COVID-19, social isolation and the mental health of autistic people and their families: A qualitative study

LAY ABSTRACT

In this study, we show that autistic people and their families have found it very difficult to deal with the lockdowns during the COVID-19 pandemic. Autistic and non-autistic researchers spoke to 144 people, including 44 autistic adults, 84 parents of autistic children and 16 autistic young people (12-18 years old). We asked them about their everyday lives and mental health during lockdown. People told us that they enjoyed having fewer obligations and demands compared to pre-COVID-19 life. They felt that life was quieter and calmer. But people also told us again and again how much they missed meeting people in real life, especially their friends, and their therapists and support workers. People told us that their mental health suffered because they did not have contact with their friends and services. Importantly, many people (including researchers) think that autistic people do not want friends or to be around people. But our results show that is not true. Many autistic people do want friends and to be around other people. Some people's mental health has been damaged by not being able to see people during COVID-19. Autistic people need support in many areas of life so they can keep socialising and seeing their friends even through difficult times, like pandemics.

Perceptions of social and work functioning are related to social anxiety and executive function in autistic adults

LAY ABSTRACT

Many autistic adults have trouble in social situations and at work. Researchers do not know exactly why autistic people might find it difficult in these environments, and no studies to date have looked the way anxiety or other cognitive processes might affect autistic peoples' ability to socialise and succeed in getting and keeping jobs. Anxiety (how much you worry) and difficulty with getting stuff done or switching attention (known as executive function) can be concerns for autistic people and may contribute to social and work difficulties. This study looked at the relationships between the way autistic people perceived their anxiety and executive functioning and their ability to socialise and work. Sixty-two autistic participants completed questionnaires related to their ability to socialise and work, their social anxiety and their executive function. We found that participants who thought that they had poorer ability to work also found themselves to have more difficulties with executive function and they were more socially anxious. Our results showed that how autistic participants perceived their social anxiety and executive function were important in their perception of their social skills and work ability. This study supports the idea that anxiety and executive function could be targeted in interventions to support autistic people and their social and work outcomes.

Experiences of autistic and non-autistic individuals participating in a corporate internship scheme

Autistic people have significant challenges in obtaining and maintaining employment yet there remains a shortage of research in this area, especially research directly comparing the experiences of autistic individuals to their non-autistic colleagues in the same organisation. The present study examined the experiences of autistic and non-autistic interns, and their managers, taking part in a corporate internship scheme. Data were gathered via semi-structured interviews and online questionnaires prior to, and following, the internship. Many commonalties were identified, with both groups of interns and managers sharing positive journeys through the internship. Specific issues raised by autistic interns centred around impact of prior employment experiences, mental health and communication. Compared to managers of non-autistic interns, managers of autistic interns reported having a greater range of pre-internship concerns, including concerns about providing the right level of support, communicating successfully and being equitable in treatment of all employees. Structured delegation of tasks and flexible communication were successful strategies used by managers to support autistic interns; clear communication and more consistent support were perceived to benefit both intern groups. The findings highlight specific challenges experienced by autistic individuals in the workplace and suggest effective ways to ensure that autistic interns succeed alongside non-autistic peers.

Defining autistic burnout through experts by lived experience: Grounded Delphi method investigating #AutisticBurnout

LAY ABSTRACT

Autistic burnout has been commonly described in social media by autistic people. There is little mention of autistic burnout in the academic literature. Only one recent study has used interviews and reviews of social media descriptions to try to understand autistic burnout. Anecdotally, autistic burnout is a very debilitating condition that reduced people's daily living skills and can lead to suicide attempts. It is suggested that autistic burnout is caused by the stress of masking and living in an unaccommodating neurotypical world. We wanted to create a definition of autistic burnout that could be used by clinicians and the autism community. We used the Grounded Delphi method, which allowed autistic voice to lead the study. Autistic adults who had experienced autistic burnout were considered as experts on the topic, in the co-production of this definition. The definition describes autistic burnout as a condition involving exhaustion, withdrawal, problems with thinking, reduced daily living skills and increases in the manifestation of autistic traits. It is important for future research that there is a specific description of the condition. In practice, it is important for clinicians to be aware that autistic burnout is different from depression. Psychological treatments for depression potentially could make autistic burnout worse. Further awareness of autistic burnout is needed, as well as further research to prove this condition is separate from depression, chronic fatigue and non-autistic burnout.

Reduced differentiation of emotion-associated bodily sensations in autism

LAY ABSTRACT

More research has been conducted on how autistic people understand and interpret other people's emotions, than on how autistic people experience their own emotions. The experience of emotion is important however, because it can relate to difficulties like anxiety and depression, which are common in autism. In neurotypical adults and children, different emotions have been associated with unique maps of activity patterns in the body. Whether these maps of emotion are comparable in autism is currently unknown. Here, we asked 100 children and adolescents, 45 of whom were autistic, to color in outlines of the body to indicate how they experienced seven emotions. Autistic adults and children sometimes report differences in how they experience their internal bodily states, termed interoception, and so we also investigated how this related to the bodily maps of emotion. In this study, the autistic children and adolescents had comparable interoception to the non-autistic children and adolescents, but there was less variability in their maps of emotion. In other words, they showed more similar patterns of activity across the different emotions. This was not related to interoception, however. This work suggests that there are differences in how autistic people experience emotion that are not explained by differences in interoception. In neurotypical people, less variability in emotional experiences is linked to anxiety and depression, and future work should seek to understand if this is a contributing factor to the increased prevalence of these difficulties in autism.

Autistic parents' views and experiences of talking about autism with their autistic children

LAY ABSTRACT

Previous research examining how parents talk about autism with their children has tended to focus on parents who are not autistic themselves. We collected information on this topic from 34 autistic parents of autistic children (most of whom had told their children about their diagnosis). We found similarities, but also differences, between the views and experiences of autistic parents in this research and those reported in previous research (in studies of largely non-autistic parents). Similarities include the following: it is important to be open and honest about the diagnosis; the diagnosis should be introduced/discussed as early as possible; discussions should be tailored to each individual child's needs; and we should not overlook the challenges associated with autism, but it is important to focus on positive aspects too. Differences include the following: autistic parents used personal experiences in conversations about autism, which was felt to result in increased understanding and empathy with their children; autistic parents overwhelmingly focused on more positive aspects of an autism diagnosis; our sample did not express concerns that discussions could have negative consequences too (e.g. making children more anxious); and autistic parents did not want or need professional support to talk about autism with their children (instead, they felt confident in using their own knowledge/experiences to guide discussions).

