The Need for a Broader Approach to Emotion Regulation Research in Autism

Examining the feasibility and utility of heart rate variability on intervention outcomes targeting emotion regulation in autism: a brief report

Autistic youth experience several behavioral and emotional characteristics that can predispose them to emotion dysregulation (ED). Current literature examining ED in autism spectrum disorder (ASD) is limited to parent- and self-reported measures, indicating a need for biological or physiological methods to better assess emotion regulation in ASD. Utilizing the autonomic nervous system, specifically heart rate variability (HRV), may be a promising method to objectively measure ED in ASD, given it is one of the body's primary means of regulating physiological arousal. Our pilot study is one of the first to examine the feasibility, utility, and construct validity of HRV along with clinical measures within an intervention targeting ED-specific symptoms in ASD. Participants included 30 autistic youth ages 8-17 years who participated in the pilot study of Regulating Together, a group-based intervention targeting emotion regulation. We demonstrate HRV is feasible, demonstrates adequate test-retest reliability, and is complimentary to clinician- and parent-reported measures. Our preliminary findings also point to certain HRV profiles being indicative of long-term outcomes after receiving treatment. HRV may be a useful, objective tool in determining differential needs of long-term follow-up care for treatment maintenance at screening or baseline stages.

Leveling Up Dialectical Behavior Therapy for Autistic Individuals with Emotion Dysregulation: Clinical and Personal Insights

Autistic people may experience high emotion and sensory sensitivities and a slow return to baseline emotional state. Dialectical behavior therapy (DBT) was developed to address reactivity, impulsivity, and mood dysregulation in individuals with mood and personality disorders. DBT may be therapeutically beneficial to autistic individuals struggling with these or similar emotional and sensory challenges. This article is a synthesis of the first author's experiences of DBT as an autistic person and professional insights from all authors. We provide an overview of the development of DBT, its foundational components, and adaptations. Using this basis, the first author describes the benefits DBT has had, the modifications that have helped him, and how those modifications may enhance DBT for autistic people. Modifications include visuals, graphics, and a gaming format that target the client's personal interests. The essence of these alterations is to transform life skills and DBT skills into something meaningful and functional. Receptivity of the therapist to the modifications and neurodivergent problem solving may be foundational to therapeutic success. Client-initiated contributions in collaborative therapy may improve autistic participants' understanding, validation, and adherence with DBT. The authors suggest expanding work on DBT modifications for autism in the areas of daily self-monitoring, assessing for preferred visual and gaming formats, and utilizing personal interests.

PEERS® for Preschoolers preliminary outcomes and predictors of treatment response

PEERS® for Preschoolers (P4P) is a social skills group program for young autistic children and their caregivers, which provides everyday tools for interacting and communicating with others. Twenty-two caregiver-child dyads participated and completed pre-treatment, post-treatment, and follow-up measures (4-16 weeks after). Using single-subject analyses to examine social skills, 60% demonstrated post-treatment improvement, and 53.85% demonstrated follow-up improvement. Regarding a secondary outcome of behavioral difficulties, 33.33% demonstrated post-treatment reduction, and 7.69% demonstrated follow-up reduction. Using regressions, autistic traits predicted outcomes; fewer social communication difficulties predicted both greater social skills and fewer behavioral difficulties at post-treatment, while fewer repetitive behaviors predicted fewer post-treatment and follow-up behavioral difficulties. These results preliminarily demonstrate the benefits of P4P and how autistic traits may impact P4P outcomes.

Linehan's biosocial model applied to emotion dysregulation in autism: a narrative review of the literature and an illustrative case conceptualization

