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## A conceptual framework for understanding characteristics of selfawareness associated with autism spectrum disorder

Mette Elmose

Department of Psychology, University of Southern Denmark

Corresponding author:

melandersen@health.sdu.dk

## Introduction

Self-awareness has been investigated both theoretically  and  empirically  by  a  wide  range  of disciplines (1-3). This has included the exploration of self-awareness  among specific clinical  groups, such as patients with right-hemisphere stroke, frontal lobe damage, schizophrenia, and autism. Still, a comprehensive  model  of  self-awareness  is  lacking (3),  and  even  the  functional  importance  of  selfawareness has not yet been established (4). The lack of  a  comprehensive  model of  self-awareness  limits the current understanding of variations in and deficits of self-awareness.

Autism spectrum disorder (ASD) is a neurodevelopmental condition characterized by difficulties with social communication and interaction as well as by repetitive patterns of behavior, interest, or activity, including differences in sensory responses (5). Specific characteristics of selfawareness are not specified in the current diagnostic criteria. However, the term autism -which was first coined in relation to schizophrenia-comes from the Greek autos meaning  'self'; Asperger's  (6)  and Kanner's (7) early and defining descriptions suggest variations  in  awareness  of  the  self  among  their original  cases  (8).  Subsequent  clinical  descriptions, autobiographies, and other types of contributions by individuals on the spectrum, as well as parent reports, indicate that there seem to be very relevant differences possibly related to self-awareness that can often be linked to some of the everyday difficulties associated  with  ASD.  In  line  with  the  notion  of  a spectrum  of  disorder  is  the  fact  that  the  indicated differences appear very heterogeneous with regard to their  expression  and  how  people  on  the  spectrum experience them. Differences in self-awareness may, for example, encompass the following: the sense that you  do  not  know  what  you  do  not  know  and therefore  have  difficulty  judging  when  it  would  be relevant to get more information; difficulty distinguishing between your own or others' preferences and moods when you are together with them;  perceiving  your  own  actions  (e.g.,  not  being able to get out of the door in time for school, selfdestructive actions) as 'freestanding' actions without  any  link  to  antecedents,  current  situation, others' reactions, or your own thoughts or feelings.

Addressing the concept of self-awareness and its potential  differences  among  individuals  with  ASD should  not  be  perceived  as  a  devaluation  of  or  a challenge to the validity of either the self-awareness or the selfhood of persons with ASD. Self-awareness and the experience of self are unique and valid for all persons. However, for each individual, the concept of the self and self-awareness may be more or less efficient  for  helping  individuals  to  navigate  in  the world  in  a  way  that  supports  his  or  her  everyday needs, helps him or her to reach goals, and meets his or her personal values. Insight into the characteristics and mechanisms of self-awareness may help people of all degrees of ability to calibrate this fine instrument  and  thereby  improve  their  ability  to navigate and manage the challenges of life.

The  aim  of  this short paper  is to sketch a conceptual framework for describing self-awareness to  begin  to  integrate  the  accumulating  knowledge about characteristics of and variations in selfawareness  related  to  ASD.  The  formulation  of  a conceptual  framework  is  important  as a future common ground for the design and interpretation of new  studies,  theoretical discussions, and  clinical work. It is especially important that the framework encompass  the  wide  individual  variation  in  selfawareness  that  may  characterize  ASD  due  to  the heterogeneity of the  condition.  The  framework presented  consists  of  different  putative  levels  and dimensions  of  self-awareness  that  are  identified  in selected theoretical contributions. It aims to span not just the 'what' of self-awareness but also the more procedural  and  functional  aspects  of  'how'  and 'when.'

