A momentary assessment study on emotional and biological stress in adult males and females with autism spectrum disorder

Diurnal cortisol profiles in autistic adolescents and young adults: Associations with social difficulties and internalizing mental health symptoms

Several autism-related characteristics, such as social difficulties, may contribute to high perceived stress and increased exposure to stressful life events in some autistic individuals. Repeated exposure to stress might lead to the dysfunction of the hypothalamic-pituitary-adrenocortical-axis and be a vulnerability factor for developing mental health difficulties. Previous studies show contradictory findings on salivary cortisol in autism. In the current study, we investigated diurnal cortisol profiles in autistic adolescents and young adults, as well as their associations with social difficulties, stress exposure, and mental health symptoms. Autistic (n = 48, Mage = 17.6) and nonautistic (n = 51, Mage = 18.4) participants collected salivary cortisol at home six times a day for 2 days. Social difficulties, exposure to stressful life events/bullying, and mental health symptoms were assessed with questionnaires and clinical interviews. Similar diurnal cortisol slopes (DCS) and cortisol awakening responses were observed between the groups, but autistic participants showed higher total cortisol output (AUCG, area under the curve with respect to ground) during the day (b = 19.09, p = 0.009). In the autistic group, more severe social difficulties were associated with flatter DCS (b = 0.01, p = 0.007). Finally, cortisol alterations were associated with self-reported mental health symptoms, especially in autistic females in analyses uncorrected for multiple comparisons. In conclusion, our results do not indicate autism-related group-level alterations in most diurnal cortisol measures, but autistic youth showed higher total cortisol (AUCG) compared with nonautistic peers. More detailed investigation of interindividual variability in cortisol profiles within autistic people might give us important insights into vulnerability to developing stress-related mental health difficulties.

Cognitive emotion regulation difficulties increase affective reactivity to daily-life stress in autistic adolescents and young adults

LAY ABSTRACT

Previous research has shown that autistic individuals report high levels of perceived stress and have an increased likelihood of developing mental health difficulties. Increase in individuals' negative emotions in relation to perceived stress (i.e. affective reactivity to stress) is a known risk factor for mental health difficulties. In this study, we investigated perceived daily stress and affective reactivity to stress in autistic (n = 39, age = 18.4) and non-autistic (n = 55, age = 18.1) adolescents and young adults. We used the ecological momentary assessment, a technique that allows to assess individuals repeatedly in their daily life using their smartphone. Moreover, participants filled a questionnaire to evaluate the strategies they use to regulate emotions when faced with difficulties. Finally, a clinical interview and a parent-report questionnaire were used to assess mental health symptoms. Autistic youth reported higher levels of perceived daily stress compared with non-autistic peers. Moreover, they showed increased affective reactivity to stress related to their daily activities. Autistic participants reported more emotion regulation difficulties (e.g. more repetitive thinking of difficulties) compared with non-autistic participants. Difficulties in emotion regulation increased negative emotions in relation to stress and might contribute to the severity of mental health symptoms. We conclude that adolescents and young adults with autism report high perceived stress in their daily lives. To minimize the negative impact of stress and the development of mental health symptoms, people supporting autistic young people could focus on stress management skills and the strategies that the youth use to manage emotions.

Clinical stance on response initiation in autistic adults: co-creating an integrative approach based on theory and lived experiences to act from language, via motor movement to wellbeing

