H., and Bussanich, P. M.
(2014). Division of labor in families of children and adolescents with
autism spectrum disorder. Fam. Relat. 63, 627–638. doi: 10.1111/fare.
12093
Hartley, S. L., and Schultz, H. M. (2015). Support needs of fathers and
mothers of children and adolescents with autism spectrum disorder.
J. Autism Dev. Disord. 45, 1636–1648. doi: 10.1007/s10803-014-
2318-0
Hirschler-Guttenberg, Y., Golan, O., Ostfeld-Etzion, S., and Feldman, R.
(2015). Mothering, fathering, and the regulation of negative and positive
emotions in high-ˇ
Rfunctioning preschoolers with autism spectrum
disorder. J. Child Psycho. Psychiatry 56, 530–539. doi: 10.1111/jcpp.
12311
Hus, V., and Lord, C. (2014). The autism diagnostic observation schedule, module
4: revised algorithm and standardized severity scores. J. Autism Dev. Disord. 44,
1996–2012. doi: 10.1007/s10803-014- 2080-3
Hutman, T., Siller, M., and Sigman, M. (2009). Mothers’ narratives regarding
their child with autism predict maternal synchronous behavior during play.
J. Child Psychol. Psychiatry 50, 1255–1263. doi: 10.1111/j.1469-7610.2009.
02109.x
Kahane, L., and El-Tahir, M. (2015). Attachment behavior in children with Autistic
Spectrum Disorders. Adv. Ment. Health Intell. Disabil. 9, 79–89. doi: 10.1108/
AMHID-06-2014-0026
Kearney, J. A., Britner, P. A., Farrell, A. F., and Robinson, J. L. (2011). Mothers’
resolution of their young children’s psychiatric diagnoses: associations with
child, parent, and relationship characteristics. Child Psychiatry Hum. Dev. 42,
334–348. doi: 10.1007/s10578-011- 0217-6
Koren-Karie, N., and Oppenheim, D. (2004). Insightfulness
Procedure Administration and Coding Manual. Haifa: University
of Haifa.
Koren-Karie, N., and Oppenheim, D. (2018). Parental insightfulness: retrospect
and prospect. Attach. Hum. Dev. 20, 223–236. doi: 10.1080/14616734.2018.
1446741
Koren-Karie, N., Oppenheim, D., Dolev, S., Sher, E., and Etzion-Carasso, A. (2002).
Mothers’ insightfulness regarding their infants’ internal experience: relations
with maternal sensitivity and infant attachment. Dev. Psychol. 38, 534–542.
doi: 10.1037//0012-1649.38.4.534
Krsti´
c, T., Bati´
c, S., Mihi´
c, L., and Milankov, V. (2016). Mothers’ reactions
to the diagnosis of cerebral palsy: associations with their educational
level. Int. J. Disabil. Dev. Educ. 63, 467–483. doi: 10.1080/1034912X.2016.
1142068
Krsti´
c, T., Mihi´
c, L., and Mihi´
c, I. (2015). Stress and resolution in mothers of
children with cerebral palsy. Res. Dev. Disabil. 47, 135–143. doi: 10.1016/j.ridd.
2015.09.009
LaGasse, A. B., and Hardy, M. W. (2013). Considering rhythm for sensorimotor
regulation in children with autism spectrum disorders. Music Therapy
Perspectives 31, 67–77. doi: 10.1093/mtp/31.1.67
Landry, S. H., Smith, K. E., and Swank, P. R. (2006). Responsive parenting:
establishing early foundations for social, communication, and independent
problem-solving skills. Dev. Psychol. 42, 627–642. doi: 10.1037/0012-1649.42.
4.627
Lecciso, F., Petrocchi, S., Savazzi, F., Marchetti, A., Nobile, M., and
Molteni, M. (2013). The association between maternal resolution
of the diagnosis of autism, maternal mental representations of the
relationship with the child, and children’s attachment. Life Span Disabil. 16,
21–38.
Leerkes, E. M., Blankson, A. N., and O’Brien, M. (2009). Differential
effects of maternal sensitivity to infant distress and nondistress on social-
emotional functioning. Child Dev. 80, 762–775. doi: 10.1111/j.1467-8624.2009.