## Levels of self-awareness: a general review

Most  theories  tend  to  distinguish  among  different levels of self-awareness. On the basis of a review of nine different theories of self-awareness, Morin (9) has suggested four levels that can work as reference points for different theoretical conceptions and that may  help  researchers  to  compare,  contrast,  and integrate these theories: 1) unconsciousness; 2) consciousness;  3)  self-awareness;  and  4)  meta-selfawareness. At the unconscious level, the organism is unresponsive to both the self and the environment. At the level of consciousness, the organism focuses attention  on  the  environment  and  on  processing stimuli. At this level, a basic sense of self is involved, but mainly as a primitive experience of one's body in relation  to  the  environment,  with  the  sense  of  self being  implicit  and  diffuse.  At  the  level  of  selfawareness, the organism focuses attention on the self and on certain aspects of the self more directly. At the level of meta-self-awareness, an awareness of the self as being aware of either the environment or the self is added. Two dimensions are seen as underlying the graded distinctions between  the  levels: the perception of self in time and the complexity of the information being accessed and processed (9). At the lower levels, the information processed is of a more sensory  and  perceptual  nature;  this  information  is primarily situated in the immediate present. At the higher  levels,  the  information  processed  is  more conceptual and complex; this information is linked to the  present  as  well  as  to  the  past  and  the  future, thereby  enabling  the  individual  to  plan,  act,  and monitor  his  or  her  actions  on  the  basis  of  both previous experiences and future goals.

## Levels  of  self-awareness:  a  specific  review  for individuals with autism spectrum disorder

The  question  of  self-awareness  among  individuals with ASD  has  been  addressed theoretically by different  authors,  some  from  within  the  autism research community (10-14) and others from a more philosophical standpoint (15-17).

Hobson (10) argues that self-awareness is dependent  on  the  individual  being  a  self.  With inspiration from Buber's theoretical work (18), Hobson  specifies  two  modes  of  being  a  self  and therefore of self-awareness. In the first mode, which Hobson calls self-awareness, the  self  is  distinct  from non-self  (I-It).  This  is  an  impersonal  distinction between  the  organism  and  all  other  things.  In  the second mode, reflective self-awareness, the self is distinct from  other  selves  (I-Thou).  This  is  a  personal distinction that allows for an outside perspective on one's  own  attitudes.  The  awareness  of  the  self  as distinct from the non-self is seen as a prerequisite for reflective  self-awareness.  The  distinction  between the  modes  is  gradual,  and  reflective  self-awareness itself  includes  a  continuum  that  is  based  on  an increasingly  complex  conceptualization  of  the  self. Hobson argues that awareness of the self as distinct from the non-self is typically unaffected in individuals with ASD, whereas the distinction of the self  from  other  selves  may  not  be  conceptually differentiated enough  to  support  reflective selfawareness in these individuals. With the distinction of  the  self  from  other  selves  and  the  notion  of reflective self-awareness as a continuum based on the increasing complex conceptualization of the self, this seems potentially to map onto both Morin's description of self-awareness and meta-selfawareness,  with  the  differences  in  ASD  linked  to these levels.

Powell and Jordan (11) have suggested that individuals with ASD are characterized by deficits in personal episodic memory. They describe deficits of both encoding and recall that arise from problems with  the  development  of  an  'experiencing  self' responsible for coding events as something experienced  by  and  thus  belonging  to  the  self. Deficits  in  this  encoding  would  lead  to  deficits  in personal  episodic  memory,  with  the  person  being able  to  recall  personal  facts  and  knowledge  but 'unable  to  remember  themselves  as  performing actions, participating in events or possessing knowledge and strategies' (11: p. 361). The experiencing self is also seen as allowing the individual to search his or her memory independently of specific situational cues, with the recall of episodic memory  otherwise  being  dependent  on  situational clues (11). Powell and Jordan see this independence of situational clues as essential for problem solving that  involves  reflection  on  personal  experiences, strategies,  and  knowledge.  In  relation  to  Morin's levels,  remembering  personal  facts  and  knowledge seems to relate to the level of consciousness and selfawareness, whereas remembering the self as acting and participating and as processing knowledge and strategies  seem  to  relate  to  the  level  of  meta-selfawareness, both due to the representational complexity of the self and to the implied perception of the self across time. Powell and Jordan's reflections are primarily focused on the flexible use of personal information in time, but the dimension of  conceptual  abstraction  is  also  relevant  to  the descriptions of experiences being encoded as personal and this conceptualization as being essential for later recall.