"The Real Thing I Struggle with is Other People's Perceptions": The Experiences of Autistic Performing Arts Professionals and Attitudes of Performing Arts Employers in the UK

This research examined in-depth the employment experiences of autistic performing arts professionals and the attitudes and adjustments of performing arts employers. We interviewed 18 autistic performing arts professionals and 19 performing arts employers. Autistic performing arts professionals described facing challenges in the workplace. Some autistic professionals had access to support, but the majority felt that there was not enough available and highlighted many ways in which they could be better supported. Performing arts employers varied in their experiences of working with autistic people, many had limited knowledge about autism-specific support or relied on other professionals to provide it. These findings shed light on current unmet support needs of autistic performing arts professionals, and provide key recommendations for research and practice.

"It just fits my needs better": Autistic students and parents' experiences of learning from home during the early phase of the COVID-19 pandemic

BACKGROUND AND AIMS

The COVID-19 pandemic has caused unprecedented disruption to people's lives, especially for families, whose children have been taken out of schools during lockdown restrictions and required to learn from home. Little is known, however, about the perceived impact of the lockdown restrictions on the educational experiences of autistic children and young people - a group whose conventional schooling experiences are already often challenging. In this study, we sought to (1) understand these experiences from the perspectives of autistic young people and their parents, and (2) identify the underlying sources of positive experiences at this challenging time, in order to inform the ways in which autistic children might flourish at school in more normal times.

METHODS

Ninety-one Australian participants, including 16 autistic young people aged 12-18 years, 32 autistic parents and 43 non-autistic parents of autistic young people aged 3-18 years, took part in semi-structured interviews about their experiences of life during the initial phase of the COVID-19 pandemic. The interviews were subjected to reflexive, thematic analysis to identify themes and subthemes for each research question.

RESULTS

Overall, our participants initially found the transition to learning from home extremely challenging, with parents reporting that the support received from schools was far from adequate. After that initial period of transition, however, many autistic children reported flourishing at home both educationally and personally. For these children and families, we identified three key ingredients essential to this flourishing, including: (i) the importance of connected, trusting relationships ('people'); (ii) the sensory and social safety of home ('place'); and (iii) the flexibility to pace and structure learning to suit the individual child ('time').

CONCLUSIONS

While the initial COVID-19 lockdown presented many challenges to children learning at home, there were aspects of this otherwise-unsettling situation that enabled children to thrive and from which we can learn for the future.

IMPLICATIONS

These findings have important implications for understanding how and when autistic children might thrive in institutional educational settings once the pandemic subsides, focusing on the relationships between teachers and students, the nature of the physical learning environment and the need for greater flexibility in planning the school day.

Supporting Minimally Verbal Autistic Girls with Intellectual Disabilities Through Puberty: Perspectives of Parents and Educators

Limited research has examined puberty in autistic girls, yet alone those who are minimally verbal and with additional intellectual disabilities. In this study, ten parents and ten educators were interviewed about their views and experiences of supporting these girls through puberty. Results demonstrated that many parents had concerns prior to the onset of puberty in these girls. Yet, for most girls, experiences of puberty were felt to be positive, with the girls coping well with changes that they were experiencing (e.g. menstruation, breast development and developing body hair). Thematic analysis of interview data highlighted three main themes: a range of individual experiences and needs; the importance of promoting dignity and respect; and identifying ways to support these girls through puberty.

Autistic adults' views of their communication skills and needs

BACKGROUND

Autistic people require varying levels of support at different stages of their lives. Yet, the healthcare needs of autistic adults are largely unmet. Speech and language therapy (SLT) is one healthcare service that has an important role in supporting autistic people: both with initial diagnosis, and with the ongoing support needed to navigate different communicative challenges across the lifespan. Despite recommendations for such support, currently there is no clear SLT pathway for autistic adults, and a lack of established approaches to support autistic adults' speech, language and communication needs.

AIMS

To seek autistic adults' views on (1) their communication skills and support needs; (2) the type of support SLT could offer; and (3) how such support could be provided.

METHODS & PROCEDURES

A total of 18 autistic adults were interviewed in their preferred mode of communication (e.g., face to face, phone call, text messaging, e-mail), expressing their views on their communication skills and needs. Interview data were analysed using thematic analysis.

OUTCOMES & RESULTS

Autistic adults presented complex views on communication, identifying the benefits of communication, while also emphasizing the significant negative impact that communication difficulties can have on their everyday lives. Identifying a range of internal (e.g., personal feelings) and external (e.g., the communication partner) factors, they highlighted the need for support at both individual levels (for specific life situations) and broader societal levels (to increase awareness and acceptance of communication difficulties).

CONCLUSIONS & IMPLICATIONS

Considering the negative impact that communication difficulties can have for autistic adults, a need for support was emphasized. Despite recognition of this need within current legislation (in the UK) and positive steps toward providing support, more needs to be done. As experts in supporting individuals with communication difficulties, speech and language therapists could play a pivotal role in providing support at an individual level, as well as increasing awareness of communication differences more widely. What this paper adds What is already known on this subject There is a growing population of autistic adults with unmet support needs. A core characteristic of autism is difficulty with neurotypical social communication and interaction, which persists into adulthood and impacts across various life domains. What this paper adds to existing knowledge Autistic adults outlined the types of communication difficulties they experience, and how these can negatively impact on physical and mental health. Results highlight how these difficulties are not just rooted within the person themselves but can be influenced by external factors (e.g., the environment and the communication partner). What are the potential or actual clinical implications of this work? Some autistic adults may benefit from direct support from SLT services. However, increased awareness and respect for communication differences at a broader societal level is also needed. Speech and language therapists can play an important role in increasing this level of awareness, positively highlighting differences in communication and ways to support people with communication difficulties/differences.