01296.x
Frontiers in Psychology | www.frontiersin.org 11 August 2020 | Volume 11 | Article 1849

fpsyg-11-01849 September 11, 2020 Time: 18:42 # 12
Di Renzo et al. Parental Attunement, Insightfulness, and Acceptance of Diagnosis
Lord, B., Ungerer, J., and Wastell, C. (2008). Implications of resolving the diagnosis
of PKU for parents and children. J. Pediatr. Psychol. 33, 855–866. doi: 10.1093/
jpepsy/jsn020
Lord, C., Luyster, R., Gotham, K., and Guthrie, W. (2012a). Autism Diagnostic
Observation Schedule, Second Edition (ADOS-2) Manual (Part II): Toddler
Module. Torrance, CA: Western Psychological Services.
Lord, C., Rutter, M., DiLavore, P. C., Risi, S., Gotham, K., and Bishop, S. (2012b).
Autism Diagnostic Observation Schedule, Second Edition (ADOS-2) Manual
(Part I): Modules 1–4. Torrance, CA: Western Psychological Services.
Manini, B., Cardone, D., Ebisch, S., Bafunno, D., Aureli, T., and Merla, A. (2013).
Mom feels what her child feels: thermal signatures of vicarious autonomic
response while watching children in a stressful situation. Front. Hum. Neurosci.
7:299. doi: 10.3389/fnhum.2013.00299
Marcu, I., Oppenheim, D., and Koren-Karie, N. (2016). Parental insightfulness
is associated with cooperative interactions in families with toddlers. J. Fam.
Psychol. 30, 927–934. doi: 10.1037/fam0000240
Martinez-Torteya, C., Rosenblum, K. L., Beeghly, M., Oppenheim, D., Koren-
Karie, N., and Muzik, M. (2018). Maternal insightfulness protects against the
detrimental effects of postpartum stress on positive parenting among at-risk
mother–infant dyads. Attach. Hum. Dev. 20, 272–286. doi: 10.1080/14616734.
2018.1446735
Marvin, R. S., and Pianta, R. C. (1996). Mothers’ reactions to their child’s diagnosis:
Relations with security of attachment. J. Clin. Child Psychol. 25, 436–445. doi:
10.1207/s15374424jccp2504_8
Mazefsky, C. A., and Oswald, D. P. (2006). The discriminative ability and diagnostic
utility of the ADOS-G, ADI-R, and GARS for children in a clinical setting.
Autism 10, 533–549. doi: 10.1177/1362361306068505
Mesman, J., and Emmen, R. A. (2013). Mary Ainsworth’s legacy: a systematic review
of observational instruments measuring parental sensitivity. Attach. Hum. Dev.
15, 485–506. doi: 10.1080/14616734.2013.820900
Milshtein, S., Yirmiya, N., Oppenheim, D., Koren-Karie, N., and Levi, S. (2010).
Resolution of the diagnosis among parents of children with autism spectrum
disorder: associations with child and parent characteristics. J. Autism Dev.
Disord. 40, 89–99. doi: 10.1007/s10803-009- 0837-x
Mitchell, J., and Lashewicz, B. (2018). Quirky kids: fathers’ stories of embracing
diversity and dismantling expectations for normative play with their children
with autism spectrum disorder. Disabil. Soc. 33, 1120–1137. doi: 10.1080/
09687599.2018.1474087
Oppenheim, D., and Koren-Karie, N. (2009). “Parents’ insightfulness regarding
their children’sinternal worlds: Assessment, research, and clinical implications,”
in Handbook of Infant Mental Health, 3rd Edn., ed. C. Zeanah (New York, NY:
Guilford), 266–280.
Oppenheim, D., Koren-Karie, N., Dolev, S., and Yirmiya, N. (2008). Secure
attachment in children with autistic spectrum disorder: the role of maternal
insightfulness. Zero Three 28, 25–30.
Oppenheim, D., Koren-Karie, N., Dolev, S., and Yirmiya, N. (2009). Maternal
insightfulness and resolution of the diagnosis are associated with secure
attachment in preschoolers with autism spectrum disorders. Child Dev. 80,
519–527. doi: 10.1111/j.1467-8624.2009.01276.x
Oppenheim, D., Koren-Karie, N., Dolev, S., and Yirmiya, N. (2012). Maternal
sensitivity mediates the link between maternal insightfulness/resolution and
child–mother attachment: the case of children with Autism Spectrum Disorder.