Frith  and  Happé  (12)  build  on  the  cognitive account that persons with ASD may have impaired 'theory of mind' (ToM), which refers to the ability to represent the mental states of the self and others. Frith and Happé focus on introspection and suggest that a mind without introspective awareness would consist  only  of  first-order  representations,  which would primarily be descriptions of objects and events on a concrete descriptive and perceptual level. What may be different in individuals with ASD would be a meta-representational  level,  where  the  first-order representation is re-represented, thereby differentiating the propositional attitude (e.g., desire, belief, pretense), the content (i.e., believing 'X'), and the source status (i.e., who holds the belief: the self or the other). Potential problems that follow from a lack of or differences at the level of metarepresentations may include the difficulties to distinguish between one's own and others' opinions or  trouble  understanding  why  you  act  as  you  do. More recently, Happé (19) has expanded and further defined some of the potential downstream developmental  effects  of  problems  with  'reading [one's] own mind.' Happé also highlights how some of these developmental effects may also be beneficial, such as the personal perspective being less conforming and less restricted by assumed knowledge  (19).  The  differences  in  self-awareness among individuals with ASD are understood primarily as differences at the meta-representational level  of  processing,  which  are  also  responsible  for problems  representing  other  people's  thoughts  or ToM. In relation to Morin's levels (9), the differences among individuals with ASD as proposed by Frith and Happé seem to fall mainly at the level of metaself-awareness.

Raffman (15), who is coming from a philosophical perspective, suggests different ways of conceptualizing deficits of self-awareness and highlighting the different levels of awareness introduced in Frith  &  Happé's  argument (12). Raffman views self-knowledge as a cognitive achievement,  whereas  self-awareness  is  viewed  in two different senses: a 'thin' sense of self-awareness and  a  'strong'  sense  of  self-awareness.  The  thin sense  of  self-awareness  involves  the  direction  of attention and is non-conceptual; it is viewed as direct, immediate, and non-inferential. The strong sense of self-awareness is characterized as introspection and self-knowledge.  Self-awareness  in  the  thin  sense  is the source of introspection and self-knowledge and as  such  the  foundation  of  self-awareness  in  the stronger  sense  (15).  Self-awareness  in  the  strong sense  involves  a  conceptual  judgement,  in  ToM

terms,  of  the  thin  sense  of  self-awareness;  this conceptual judgement is involved in both the conceiving  and  reporting  of  this  knowledge.  In relation to ASD, Raffman argues that difficulties with self-awareness could be understood more as difficulties  with  representing  and  reporting  mental states in  ToM  terms  rather  than  as  a  lack  of awareness of these states as such. Raffman goes on to add the possibility that some of the differences in self-awareness  in  individuals  with  ASD  could  be related to potential differences in the self-ascription of mental states based on differences in perceptual processing.

Raffman suggests that differences in self-awareness among  individuals  with  ASD  is  a  question  of  the character of the mental state one is having rather than a question of having or not having mental states as such  (15).  Raffman  adds  to  the  discussion  of  the relationships between the levels and makes explicit how more basic deficits or differences can affect the higher levels of processing. Thus, deficits or differences in self-awareness-although they may be seen at a higher level of awareness processing-may be explained by processing difficulties at more basic levels (e.g., perception), because these are the source of  self-awareness  and  so  influence  all  levels.  In relation to Morin's levels (9), the strong sense of selfawareness is seen as indicative of meta-selfawareness, whereas the thin sense of self-awareness is related to both the level of consciousness and the level  of  self-awareness.  Raffman's  suggestions with regard  to  self-awareness  among  individuals  with ASD  place  a  potential  difference  at  the  levels  of meta-self-awareness and consciousness, with potential  differences  here  influencing  the  higher levels of processing (15).