'I'm not just a guinea pig': Academic and community perceptions of participatory autism research

LAY ABSTRACT

Participatory research means working together (engaging) with the community that is affected by research to make decisions about that research. Participatory research is common in some fields, but it is still rare in autism research. In this study, we wanted to find out how Australian autism researchers and community members feel about participatory research. We worked with an Autistic Advisory Group to design this study, understand the results and write this article. We asked 127 people, all working on research from the Cooperative Research Centre for Living with Autism, to complete an online survey about participatory research. The survey included some questions that were answered on rating scales, and some where participants wrote their own answers. Seventy-nine people (64 researchers and 15 community members) completed most or all of the survey. The rating scales showed that most participants (82%) supported moderate or extensive community engagement in research, and most participants (72%) thought there should be more community engagement in autism research. In general, the participants rated their experiences of participatory research positively. Using the participants' own written answers, we found four main ideas: (1) participatory research is important, but difficult; (2) many people do not fully understand what participatory research is; (3) academics and community members do not work together as = and (4) research systems are not designed for participatory research. Our results suggest that autism researchers and community members want to do more participatory research, but they might need training, support and funding to do participatory research well.

Inclusion, acceptance, shame and isolation: Attitudes to autism in Aboriginal and Torres Strait Islander communities in Australia

LAY ABSTRACT

There has been almost no research done about autism in Aboriginal and Torres Strait Islander communities in Australia. This article is the first detailed report on attitudes to autism in these communities. Understanding attitudes to autism is important because they influence whether or not children are diagnosed, as well as the kinds of support autistic people are getting. Twelve families who lived in different parts of Australia were interviewed. They told us that there is a range of attitudes to autism in Aboriginal and Torres Strait Islander communities. These include negative ideas such as sometimes feeling shame associated with children's unusual behaviour, as well as feeling stigmatised and socially isolated. The negative attitudes reported may mean that some children are missing out on an autism diagnosis or being wrongly diagnosed with a different condition in these communities. They also included positive ideas such as the importance of looking after each other and of accepting autistic people and their differences. We can all learn from these positive attitudes. It will be interesting to know in future projects whether these accepting attitudes lead to better outcomes for autistic children and adults in these communities. This research helps us to understand how autism is thought about in different cultures and how attitudes impact diagnosis and support. It will also help people to plan supports that reflect what Aboriginal and Torres Strait Islander families actually want and need.

Adaptation to the Speed of Biological Motion in Autism

Autistic individuals often present atypicalities in adaptation-the continuous recalibration of perceptual systems driven by recent sensory experiences. Here, we examined such atypicalities in human biological motion. We used a dual-task paradigm, including a running-speed discrimination task ('comparing the speed of two running silhouettes') and a change-detection task ('detecting fixation-point shrinkages') assessing attention. We tested 19 school-age autistic and 19 age- and ability-matched typical participants, also recording eye-movements. The two groups presented comparable speed-discrimination abilities and, unexpectedly, comparable adaptation. Accuracy in the change-detection task and the scatter of eye-fixations around the fixation point were also similar across groups. Yet, the scatter of fixations reliably predicted the magnitude of adaptation, demonstrating the importance of controlling for attention in adaptation studies.

Documenting the untold histories of late-diagnosed autistic adults: a qualitative study protocol using oral history methodology

INTRODUCTION

Receiving a diagnosis of autism in adulthood is increasingly common for a subset of individuals who were either misdiagnosed in childhood or missed out on a diagnosis altogether. This qualitative study, coproduced with autistic people, invites late-diagnosed autistic adults to share their life histories to (1) understand better the consequences of living without a diagnosis, (2) elucidate what precipitates an autism diagnosis in mid-to-late adulthood and (3) identify the perceived impact of receiving that diagnosis.

METHODS AND ANALYSIS

Oral histories have been a successful way to uncover overlooked and marginalised voices. We therefore adopt qualitative, oral history methodology in this study to understand these adults' experiences, especially of living in an era when autism was not well known. We will recruit 24 participants who will (1) have been born before 1975, (2) have received a clinical, autism diagnosis after the age of 35, (3) be English-speaking and (4) have spent most of their childhood and adulthood living in Australia. Participants will take part in four sessions, including the main, qualitative, oral history interview, through a range of possible formats to facilitate inclusion. The interview data will be analysed using reflexive thematic analysis.

ETHICS AND DISSEMINATION

The protocol has received institutional research ethics approval from Macquarie University's Human Research Ethics Committee (Ref.: 52019556310562). This study will yield understanding of the life experiences of autistic adults, especially middle-aged and older Australians, should inform more effective diagnostic practices and provide insight into the key factors that might promote resilience and enhance quality of life in autistic people. The findings will be disseminated to academic and clinical audiences through journal articles and conference presentations and to the autistic and autism communities through accessible reports. The interviews will also be prepared for digital archiving, which will enable ongoing access for future generations and communities.

Commentary: Broadening the research remit of participatory methods in autism science - a commentary on Happé and Frith (2020)

Autism science has transformed beyond recognition in the last two decades. International investment has grown extensively and the number of papers published on autism has increased 10-fold (Pellicano et al., 2014), far surpassing publications on related topics. The sheer amount of scientific research on autism has no doubt been instrumental in many of the discoveries and insights so eloquently described by Happé and Frith (2020). But, as autistic scientist Michelle Dawson reminds us, quality matters too and, for that reason, it is a delight to recognise the contribution that both Happé and Frith have made, dramatically changing our understanding of autism in a host of ways.

Educators' Views on Using Humanoid Robots With Autistic Learners in Special Education Settings in England

Researchers, industry, and practitioners are increasingly interested in the potential of social robots in education for learners on the autism spectrum. In this study, we conducted semi-structured interviews and focus groups with educators in England to gain their perspectives on the potential use of humanoid robots with autistic pupils, eliciting ideas, and specific examples of potential use. Understanding educator views is essential, because they are key decision-makers for the adoption of robots and would directly facilitate future use with pupils. Educators were provided with several example images (e.g., NAO, KASPAR, Milo), but did not directly interact with robots or receive information on current technical capabilities. The goal was for educators to respond to the general concept of humanoid robots as an educational tool, rather than to focus on the existing uses or behaviour of a particular robot. Thirty-one autism education staff participated, representing a range of special education settings and age groups as well as multiple professional roles (e.g., teachers, teaching assistants, speech, and language therapists). Thematic analysis of the interview transcripts identified four themes: Engagingness of robots, Predictability and consistency, Roles of robots in autism education, and Need for children to interact with people, not robots. Although almost all interviewees were receptive toward using humanoid robots in the classroom, they were not uncritically approving. Rather, they perceived future robot use as likely posing a series of complex cost-benefit trade-offs over time. For example, they felt that a highly motivating, predictable social robot might increase children's readiness to learn in the classroom, but it could also prevent children from engaging fully with other people or activities. Educator views also assumed that skills learned with a robot would generalise, and that robots' predictability is beneficial for autistic children—claims that need further supporting evidence. These interview results offer many points of guidance to the HRI research community about how humanoid robots could meet the specific needs of autistic learners, as well as identifying issues that will need to be resolved for robots to be both acceptable and successfully deployed in special education contexts.