Getting 'stuck', literally and figuratively, is a common experience for autistic people. Literally 'stuck' means exhibiting limited response initiation due to immobility with tense muscles and inability to move. Figuratively 'stuck' means loneliness, passivity or captivity in activities that do not offer long-term satisfaction. To further conceptualize this complex phenomenon of limited response initiation in autistic individuals, we performed qualitative interviews and focus groups with autistic people and their family members, followed by brainstorm sessions and a Delphi study with input from a larger panel of experts from multiple backgrounds. We aimed to co-create the outline of an integrative approach to support autistic people in moving away from this 'stuck state' to more flexible, limber 'supple states' in order to live freer, more meaningful, satisfying and peaceful lives. Over time, in interaction with all participants, our shared insight grew. Based on this, we here stipulate a conceptual framework, in which the described 'stuck state' at the micro-level of the muscles/behavior of one individual, probably is caused by feeling/being 'stuck' or 'cramped' at several overarching (i.e., meso and macro) levels. For instance, stuck in relationships with unhealthy dynamics, stuck at home creating short-term calm, trance-like states (e.g., gaming), stuck at an educational level that might fit the individuals' current social-emotional state rather than their potential cognitive level, stuck in a job that pays the bills but does not feel meaningful, nor contributes to a satisfying life with opportunities for personal development. Stuck in a mental/public health care system where ever ongoing changes in policies hinder sustained support to suit care-needs. Stuck in a regulated societal system making it likely to repeatedly get stuck. Is this phenomenon specific to autism? Formally we have only conducted interviews with this population, but in another smaller, related project we also spoke to people from the general population with careers that are considered successful in the general society. These people actually voiced similar experiences. Therefore, we hypothesize that this numbing state of being or feeling 'stuck' may be a prevalent phenomenon that needs to be addressed. In this article, we discuss several types of interventive approaches (i.e., language-based talking therapies, affective experiential expressive therapies, physical therapies and systemic therapies), prevention as well as intervention programs, directed at different primary stakeholders, that can complement and enrich each other in an integrative policy, that leads to tailor-made, personalized trajectories of interdisciplinary support to enable people to live satisfying, meaningful, dignified and peaceful lives.

Applications of identity-based theories to understand the impact of stigma and camouflaging on mental health outcomes for autistic people

Autistic people have long been conceptualized from a deficit-based model of disability, but recent self-advocates and scholars have asserted the importance of recognizing autism as both a disability and an important part of a person's social identity. The autistic identity is subject to specific stigma and stressors beyond everyday discrimination and prejudice, which can have many downstream implications on mental health and well-being. Prior research on camouflaging has explained both quantitatively and qualitatively how autistic people conform to norms and mask their autistic traits to better fit in with non-autistic societal standards. Given this paradigm shift in understanding autistic peoples' lived experiences, researchers must also begin to reshape the theories guiding their work in order to improve diagnosis, intervention, and supports. This review examines the extant research on identity-related stigma and camouflaging and their subsequent impacts on mental health outcomes in autism. A model is proposed integrating identity-based theories-specifically the social model of disability, social identity theory, and minority stress model-to explain relationships across research areas and better explain the experiences of autistic people. We discuss how identity-based theories can be applied in autism research to better understand the impacts of stigma and camouflaging on autistic peoples' lived experiences and reduce disparities in their mental health outcomes.

Increased affective reactivity to daily social stressors is associated with more severe psychotic symptoms in youths with 22q11.2 deletion syndrome

BACKGROUND

Increased reactivity to minor stressors is considered a risk factor for psychosis, especially in vulnerable individuals. In the present study, we investigated affective and psychotic stress reactivity as well as its link with psychotic symptoms and psychopathology in youths with 22q11.2 deletion syndrome (22q11DS), a neurogenetic condition associated with a high risk for psychosis.

METHODS

A 6-day ecological momentary assessment protocol was used to assess perceived daily-life stress as well as affective and psychotic reactivity to stress in participants with 22q11DS (n = 38, age = 18.4) and healthy controls (HC; n = 53, age = 19.1). Psychotic symptoms, general psychopathology, and coping strategies were also assessed through clinical interviews and questionnaires.

RESULTS

Participants with 22q11DS reported higher levels of perceived social stress (b = 0.21, p = 0.036) but lower levels of activity-related stress (b = -0.31, p = 0.003) in their daily lives compared to HC. The groups did not differ in affective or psychotic reactivity to stress, but individuals with 22q11DS who reported increased affective reactivity to social stressors showed more severe positive psychotic symptoms (rs = 0.505, p = 0.008). Finally, avoidance coping strategies moderated the association between stress and negative affects.