McGeer  (16)  argues  that  self-awareness  is  the direction  of  attention  during  an  experience  of  the world. In self-reports, it is these experiences of the world  that  are  being  reported  directly.  In  contrast with the levels suggested by Frith and Happé (12), McGeer  (16)  argues  to  collapse the distinction between  an  experience  and  the  awareness  of  that experience. When you are aware of 'X,' it is not the experience  of  something  that  you  are  aware  of; rather, you are simply experiencing 'X,' and during this experience you are aware of 'X' itself. In this sense,  McGeer  also  seems  to  challenge  the  notion that a concept  or  representation  of  the  self  is necessary for this type of self-awareness. However, McGeer does recognize a cognitive awareness as a sophistication  of  this  basic  self-awareness,  which includes the understanding that the actuality of world may  differ  from  one's  subjective  experience.  In relation to Morin's levels (9), cognitive selfawareness is clearly related to the level of meta-selfawareness. The level of direct self-awareness during the experience seems related to both consciousness and self-awareness, and it seems in many ways to be closely related to Raffman's thin sense of self  (15). The connection to ASD is less explicit. In line with Raffman's second suggestion, McGeer suggests that differences in sensory perception may influence the developmental process of higher-order social cognitive abilities, thereby resulting in social cognitive  difficulties,  which  is  one  of  the  defining characteristics of ASD.

Williams (14) addresses aspects of self-awareness in his review of studies examining the 'theory of own mind.' Williams concludes that, although an awareness  of  one's  own  mind-the  psychological self, is dependent on metarepresentations, this level of  representation  is  not  so  necessary  for  reflexive awareness of the physical self. Further, differences in self-awareness that have been described for persons with ASD seem to be primarily evident in relation to tasks and aspects related to awareness of the psychologicial self. With this in mind, Williams (14) argues  for  the  relevance  of  distinguishing  between the physical and psychological domains of the self in the understanding of self-awareness. Recent studies of  interoception  (percieving  the  internal  state  of one's body) have indicated that persons with ASD may be characterised by atypical interoception (20), which challenges the idea of intact awareness of the physical domain of the self in these persons. However, Shah and colleagues (21) investigated the relevance  of  comorbid  alexithymia  and  found  that 'Alexithymia, not autism, is associated with impaired interoception' (19: p. 215).

The distinction between the physical and psychological  domains  of  the  self  as  suggested  by Williams  is  not  explicitly  represented  in  Morin's levels of awareness (9), and whether it makes sense to consider the level of meta-self-awareness in relation to the domain of the physical self is not quite clear.  In  Table  1,  this  distinction  has  been  merged with Morin's levels of awareness, and the presented theories  of  deficits  or  variations  in  self-awareness among  individuals  with  ASD  have  been  mapped onto  the  model.  With  the  distinction  between  the physical  and  psychological  domains  of  the  self,  it becomes clear that the differences suggested by the other authors are also primarily related to the domain of the psychological self.

TABLE 1. Suggested differences in self-awareness for persons with autism spectrum disorder mapped onto levels of self-awareness and domains of the self

FH, Frith and Happé (12); H, Hobson (10); M, McGeer (16); PJ, Powell and Jordan (11); R, Raffman (15); W, Williams (14).

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| Level and definition (Morin, 2006)                                                                                                    |                                                                                                                                                           | Psychological                                                                                                                                                                                                                                    |                                                                                                                                                           |
|---------------------------------------------------------------------------------------------------------------------------------------|-----------------------------------------------------------------------------------------------------------------------------------------------------------|--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-----------------------------------------------------------------------------------------------------------------------------------------------------------|
|                                                                                                                                       |                                                                                                                                                           | Specific difficulties related to awareness of the psychological self (W)                                                                                                                                                                         | Specific difficulties related to awareness of the psychological self (W)                                                                                  |
| Meta-self-awareness Being aware that one is self-aware 3. Self-awareness Focusing attention on the self; processing self- information | 4.                                                                                                                                                        |  Difficulties with meta-representing (FH)  Difficulties with conceptualizing or reporting in mentalizing terms (R)  Problems with the conceptual differentiation of the self from other-selves (H)  Experiences not encoded as personal (PJ) | Conceptual complexity                                                                                                                                     |
| 2. Consciousness Focusing attention on the environment; processing external stimuli 1. Unconsciousness                                |  Differences in perceptual processing leading to different mental states affecting later levels of awareness (R)  Differences in sensory processing (M) |  Differences in perceptual processing leading to different mental states affecting later levels of awareness (R)  Differences in sensory processing (M)                                                                                        |  Differences in perceptual processing leading to different mental states affecting later levels of awareness (R)  Differences in sensory processing (M) |
| Being unresponsive to the self and the                                                                                                | environment                                                                                                                                               | environment                                                                                                                                                                                                                                      | environment                                                                                                                                               |