'People should be allowed to do what they like': Autistic adults' views and experiences of stimming

'Stereotyped or repetitive motor movements' are characterised as core features in the diagnosis of autism, yet many autistic adults (and the neurodiversity movement) have reclaimed them as 'stimming'. Supported by a growing body of scientific research, autistic adults argue that these behaviours may serve as useful coping mechanisms, yet little research has examined stimming from the perspective of autistic adults. Through interviews and focus groups, we asked 32 autistic adults to share their perceptions and experiences of stimming, including the reasons they stim, any value doing so may hold for them and their perceptions of others' reactions to stimming. Using thematic analysis, we identified two themes: stimming as (1) a self-regulatory mechanism and (2) lacking in social acceptance, but can become accepted through understanding. Autistic adults highlighted the importance of stimming as an adaptive mechanism that helps them to soothe or communicate intense emotions or thoughts and thus objected to treatment that aims to eliminate the behaviour.

Feasibility study of the National Autistic Society EarlyBird parent support programme

The EarlyBird programme is a group-based psychoeducation intervention for parents of young children with autism. Although it is widely used in the United Kingdom, the evidence base for the programme is very limited. Using a mixed method, non-randomised research design, we aimed to test (1) the acceptability of the research procedures (recruitment, retention, suitability of measures), (2) the parental acceptability of EarlyBird (attendance, views of the programme, perceived changes) and (3) the facilitator acceptability of EarlyBird (fidelity, views of the programme, perceived changes). Seventeen families with a 2- to 5-year-old autistic child and 10 EarlyBird facilitators took part. Pre- and post-intervention assessment included measures of the child’s autism characteristics, cognitive ability, adaptive behaviour, emotional and behavioural problems and parent-reported autism knowledge, parenting competence, stress and wellbeing. Semi-structured interviews were completed at post-intervention with parents and facilitators. For those involved in the study, the research procedures were generally acceptable, retention rates were high and the research protocol was administered as planned. Generally, positive views of the intervention were expressed by parents and facilitators. Although the uncontrolled, within-participant design does not allow us to test for efficacy, change in several outcome measures from pre- to post-intervention was in the expected direction. Difficulties were encountered with recruitment (opt-in to the groups was ~56% and opt-in to the research was 63%), and strategies to enhance recruitment need to be built into any future trial. These findings should be used to inform protocols for pragmatic, controlled trials of EarlyBird and other group-based interventions for parents with young autistic children.

Friends and Lovers: The Relationships of Autistic and Neurotypical Women

Background

Little is known about the friendships and relationships of autistic adults, despite decades of research evidence showing the benefits of close relationships for neurotypical adults. Even less is known about the relationships of autistic women, or how their relationships compare with those of neurotypical women. This mixed-methods study, therefore, examined differences in the social relationships of autistic women in relation to their neurotypical counterparts.

Methods

Thirty-eight women (19 autistic women, 19 neurotypical women), aged between 20 and 40 years, completed the Unidimensional Relationship Closeness Scale, The Awareness of Social Inference Test, and a semistructured interview about their current and former friendships and romantic relationships.

Results

In many ways, the social relationships and experiences of autistic women were much like those of neurotypical women. Autistic women, however, had greater difficulty with social inference skills, and reported experiencing more negative social situations. This was particularly the case in terms of social and sexual vulnerability, a feature that the autistic women themselves linked to their difficulties with social inference. Despite these challenges, autistic women were happier and more self-assured in their adult relationships than they remembered being in adolescence.

Conclusions

These findings highlight an urgent need for specific and tailored personal safety training and support for autistic women-and, by extension, autistic girls-to ensure that they can enjoy a safe transition to adulthood and positive adult relationships.

Lay Summary

Why was this study done?: At the moment, we know lots about adult friendships and relationships among neurotypical people, but we know very little about friendships and relationships for autistic adults. This is especially the case for autistic women, who are an understudied group and who are not often studied in their own right.What was the purpose of this study?: We wanted to find out whether autistic women have similar friendship and romantic relationship experiences to neurotypical women. We also wanted to know more about the ways these relationships had changed since adolescence-whether any changes over time were similar or different to those of neurotypical women.What did the researchers do?: We included 38 women in the study. Half of them were autistic and half were neurotypical. They were aged between 20 and 40 years old. They completed a questionnaire measuring the closeness of their relationships, and a test of how well they understood social situations. They also took part in an interview where we asked them about their current and past friendships and romantic relationships, and if/how these had changed over time.What were the results of this study?: We found that autistic and neurotypical women had friendships and relationships that were very similar. Both groups had friends, and similar number of women in each group had partners and children. Autistic women, though, found it harder to interpret social situations, and generally reported having more difficult friendship/relationship experiences than neurotypical women. This was especially true in terms of social and sexual experiences, where autistic women reported that they were much more vulnerable to exploitation than neurotypical women. Autistic women themselves linked this to their difficulties interpreting social situations. Despite these difficulties though, autistic women were happier with their relationships and much more confident in their social skills in adulthood than they remembered being as teenagers.What do these findings add to what we already knew?: These findings give us new information about the social experiences of autistic women, giving them the opportunity to talk about things that have gone well alongside some of the difficulties they can face. The positive outcomes women talked about were different to those reported in autistic men (in previous research). This is important because it shows that gender shapes social experiences as much as being autistic itself.What are the potential weaknesses in the study?: We had to ask women to look back on their teenage years, so there is always a chance that people have misremembered things or are interpreting them differently in adulthood to how they felt at the time. Also, as only those comfortable being included as women were involved in this study, it was not possible to carry out direct comparisons between the friendships and relationships of women and men, or those of autistic nonbinary or trans people, who likely have unique experiences.How will these findings help autistic people now or in the future?: We hope that the findings of this research will help families and professionals to better support autistic girls and women in their relationships, particularly in terms of romantic and sexual relationships, as well as education on personal safety. It also goes some way toward dismissing popular myths about autistic people struggling to make real friendships by showing a variety of successful relationships among autistic women.