Attach. Hum. Dev. 14, 567–584. doi: 10.1080/14616734.2012.727256
Oppenheim, D., Koren-Karie, N., and Sagi, A. (2001). Mother’s insightfulness of
their preschoolers’ internal experience: relations with early attachment. Int. J.
Behav. Dev. 25, 16–26. doi: 10.1080/01650250042000096
Ostfeld-Etzion, S., Feldman, R., Hirschler-Guttenberg, Y., Laor, N., and Golan,
O. (2016). Self-regulated compliance in preschoolers with autism spectrum
disorder: the role of temperament and parental disciplinary style. Autism 20,
868–878. doi: 10.1177/1362361315615467
Pianta, R. C., and Marvin, R. S. (1993). Manual for Classification of the Reaction to
Diagnosis Interview. Charlottesville, VA: University of Virginia.
Pianta, R. C., Marvin, R. S., Britner, P. A., and Borowitz, K. C. (1996). Mothers’
resolution of their children’s diagnosis: organized patterns of caregiving
representations. Infant Ment. Health J. 17, 239–256. doi: 10.1002/(sici)1097-
0355(199623)17:3<239::aid-imhj4>3.0.co;2- j
Pianta, R. C., Marvin, R. S., and Morog, M. C. (1999). “Resolving the
past and present: relations with attachment organization,” in Attachment
Disorganization, eds J. Solomon and C. George (New York, NY: Guilford Press),
379–398.
Popp, J. M., Robinson, J. L., Britner, P. A., and Blank, T. O. (2014). Parent
adaptation and family functioning in relation to narratives of children
with chronic illness. J. Pediatr. Nurs. 29, 58–64. doi: 10.1016/j.pedn.2013.
07.004
Poslawsky, I. E., Naber, F. B., Van Daalen, E., and Van Engeland, H. (2014).
Parental reaction to early diagnosis of their children’s autism spectrum disorder:
an exploratory study. Child Psychiatry Hum. Dev. 45, 294–305. doi: 10.1007/
s10578-013-0400-z
Pouillaude, E. (2018). Autistic children, their parents, and the failures of
intersubjectivity: a narrative approach. L’Évol. Psychiatr. 83, e27–e36. doi: 10.
1016/j.evopsy.2018.06.001
Ramsauer, B., Lotzin, A., Quitmann, J. H., Becker-Stoll, F., Tharner, A., and Romer,
G. (2014). Insightfulness and later infant attachment in clinically depressed
and nonclinical mothers. Infant Ment. Health J. 35, 210–219. doi: 10.1002/imhj.
21446
Rankin, J. A., Paisley, C. A., Tomeny, T. S., and Eldred, S. W. (2019).
Fathers of youth with autism spectrum disorder: a systematic review of
the impact of fathers’ involvement on youth, families, and intervention.
Clin. Child Fam. Psychol. Rev. 22, 458–477. doi: 10.1007/s10567-019-
00294-0
Raver, C. C., and Zigler, E. F. (1997). Social competence: an untapped dimension in
evaluating Head Start’s success. Early Child. Res. Q. 12, 363–385. doi: 10.1016/
S0885-2006(97)90017-X
Reed, P., and Osborne, L. A. (2019). Reaction to diagnosis and subsequent health
in mothers of children with autism spectrum disorder. Autism 23, 1442–1448.
doi: 10.1177/1362361318815641
Rosner, B. (2010). Fundementals of Biostatistics, 7th Edn. Boston, MA: Brooks/Cole;
Cengage Learning Inc.
Samson, A. C., Huber, O., and Gross, J. J. (2012). Emotion regulation in Asperger’s
syndrome and high-functioning autism. Emotion 12, 659–665. doi: 10.1037/
a0027975
Schore, A. N. (2001). Effects of a secure attachment relationship on right
brain development, affect regulation, and infant mental health. Infant Ment.
Health J. 22, 7–66. doi: 10.1002/1097-0355(200101/04)22:1<7::aid-imhj2>3.