## Dimensions of self-awareness

As mentioned previously, Morin's levels are defined by  the  perception  of  the  self  in  time  and  the complexity  of  the  information  being  accessed  and processed. Morin further identifies and promotes the variables of frequency, amount, and accuracy of selfawareness as relevant for understanding an individual's level of self-awareness. The term frequency of self-awareness refers  to  the  engagement  of  the individual in either situational or dispositional selfobservations; the amount of self-awareness refers to the quantity of self-information and seems to relate to both the type and extent of self-knowledge; and the accuracy  of  self-awareness refers  to  the  quality  of  the information, such as the degree of consistency of the information  as  compared  with  the  actual  situation, with  patients  with  brain  injuries  and  psychiatric disorders such as schizophrenia providing case examples of inaccurate self-awareness. These variables  can  all  be  seen  as  more  procedural  and functional  aspects  of  self-awareness,  and,  as  such, they  seem  to  be  essential  to  describe  the  potential quality, efficiency, and usability of self-awareness in neurotypical  individuals  and  individuals  with  ASD. However, these concepts are only briefly introduced in Morin's review, and they are not directly addressed in  the  work  summarized  previously  regarding  selfawareness among individuals with ASD. This procedural aspect of self-awareness is also evident in the  theoretical  distinction  made  by  Crosson  and colleagues (22) and summarized by Prigatano (3) in his  summary  of  20  years'  work  on  understanding disturbances of self-awareness. The distinction that is made is that different deficits are related to one of the following: 1) an intellectual awareness  (i.e., knowing  that  you  have  a  problem);  2)  emergent awareness  (i.e.,  knowing  that  you  have  a  problem when  it  occurs);  or  3)  anticipatory  awareness  (i.e., knowing in advance that you have a problem that will affect future behavior or functioning). This distinction highlights the idea that, when it comes to understanding self-awareness, it is not just a question of having self-awareness; when and how the individual  comes  to  understand  this  self-awareness and how it is applied must also be considered.

Being self-aware is not always necessary and may sometimes be a hindrance to effective functioning, especially  if  the  individual  is  not  able  to  flexibly regulate  his  or  her  self-awareness.  I  would  suggest that it is necessary to consider an additional dimension  that  addresses  the  attunement  between the  organism  and  the  context.  Here,  the  idea  of attunement means the extent to which self-awareness is relevant to making the most of, on one hand, the prerequisites and objectives of the organism and, on the other, the prerequisites, requirements, and demands inherent in the context. The dimension of attunement  is  in  many  ways  influenced  by  the variables of frequency, amount, and accuracy suggested  by  Morin  (9),  but  it  can  also  be  seen  as dependent  on  the  relevance,  timing,  and  potential self-directed  control  of  both  the  activation  of  the different levels of self-awareness and the translation of this information into relevant action. Relevance is implicit in this understanding of attunement; it refers to  the  pertinence  of  the  content  of  self-awareness relative to the  organism and the context. For example, in a classroom, certain actions are required by the persons participating. In this context, awareness of the self in relation to these requirements is more relevant than other aspects of the  self.  Likewise,  if  one  of  the  children  in  the classroom  is  easily  distracted  by  noise,  then  that child's  awareness  of  his  or  her  current  level  of concentration, task behavior, reactions to the level of noise, knowledge of previous reactions, the outcome of these reactions, and special arrangements with the teacher (e.g., being allowed to put on earmuffs) are more important for him or her to be aware of at that moment as compared with other aspects of self.