Understanding psychiatrists' knowledge, attitudes and experiences in identifying and supporting their patients on the autism spectrum: online survey

BACKGROUND

Psychiatrists play a critical role in identifying and supporting their patients on the autism spectrum in the UK, yet little is known about their knowledge, attitudes and experiences in this regard.

AIMS

To understand psychiatrists' experiences of working with autistic individuals, their confidence in making diagnostic/management decisions and the factors that affect such decisions.

METHOD

A total of 172 psychiatrists took part in an online self-report survey.

RESULTS

Most psychiatrists reported receiving useful training on autism and were knowledgeable about the condition, particularly those with a personal connection to autism. Higher confidence in working with autistic patients was linked to greater levels of autism knowledge, experience and training. Several systemic and autism-specific factors were highlighted by psychiatrists, which were felt to challenge their ability to provide effective care and support for their patients on the autism spectrum.

CONCLUSIONS

Psychiatrists' views corroborated previous research with the autism community, highlighting the need to co-design services that are accessible, respectful and person-centred.

DECLARATION OF INTEREST

I.D. is the Royal College of Psychiatrists' Autism Champion.

Parents' views and experiences of talking about autism with their children

The way an autism diagnosis is disclosed to parents has been found to play a crucial role in their acceptance of, and the way they cope with, their child's diagnosis. Yet, research into parents' subsequent experiences of disclosing a diagnosis to their children, and talking to their families about autism more generally, is limited. Using an online survey, the current study examined 558 parents' experiences of talking about autism with their autistic and non-autistic children. Results demonstrated that most parents (n = 379, 67.9%) had told their autistic children about their diagnosis. Despite few parents (n = 163, 20.4%) receiving advice or support regarding the disclosure of the diagnosis, those that had disclosed felt satisfied with the process (n = 319, 84.2%) and felt confident in talking about autism with their children (n = 339, 92.4%). Those who had not told their autistic children about the diagnosis largely planned to discuss this with their child in the future (n = 100, 73.5%), felt confident in doing so (n = 95, 70.9%) and were satisfied with their decision (n = 95, 70.4%). Analysis of open-ended data, using thematic analysis, highlighted the importance of openness and the need to tailor explanations to individual children's needs, while acknowledging that disclosure could often be challenging for parents.

'I definitely feel more in control of my life': The perspectives of young autistic people and their parents on emerging adulthood

Long-term outcomes studies often paint a discouraging picture of the lives lived by autistic adults. Yet, their outcomes are often measured against normative markers of traditional adult roles, which may not apply to autistic people making the transition to adulthood. Here, we investigated the transition experiences of a group of young autistic people who were followed from childhood. Twenty-six young people and their parents (n = 28) participated in semistructured interviews on the process of transition and their aspirations for the future. Parents often voiced serious concerns about the ongoing support their children would require and the severe lack of services designed to support them as adults. Yet, overall, young people reported feeling more in control of their own lives, including developing a sense of identity and personal autonomy, both of which may be rooted in young autistic people's executive skills and their ability to develop and maintain trusting relationships with others - two potential candidate areas for targeted support. These results call into question whether the traditional standards to which we often hold young autistic people are developmentally appropriate and suggest that the pressures of striving towards more normative ways of engaging in the world may be detrimental to their well-being.

"Life is Much More Difficult to Manage During Periods": Autistic Experiences of Menstruation

Although menarche and menstruation are perceived to be overwhelmingly negative events for developmentally-disabled women, women’s health issues remain under-researched in autism. Here, we conducted a preliminary investigation of the experiences of post-menarcheal autistic (n = 123) and non-autistic (n = 114) respondents to a brief online survey. Although autistic respondents reported many overlapping issues and experiences with non-autistic respondents, they also highlighted distinct—and sometimes-distressing—issues relating to menstruation, especially a cyclical amplification of autistic-related challenges, including sensory differences and difficulties with regulating emotion and behavior, which had a significant, negative impact on their lives. These initial findings call for systematic research on the potential causes, correlates and consequences of menstrual-related problems in autistic individuals—across the spectrum and the lifespan.

Understanding and awareness of autism among Somali parents living in the United Kingdom

Using vignettes and interviews, this study examined understanding and awareness of autism, and (a)typical development more broadly, among 32 Somali parents living in the United Kingdom. Results demonstrated that parents of both autistic (n = 16) and non-autistic (n = 16) children were just as likely to identify vignettes of typically developing children, yet parents of autistic children appeared more astute to signs of atypical development. Across the whole sample, parents commonly identified and labelled vignettes of autistic children, but experienced more difficulty labelling vignettes that described children with other forms of atypical development, sometimes mislabeling these children as autistic. This suggests that there is a need for greater support in recognising and identifying different types of atypical development in the Somali community (to mitigate the risk that the term 'autism' may take on its own meaning within the Somali community, becoming a euphemism for a range of developmental conditions). Analysis of interview data identified key sociocultural factors that either helped or hindered the inclusion of families with autistic children within the community, including the Somali community's: (1) perceptions of disability, (2) beliefs about the causes of autism in the Western world and (3) strong reliance on religious beliefs in understanding and accepting an autism diagnosis.

'It's different for girls': Gender differences in the friendships and conflict of autistic and neurotypical adolescents

This mixed-methods study examined gender differences in the friendships and conflict experiences of autistic girls and boys relative to their neurotypical peers. In total, 102 adolescents (27 autistic girls, 26 autistic boys, 26 neurotypical girls, and 23 neurotypical boys), aged between 11 and 18 years completed the Friendship Qualities Scale, the Revised Peer Experiences Questionnaire and were interviewed about their friendships. Results demonstrated that in many ways, the friendships and social experiences of autistic girls are similar to those of neurotypical girls. Autistic girls, however, have significantly more social challenges than their neurotypical peers, experiencing more conflict and finding that conflict harder to manage successfully. Autistic boys showed quantitatively different friendship patterns to all other groups. There were consistent gender differences in the type of conflict which boys and girls experienced, regardless of diagnostic status. These findings suggest that gender, rather than diagnosis per se, plays a critical role in the way that autistic adolescents perceive and experience their social relationships.