0.co;2-n
Schuengel, C., Rentinck, I. C. M., Stolk, J., Voorman, J. M., Loots, G. M. P.,
Ketelaar, M., et al. (2009). Parents’ reactions to the diagnosis of cerebral
palsy: associations between resolution, age and severity of disability. Child 35,
673–680. doi: 10.1111/j.1365-2214.2009.00951.x
Sheeran, T., Marvin, R. S., and Pianta, R. (1997). Mothers’ resolution of their
childs’s diagnosis and self-reported measures of parenting stress, marital
relations, and social support. J. Pediatr. Psychol. 22, 197–212. doi: 10.1093/
jpepsy/22.2.197
Stern, D. N. (1998). The Motherhood Constellation: A Unified View of Parent-Infant
Psychotherapy. London: Karnac books.
Stern, D. N., Hofer, L., Haft, W., and Dore, J. (1985). “Affect attunement: the
sharing of feeling states between mother and infant by means of inter-modal
fluency,” in Social Perception in Infants, eds T. M. Fields and N. A. Fox
(Norwood, NJ: Ablex), 249–268.
Tager-Flusberg, H. (2016). Risk factors associated with language in autism
spectrum disorder: clues to underlying mechanisms. J. Speech Lang. Hear. Res.
59, 143–154. doi: 10.1044/2015_JSLHR-L-15- 0146
Trevarthen, C., and Delafield-Butt, J. T. (2013). Autism as a developmental
disorder in intentional movement and affective engagement. Front. Integr.
Neurosci. 7:49. doi: 10.3389/fnint.2013.00049
Vaughan Van Hecke, A., Mundy, P. C., Acra, C. F., Block, J. J., Delgado, C. E.,
Parlade, M. V., et al. (2007). Infant joint attention, temperament, and social
competence in preschool children. Child Dev. 78, 53–69. doi: 10.1111/j.1467-
8624.2007.00985.x
Waizbard-Bartov, E., Yehonatan-Schori, M., and Golan, O. (2019). Personal
growth experiences of parents to children with autism spectrum disorder.
J. Autism Dev. Disord. 49, 1330–1341. doi: 10.1007/s10803-018-3784-6
World Medical Association (2013). World medical association declaration
of helsinki: ethical principles for medical research involving
human subjects. JAMA 310, 2191–2194. doi: 10.1001/jama.2013.
281053
Frontiers in Psychology | www.frontiersin.org 12 August 2020 | Volume 11 | Article 1849

fpsyg-11-01849 September 11, 2020 Time: 18:42 # 13
Di Renzo et al. Parental Attunement, Insightfulness, and Acceptance of Diagnosis
Yirmiya, N., Seidman, I., Koren-Karie, N., Oppenheim, D., and Dolev, S. (2015).
Stability and change in resolution of diagnosis among parents of children with
autism spectrum disorder: child and parental contributions. Dev. Psychopathol.
27, 1045–1057. doi: 10.1017/S095457941500067X
Zand, D., Pierce, K., Thomson, N., Baig, M. W., Teodorescu, C., Nibras, S., et al.
(2014). Social competence in infants and toddlers with special health care needs:
the roles of parental knowledge, expectations, attunement, and attitudes toward
child independence. Children 1, 5–20. doi: 10.3390/children1010005
Zavattini, G. C. (2016). La reazione dei genitori alla diagnosi dei figli. [Parental
reaction to the children diagnosis]. Psicol. Clin. dello Svilupp. 20, 331–354.
doi: 10.1449/85041
Conflict of Interest: The authors declare that the research was conducted in the
absence of any commercial or financial relationships that could be construed as a
potential conflict of interest.
Copyright © 2020 Di Renzo, Guerriero, Zavattini, Petrillo, Racinaro and Bianchi
di Castelbianco. This is an open-access article distributed under the terms of
the Creative Commons Attribution License (CC BY). The use, distribution or
reproduction in other forums is permitted, provided the original author(s) and the
copyright owner(s) are credited and that the original publication in this journal
is cited, in accordance with accepted academic practice. No use, distribution or
reproduction is permitted which does not comply with these terms.
Frontiers in Psychology | www.frontiersin.org 13 August 2020 | Volume 11 | Article 1849