In addition, what is relevant may change quickly if elements  of  the  context  or  the  individual's  motive changes.  Sometimes  self-awareness  of  certain  selfinformation may hinder efficient  behavior,  such  as becoming aware of a trembling voice when commencing an academic presentation or ruminating on past actions while trying to go to sleep. Similarly, a  lack  of  self-awareness  may  be  equally  disruptive, such as not registering or differentiating the bodily signals of stress and anxiousness until actually experiencing a 'meltdown.' Timing reflects that the awareness  of  the  same  bodily  signals  at  any  other time,  while  still  potentially  relevant,  may  not  be  as helpful as being aware of them in a specific situation in which it is still possible to influence the situation and one's own reaction to the situation. Relevance is often highly interrelated with timing. The term selfregulation refers  to  the  ability  of  an  individual  to identify moments in which it is relevant to activate or deactivate  certain  aspects  of  self-awareness  and  to actually regulate his or her self-awareness accordingly; this is a procedural aspect that is closely related  to  the  level  of  meta-self-awareness.  In  this sense,  a  high  degree  of  attunement  is  an  essential foundation for efficient problem solving. Attunement may be seen as a relevant dimension at all  four  levels,  and  a  balance  among  the  different levels  may  in  itself  be  relevant  for  more  optimal attunement.  This  will  ensure  that  the  information that  is  processed,  represented,  and  reflected  on  is linked to the past and the current situation as well as to an anticipated future context.

## Conclusion and perspective

To sum up, the framework suggested for understanding and discussing variations and differences in self-awareness in individuals with ASD revolves around four levels of self-awareness across varying  domains  of  the  self.  In  various  theoretical positions related to self-awareness among individuals with  ASD, differences in self-awareness have been suggested at all levels (except the level of unconsciousness);  however,  these  differences  may relate primarily to the psychological domain of the self. The levels are differentiated on the basis of the degree of conceptual complexity and the perception of the self in time and are, as such, closely related to the  content  of  awareness.  More  procedural  and functional aspects of self-awareness are highlighted with the concept of attunement. Attunement as presented  here  refers  to  variables  of  frequency, amount, accuracy, timing, relevance, and selfdirected control; all of these aspects are relevant for understanding the how and when of self-awareness in  the  interaction  between  the  organism  and  the context. The presented framework is not seen as a final  model  of  self-awareness  for  individuals  with ASD;  it  of  course  requires  further  research  and elaboration.  However,  this  framework  may  be  a helpful stepping-stone along the path. The intention is  that  the  conceptual  framework  presented  in  this commentary may help to direct future research and to organize relevant findings and discussions in the continued  investigation  of  self-awareness  among individuals with ASD. This framework may also help to  organize  empirical  evidence  from  studies  that investigate  concepts  such  as  executive  functioning, mentalizing, autobiographical memory, selfregulation, and metacognition; although these concepts  may  not  directly  address  the  concept  of self-awareness,  together  they  may  all  add  to  the understanding of self-awareness in individuals with ASD. From a clinical perspective, understanding the variations  of  self-awareness  could  help  with  the identification  and  modification  of  interventions  to support the development of self-awareness or compensatory  strategies.  It  may  also  help  us  to understand  the  mechanisms  of  change  and  the challenges associated with ASD interventions, thereby  helping  us  increase  the  effectiveness  of clinical practice.

## Acknowledgements

I  would  like  to  acknowledge  Francesca  Happé, whose work continues to inspire my interest in and reflections  on  self-awareness.  Francesca  has  also contributed to my current ideas about self-awareness through discussions of the topic and her comments on this paper. Her thoughts on various drafts of this commentary led to many new reflections, many of which  unfortunately  could  not  fit  into  this  format and will have to be addressed at a later date.

## Conflicts of Interest

The author declares no conflict of interest.

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