The Estimated Prevalence of Autism in School-Aged Children Living in Rural Nepal Using a Population-Based Screening Tool

Few data exist on the prevalence of autism in low-income countries. We translated, adapted and tested the acceptability of a Nepali-language version of a screening tool for autism (Autism Quotient-10). Using this tool, we estimated autism prevalence in 4098 rural Nepali children aged 9-13 years. Fourteen children scored > 6 out of 10, indicative of elevated autistic symptomatology, of which 13 also screened positive for disability. If the AQ-10 screening tool is as sensitive and specific in the Nepali population as it is in the UK, this would yield an estimated true prevalence of 3 in 1000 (95% confidence interval 2-5 in 1000). Future research is required to validate this tool through in-depth assessments of high-scoring children.

Making the future together: Shaping autism research through meaningful participation

Participatory research methods connect researchers with relevant communities to achieve shared goals. These methods can deliver results that are relevant to people’s lives and thus likely to have a positive impact. In the context of a large and growing body of autism research, with continued poor implementation, and some evidence of community dissatisfaction, there is a powerful case for participatory autism research. In order to develop a framework for such collaborative working, a UK seminar series was organised and co-produced by autistic and non-autistic people with academic, practitioner and lived expertise. This article reports on the outcomes from the series, identifying five topics relevant to building a community of practice in participatory research: Respect, Authenticity, Assumptions, Infrastructure and Empathy. Each topic is connected to a specific example from within and beyond research, to inspire new practices in the field. We call for the development of participatory research skills among the autism research community and the facilitation of greater autistic leadership of, and partnership in, research. Such work, if delivered to a high standard, is likely to lead to better translation into practice and improved outcomes for autistic people and those who support them.

Psychophysics with children: Investigating the effects of attentional lapses on threshold estimates

When assessing the perceptual abilities of children, researchers tend to use psychophysical techniques designed for use with adults. However, children's poorer attentiveness might bias the threshold estimates obtained by these methods. Here, we obtained speed discrimination threshold estimates in 6- to 7-year-old children in UK Key Stage 1 (KS1), 7- to 9-year-old children in Key Stage 2 (KS2), and adults using three psychophysical procedures: QUEST, a 1-up 2-down Levitt staircase, and Method of Constant Stimuli (MCS). We estimated inattentiveness using responses to "easy" catch trials. As expected, children had higher threshold estimates and made more errors on catch trials than adults. Lower threshold estimates were obtained from psychometric functions fit to the data in the QUEST condition than the MCS and Levitt staircases, and the threshold estimates obtained when fitting a psychometric function to the QUEST data were also lower than when using the QUEST mode. This suggests that threshold estimates cannot be compared directly across methods. Differences between the procedures did not vary significantly with age group. Simulations indicated that inattentiveness biased threshold estimates particularly when threshold estimates were computed as the QUEST mode or the average of staircase reversals. In contrast, thresholds estimated by post-hoc psychometric function fitting were less biased by attentional lapses. Our results suggest that some psychophysical methods are more robust to attentiveness, which has important implications for assessing the perception of children and clinical groups.

Color Afterimages in Autistic Adults

It has been suggested that attenuated adaptation to visual stimuli in autism is the result of atypical perceptual priors (e.g., Pellicano and Burr in Trends Cogn Sci 16(10):504-510, 2012. doi: 10.1016/j.tics.2012.08.009 ). This study investigated adaptation to color in autistic adults, measuring both strength of afterimage and the influence of top-down knowledge. We found no difference in color afterimage strength between autistic and typical adults. Effects of top-down knowledge on afterimage intensity shown by Lupyan (Acta Psychol 161:117-130, 2015. doi: 10.1016/j.actpsy.2015.08.006 ) were not replicated for either group. This study finds intact color adaptation in autistic adults. This is in contrast to findings of attenuated adaptation to faces and numerosity in autistic children. Future research should investigate the possibility of developmental differences in adaptation and further examine top-down effects on adaptation.

Atypical information-use in children with autism spectrum disorder during judgments of child and adult face identity

Unusual patterns of fixation behavior in individuals with autism spectrum disorder during face tasks hint at atypical processing strategies that could contribute to diminished face expertise in this group. Here, we use the Bubbles reverse correlation technique to directly examine face-processing strategies during identity judgments in children with and without autism, and typical adults. Results support a qualitative atypicality in autistic face processing. We identify clear differences not only in the specific features relied upon for face judgments, but also more generally in the extent to which they demonstrate a flexible and adaptive profile of information use.

Reprint of "Investigating ensemble perception of emotions in autistic and typical children and adolescents"

Ensemble perception, the ability to assess automatically the summary of large amounts of information presented in visual scenes, is available early in typical development. This ability might be compromised in autistic children, who are thought to present limitations in maintaining summary statistics representations for the recent history of sensory input. Here we examined ensemble perception of facial emotional expressions in 35 autistic children, 30 age- and ability-matched typical children and 25 typical adults. Participants received three tasks: a) an ‘ensemble’ emotion discrimination task; b) a baseline (single-face) emotion discrimination task; and c) a facial expression identification task. Children performed worse than adults on all three tasks. Unexpectedly, autistic and typical children were, on average, indistinguishable in their precision and accuracy on all three tasks. Computational modelling suggested that, on average, autistic and typical children used ensemble-encoding strategies to a similar extent; but ensemble perception was related to non-verbal reasoning abilities in autistic but not in typical children. Eye-movement data also showed no group differences in the way children attended to the stimuli. Our combined findings suggest that the abilities of autistic and typical children for ensemble perception of emotions are comparable on average.

‘Something needs to change’: Mental health experiences of young autistic adults in England

There is a high incidence and prevalence of mental health problems among young people, with several barriers to help-seeking noted in this group. High rates of mental health problems have also been reported in children and adults on the autism spectrum. Taken together, young autistic people may be a particularly vulnerable group when it comes to mental health. Yet, there has been remarkably little work on the mental health needs and experiences of young autistic adults (16–25 years). Adopting a community-based participatory research (CBPR) approach – in which academic researchers and young autistic adults collaborated in an equitable research partnership – we explored young autistic people’s experiences of mental health problems and their perspectives on the support they sought, if any, for these problems. A total of 130 young autistic adults took part in the research: 109 completed an online survey and 21 took part in detailed interviews. The results highlight how young autistic people find it difficult to evaluate their mental health, experience high levels of stigma and often face severe obstacles when trying to access mental health support. The findings also demonstrate how listening to – and learning from – young autistic people is crucial in ensuring that their mental health needs are met.