CONCLUSIONS

Our results suggest an increased vulnerability for daily social stress in youths with 22q11DS, and link elevated social stress reactivity to heightened psychotic symptom severity. Given the high risk for psychosis in 22q11DS, interventions should focus on reducing social stress and developing adaptive coping strategies.

Quality of Life, Neurosensory Disorders and Co-Occurring Medical Conditions in Individuals on the Spectrum, with a Special Focus on Females Diagnosed with Autism: A Systematic Review

Autism Spectrum Disorder (ASD) is a neurodevelopmental disorder that has a high prevalence and a significant economic impact. Our knowledge regarding neurosensory disorders and co-occurring medical conditions in the ASD population is limited, particularly for autistic women. Most of the studies include male participants or do not make comparisons with their female counterparts. The objective of this systematic review article is to explore the quality of life as well as the prevalence of neurosensory disorders and co-occurring medical conditions in individuals on the spectrum, with a special focus on autistic females. The literature search was carried out in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria. A protocol of this systematic review was designed a priori and was registered in the PROSPERO database (registration number: CRD42022330368). We concluded that numerous medical areas were of concern. Autistic females are more likely than their male counterparts with ASD to suffer from psychiatric conditions such as post-traumatic stress syndrome, depression, and eating disorders. They are also more likely to report GI-related disturbances and chronic pain. Further investigations are warranted to determine quality of life, as well as the prevalence and severity of neurosensory disorders in individuals with ASD, specifically studies comparing autistic females with their male counterparts. The information derived from these studies will help develop better support systems for individuals with autism, particularly females on the spectrum, in pursuit of improving their quality of life.

Triple X syndrome: Psychiatric disorders and impaired social functioning as a risk factor

BACKGROUND

Women with triple X syndrome (TXS) have an extra X chromosome. TXS appeared to be associated with psychiatric disorders in biased or underpowered studies.

AIM

This study aims to describe the prevalence of psychiatric disorders in adults with TXS in a relatively large and less biased group of participants.

METHOD

In this cross-sectional study, data were collected from 34 women with TXS (mean age = 32.9; s.d. = 13.1) and 31 controls (mean age = 34.9; s.d. = 13.7). Psychiatric disorders were assessed using the MINI International Neuropsychiatric Interview (MINI) and the adult behavior checklist (ABCL). Trait and state anxiety were assessed using the State-Trait Anxiety Inventory.

RESULTS

In the TXS group, MINI results showed a higher prevalence of major depressive episodes (43.3%), psychotic disorders (29.4%), and suicidality (23.5%). Only 50% of the TXS group earned a normal score for the total syndrome score using the ABCL. In addition, levels of trait anxiety were higher in the TXS group. Only three women in each group received psychotropic medication. Impaired social functioning appeared to represent a major risk factor in TXS as regards psychotic, affective disorders, trait anxiety, and low self-esteem.

CONCLUSIONS

Women with TXS are vulnerable to developing psychiatric disorders, and women with both TXS and impaired social functioning are even more vulnerable.

Childhood experiences of being parented, adult attachment, psychological inflexibility, social engagement, and mental health of autistic adults

BACKGROUND

Autistic adults have an increased risk of poor mental health. Although parental care and overprotection in childhood influence later attachment and mental health in the general adult population, this has not been investigated in the autistic population. Likewise, the roles of psychological inflexibility and social engagement in influencing mental health outcomes for autistic adults have yet to be examined.

AIMS

To examine if retrospectively recalled childhood experiences of parental care and overprotection, as well as current adult attachment, psychological inflexibility and social engagement are associated with mental health in autistic adulthood. Further, to examine mediators of the association between parental care and overprotection and mental health in autistic adults.

METHODS AND PROCEDURES

A community-recruited convenience sample of 126 Australian autistic adults completed an online survey assessing childhood experiences of parental care and overprotection and current adult attachment, psychological inflexibility, social engagement, and mental health.