Semantic content outweighs low-level saliency in determining children's and adults' fixation of movies

To make sense of the visual world, we need to move our eyes to focus regions of interest on the high-resolution fovea. Eye movements, therefore, give us a way to infer mechanisms of visual processing and attention allocation. Here, we examined age-related differences in visual processing by recording eye movements from 37 children (aged 6-14years) and 10 adults while viewing three 5-min dynamic video clips taken from child-friendly movies. The data were analyzed in two complementary ways: (a) gaze based and (b) content based. First, similarity of scanpaths within and across age groups was examined using three different measures of variance (dispersion, clusters, and distance from center). Second, content-based models of fixation were compared to determine which of these provided the best account of our dynamic data. We found that the variance in eye movements decreased as a function of age, suggesting common attentional orienting. Comparison of the different models revealed that a model that relies on faces generally performed better than the other models tested, even for the youngest age group (<10years). However, the best predictor of a given participant's eye movements was the average of all other participants' eye movements both within the same age group and in different age groups. These findings have implications for understanding how children attend to visual information and highlight similarities in viewing strategies across development.

The Psychometric Properties of a New Measure of Sensory Behaviors in Autistic Children

Unusual reactions to sensory input became part of the diagnostic criteria for autism spectrum disorder in the DSM-5. Measures accurately assessing these symptoms are important for clinical decisions. This study examined the reliability and validity of the Sensory Behavior Questionnaire, a parent-report scale designed to assess frequency and impact of sensory behaviors in autistic children. The scale demonstrated excellent internal consistency and concurrent validity, and was a better predictor of autistic symptoms than the Short Sensory Profile within a group of 66 school-age autistic children. The scale also successfully discriminated between autistic and typical children of similar age and ability. The Sensory Behavior Questionnaire has potential as a measure of sensory behaviors in children on the autism spectrum.

The light-from-above prior is intact in autistic children

Sensory information is inherently ambiguous. The brain disambiguates this information by anticipating or predicting the sensory environment based on prior knowledge. Pellicano and Burr (2012) proposed that this process may be atypical in autism and that internal assumptions, or "priors," may be underweighted or less used than in typical individuals. A robust internal assumption used by adults is the "light-from-above" prior, a bias to interpret ambiguous shading patterns as if formed by a light source located above (and slightly to the left) of the scene. We investigated whether autistic children (n=18) use this prior to the same degree as typical children of similar age and intellectual ability (n=18). Children were asked to judge the shape (concave or convex) of a shaded hexagon stimulus presented in 24 rotations. We estimated the relation between the proportion of convex judgments and stimulus orientation for each child and calculated the light source location most consistent with those judgments. Children behaved similarly to adults in this task, preferring to assume that the light source was from above left, when other interpretations were compatible with the shading evidence. Autistic and typical children used prior assumptions to the same extent to make sense of shading patterns. Future research should examine whether this prior is as adaptable (i.e., modifiable with training) in autistic children as it is in typical adults.

Ensemble perception of color in autistic adults

Dominant accounts of visual processing in autism posit that autistic individuals have an enhanced access to details of scenes [e.g., weak central coherence] which is reflected in a general bias toward local processing. Furthermore, the attenuated priors account of autism predicts that the updating and use of summary representations is reduced in autism. Ensemble perception describes the extraction of global summary statistics of a visual feature from a heterogeneous set (e.g., of faces, sizes, colors), often in the absence of local item representation. The present study investigated ensemble perception in autistic adults using a rapidly presented (500 msec) ensemble of four, eight, or sixteen elements representing four different colors. We predicted that autistic individuals would be less accurate when averaging the ensembles, but more accurate in recognizing individual ensemble colors. The results were consistent with the predictions. Averaging was impaired in autism, but only when ensembles contained four elements. Ensembles of eight or sixteen elements were averaged equally accurately across groups. The autistic group also showed a corresponding advantage in rejecting colors that were not originally seen in the ensemble. The results demonstrate the local processing bias in autism, but also suggest that the global perceptual averaging mechanism may be compromised under some conditions. The theoretical implications of the findings and future avenues for research on summary statistics in autism are discussed. Autism Res 2017, 10: 839-851. © 2016 International Society for Autism Research, Wiley Periodicals, Inc.

'The dots just don't join up': Understanding the support needs of families of children on the autism spectrum

Much research has documented the elevated levels of stress experienced by families of autistic children. Yet remarkably little research has examined the types of support that these families perceive to be beneficial to their lives. This study, co-produced by researchers and school-based professionals, sought to establish these families' support needs from their own perspectives. In total, 139 parents of autistic children with additional intellectual disabilities and limited spoken communication, all attending an inner-city London school, participated in an initial survey examining parental wellbeing, self-efficacy and the extent to which they felt supported. Semi-structured interviews were conducted with a subgroup of parents ( n = 17), some of whom reported in the survey that they felt unsupported, in order to gain their in-depth perspectives. The results from both the survey and the interviews suggested that existing support (particularly from formal support services) was not meeting parents' needs, which ultimately made them feel isolated and alienated. Parents who were interviewed called for service provision that adopted a relational, family-centred approach - one that understands the specific needs of the whole family, builds a close working relationship with them and ensures that they are supported at times when the parents and families feel they need it most.

Susceptibility to Ebbinghaus and Müller-Lyer illusions in autistic children: a comparison of three different methods

Background

Studies reporting altered susceptibility to visual illusions in autistic individuals compared to that typically developing individuals have been taken to reflect differences in perception (e.g. reduced global processing), but could instead reflect differences in higher-level decision-making strategies.

Methods

We measured susceptibility to two contextual illusions (Ebbinghaus, Müller-Lyer) in autistic children aged 6–14 years and typically developing children matched in age and non-verbal ability using three methods. In experiment 1, we used a new two-alternative-forced-choice method with a roving pedestal designed to minimise cognitive biases. Here, children judged which of two comparison stimuli was most similar in size to a reference stimulus. In experiments 2 and 3, we used methods previously used with autistic populations. In experiment 2, children judged whether stimuli were the ‘same’ or ‘different’, and in experiment 3, we used a method-of-adjustment task.

Results

Across all tasks, autistic children were equally susceptible to the Ebbinghaus illusion as typically developing children. Autistic children showed a heightened susceptibility to the Müller-Lyer illusion, but only in the method-of-adjustment task. This result may reflect differences in decisional criteria.

Conclusions

Our results are inconsistent with theories proposing reduced contextual integration in autism and suggest that previous reports of altered susceptibility to illusions may arise from differences in decision-making, rather than differences in perception per se. Our findings help to elucidate the underlying reasons for atypical responses to perceptual illusions in autism and call for the use of methods that reduce cognitive bias when measuring illusion susceptibility.

Electronic supplementary material

The online version of this article (doi:10.1186/s13229-017-0127-y) contains supplementary material, which is available to authorized users.

Binocular rivalry in children on the autism spectrum

When different images are presented to the eyes, the brain is faced with ambiguity, causing perceptual bistability: visual perception continuously alternates between the monocular images, a phenomenon called binocular rivalry. Many models of rivalry suggest that its temporal dynamics depend on mutual inhibition among neurons representing competing images. These models predict that rivalry should be different in autism, which has been proposed to present an atypical ratio of excitation and inhibition [the E/I imbalance hypothesis; Rubenstein & Merzenich, 2003]. In line with this prediction, some recent studies have provided evidence for atypical binocular rivalry dynamics in autistic adults. In this study, we examined if these findings generalize to autistic children. We developed a child‐friendly binocular rivalry paradigm, which included two types of stimuli, low‐ and high‐complexity, and compared rivalry dynamics in groups of autistic and age‐ and intellectual ability‐matched typical children. Unexpectedly, the two groups of children presented the same number of perceptual transitions and the same mean phase durations (times perceiving one of the two stimuli). Yet autistic children reported mixed percepts for a shorter proportion of time (a difference which was in the opposite direction to previous adult studies), while elevated autistic symptomatology was associated with shorter mixed perception periods. Rivalry in the two groups was affected similarly by stimulus type, and consistent with previous findings. Our results suggest that rivalry dynamics are differentially affected in adults and developing autistic children and could be accounted for by hierarchical models of binocular rivalry, including both inhibition and top‐down influences. Autism Res2017. ©2017 The Authors Autism Research published by Wiley Periodicals, Inc. on behalf of International Society for Autism Research Autism Res 2017, 10: 1096–1106. © 2017 International Society for Autism Research, Wiley Periodicals, Inc.

The Relationship Between Intolerance of Uncertainty, Sensory Sensitivities, and Anxiety in Autistic and Typically Developing Children

Guided by a recent theory that proposes fundamental differences in how autistic individuals deal with uncertainty, we investigated the extent to which the cognitive construct ‘intolerance of uncertainty’ and anxiety were related to parental reports of sensory sensitivities in 64 autistic and 85 typically developing children aged 6–14 years. Intolerance of uncertainty and anxiety explained approximately half the variance in autistic children’s sensory sensitivities, but only around a fifth of the variance in typical children’s sensory sensitivities. In children with autism only, intolerance of uncertainty remained a significant predictor of children’s sensory sensitivities once the effects of anxiety were adjusted for. Our results suggest intolerance of uncertainty is a relevant construct to sensory sensitivities in children with and without autism.

Gender Differences in the Social Motivation and Friendship Experiences of Autistic and Non-autistic Adolescents

This mixed-methods study examined gender differences in the social motivation and friendship experiences of adolescent boys and girls with autism relative to those without autism, all educated within special education settings. Autistic girls showed similar social motivation and friendship quality to non-autistic girls, while autistic boys reported having both qualitatively different friendships and less motivation for social contact relative to boys without autism and to girls with and without autism. Semi-structured interviews with the adolescents corroborated these findings, with one exception: autistic girls reported high levels of relational aggression within their friendships, suggesting that girls on the autism spectrum in particular may struggle with identifying and dealing with conflict in their social lives.

The design and implementation of a CBT-based intervention for sensory processing difficulties in adolescents on the autism spectrum

BACKGROUND

Unusual reactions to sensory input now form part of the diagnostic criteria for autism. These features are common and can have an often-devastating impact on autistic individuals and their families. Yet there are few validated interventions that help to remediate or support autistic individuals' adverse sensory experiences. To date, both measurement of sensory experiences and the resulting interventions have been based on assumptions of neurological sensitivities and largely ignored the role of cognition. This study therefore sought to assess the feasibility of a new 8-week CBT-based group intervention for self-regulation of sensory processing difficulties.

METHOD

Seven cognitively able adolescents diagnosed with autism aged 11-16 years from one mainstream secondary school received the 8-week intervention. Measures of sensory reactivity, anxiety and repetitive behaviours were taken at baseline, post-intervention and follow-up, 8 weeks after the intervention had ceased. Semi-structured interviews and focus groups were also conducted with adolescents and their parents to examine further the acceptability of the intervention.

RESULTS

The results showed that the intervention itself was feasible - both in its implementation and its acceptability to participants. Qualitative analysis clearly showed that the intervention was effective in raising meta-conscious awareness and self-regulation in these autistic adolescents. Analysis of outcome variables showed no significant change over the intervention period, although effect sizes were moderate-to-large.

CONCLUSIONS

These preliminary results are encouraging and should inform the design of a future pilot randomized controlled trial to test its efficacy with a larger group of participants.

Holistic Processing of Faces in Preschool Children and Adults

Contrary to the encoding-switch hypothesis, recent research demonstrates that 6-year-olds do not rely solely on parts-based encoding to recognize upright faces. This research shows better recognition of face parts presented in the whole face than in isolation, indicating use of holistic encoding. The present study examined whether children younger than 6 years also recognize faces holistically. Four-year-olds, 5-year-olds, and adults were administered a part-whole face recognition task. Children below the age of 6 remembered parts from upright faces better when tested in the whole-face context than in isolation. This whole-face advantage did not occur when faces were inverted. Although children showed a smaller inversion decrement than adults and generally performed more poorly than adults, the different age groups showed similar patterns of performance, indicating that young preschoolers, like older children and adults, are able to recognize faces holistically.