OUTCOMES AND RESULTS

Linear regressions showed that psychological inflexibility was the strongest predictor of depression, anxiety, and stress, followed by attachment anxiety (depression, anxiety) and attachment avoidance (anxiety, stress). Mediation analyses revealed that psychological inflexibility and attachment anxiety mediated the associations between parental care and overprotection and mental health outcomes in autistic adulthood.

CONCLUSIONS AND IMPLICATIONS

Psychological inflexibility and adult attachment (anxious and avoidant attachment) are important to understanding mental health of autistic adults. Psychological inflexibility and attachment anxiety mediate associations between recalled childhood experiences of parental care and overprotection and mental health in autistic adulthood.

Physiological reactions to acute stressors and subjective stress during daily life: A systematic review on ecological momentary assessment (EMA) studies

Objective

This review aims to provide an overview of ecological momentary assessment (EMA) studies analyzing stress reactivity during daily life in terms of direct and moderated influence of acute stress on physiological responses.

Materials and methods

A systematic literature search was performed on November 29, 2021 using Web of Science, MEDLINE and PsycINFO to identify prospective EMA studies targeting acute stressors or stress under naturalistic conditions, without restrictions of publication date or population. Study quality was assessed for multiple EMA-specific sources of bias.

Results

Out of 4285 non-duplicate records, 107 publications involving 104 unique studies were included. The majority of studies assessed acute physiological stress responses primarily through salivary cortisol (n = 59) and cardiovascular outcomes (n = 32). Most studies performed at least three measurements per day (n = 59), and had a moderate risk of recall bias (n = 68) and confounding (n = 85). Fifty-four studies reported a compliance of ≥80%. Direct, non-moderated positive associations were observed between acute stress exposure and concurrent cortisol levels (44%, n = 11/25), systolic (44%, 8/18) and diastolic blood pressure (53%, 8/15) and heart rate (53%, 9/17). Several inter- and intra-individual moderators were identified, such as age, gender, health status, chronic stress, work-related resources, physical activity and stress coping indicators.

Conclusions

About half of the reviewed EMA studies demonstrated direct associations between everyday acute stress exposure and physiological responses, including increased cortisol levels, blood pressure and heart rate. Results further suggested various moderator variables that could help develop tailored prevention strategies and identify groups at higher risk for dysfunctional stress responses.

Registration

PROSPERO—Reg.-No.: PROSPERO 2020 CRD42020163178.

Chemiluminescence analysis of saliva for the assessment of emotional stress in autistic children undergoing a medical examination

Purpose

An electroencephalography (EEG) examination may cause psychological stress in children with autism that can interfere with the examination results. The objective information on the presence or absence of psycho-emotional stress in patients can help interpret electroencephalograms. This paper aimed to demonstrate the potential of noninvasive objective diagnostics of emotional stress in autistic children undergoing an EEG examination based on analysis of saliva.

Design/methodology/approach

This study involved 19 children with autism spectrum disorder (ASD) (ICD-10 F84.0); the mean age was seven years. During EEG examination of the children, behavioral parameters were assessed. The activity of cytochrome P450 reductase (CYPOR) in saliva was measured before and after the EEG procedure using lucigenin-enhanced nicotinamide adenine dinucleotide phosphate-stimulated chemiluminescence assay.

Findings

Significant differences in CYPOR activity were found between the children who were distressed during an EEG examination and the children without behavioral disturbances (Mann–Whitney test, p = 0.002). Thus, the EEG examination resulted in an increase in CYPOR activity in saliva cells, which may prove the stressful effect of this procedure on autistic children.

Originality/value

The chemiluminescent indices reflecting the activity of microsomal CYPOR in cells presenting in saliva correlate with the absence or presence of psychological stress in children; this phenomenon can be explained by an increased metabolism of the stress hormone, cortisol, by the cytochrome P450 microsomal system. Furthermore, the proposed method is completely safe, noninvasive, rapid (recording time is 20 min), inexpensive and promising for an objective assessment of psycho-emotional stress in autistic children undergoing medical examinations.