Emotion dysregulation (ED) is a transdiagnostic difficulty prevalent in autism spectrum condition (ASC). Importantly, recent research has suggested that ED is involved in self-harm and suicidality. Pre-existing models on the etiology of ED in ASC focus mainly on biological factors to ASC features, such as sensory sensitivities, poor flexibility, and sensitivity to change. However, although psychosocial factors seem to play a role in the emergence of ED in ASC as well (e.g., childhood maltreatment and camouflaging), there is a lack of a comprehensive model conceptualizing biosocial factors involved in ED in autistic people. Linehan's biosocial model (1993) is one of the leading etiological models of ED in borderline personality disorder (BPD). It conceptualizes ED as emerging from transactions between a pre-existing emotional vulnerability in the child and an invalidating developmental environment. Beyond its clinical relevance, Linehan's model has gathered empirical evidence supporting its pertinence in BPD and in other psychiatric disorders. Although ASC and BPD are two distinct diagnoses, because they may share ED, Linehan's biosocial model might be useful for understanding the development of ED in ASC. Hence, this article aims to provide an application and extension of Linehan's model to conceptualize ED in ASC. To do so, we conducted a narrative review of the literature on ED and its underlying factors in ASC from a developmental perspective. To investigate the pertinence of the biosocial model applied to ED in autistic people, we were interested on data on (i) ED and its behavioral correlates in ASC, in relation to the biosocial model, (ii) the potential biological and psychosocial correlates of ED in ASC and (iii) the overlapping difficulties in ASC and BPD. Finally, to assess the pertinence of the model, we applied it to the case of an autistic woman presenting with ED and suicidal behaviors. Our review and application to the case of an autistic woman suggest that ED in ASC encompasses factors related to both biological and psychosocial risk factors as conceptualized in the BPD framework, although in both domains ASC-specific factors might be involved.

Emotional dysregulation as a part of the autism spectrum continuum: a literature review from late childhood to adulthood

The concept of emotional dysregulation (ED) has recently gained interest in the scientific literature and is commonly defined as the inability to use the modulatory mechanisms involved in emotion regulation, resulting in a functioning meaningfully below the baseline. Even though the data available are still limited, an increasing number of studies have hypothesized a promoting role for some of the core features of autism spectrum disorder (ASD) in the development of ED, in particular being repetitive behaviors, social difficulties and alexythimia. In this framework, the purpose of this study was to review the literature that is currently available about presence and correlates of ED in young adults with autism spectrum conditions as well as to offer some insights about possible implications for illness trajectories. The data reported seems to point to a shared etiology between ED and repetitive/restricted ASD symptoms, with perseveration features serving as the foundation for the inability to control one's emotions. In this context, a neurodevelopmental basis for ED could be consistent with the transnosographic conceptualization of ASD, which hypothesizes a potential neurodevelopmental basis for several psychiatric disorders, whose autistic traits would be the phenotypical presentation.

Effect of Co-occurring Psychiatric Disorders on Treatment of Children with Autism Spectrum Disorder and Anxiety

Co-occurring psychiatric diagnoses are very common in individuals with ASD. Little is known about the effect that co-occurring psychiatric conditions may have on treatment response to CBT for children with ASD and anxiety. The present study examined the relationship between co-occurring psychiatric diagnoses and response to CBT for anxiety in ninety youth with ASD. Psychiatric complexity did not appear to differentially impact treatment response. A notable portion of youth with anxiety and externalizing disorders such as ADHD, no longer met criteria for those externalizing diagnoses following intervention. Results indicate that youth with ASD and anxiety present with complex psychiatric profiles and CBT for anxiety may positively affect co-occurring diagnoses. In addition, thorough and nuanced assessment of psychiatric symptoms in youth with ASD is needed to ensure the differentiation between diagnoses of anxiety and other co-occurring psychiatric symptoms.

Linking ADHD and ASD Symptomatology with Social Impairment: The Role of Emotion Dysregulation

Children with attention-deficit/hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) often experience social impairments. These children also frequently struggle with emotion regulation, and extant literature suggests that emotion dysregulation predicts social impairment in both clinical and neurotypical populations. However, the evidence base linking ADHD/ASD with social impairment comes primarily from samples meeting full diagnostic criteria for ADHD and/or ASD despite evidence that both syndromes reflect extreme ends of natural continuums that are normally distributed across the general population. To our knowledge, the present study is the first to concurrently examine unique and overlapping relations among ADHD/ASD symptoms, emotion regulation, and social difficulties using multi-informant measures (parent, teacher) with a clinically-evaluated sample of 108 children ages 8-13 (40 girls; 66% White/Non-Hispanic) with and without clinically-elevated ASD and ADHD symptoms and other common clinical disorders. Bias-corrected, bootstrapped conditional effects modeling revealed that ADHD-inattentive (β=-0.23) and ASD-social communication (β=-0.20) symptoms predicted social impairment directly, whereas ADHD-hyperactive/impulsive (β=-0.06) and ASD-restricted/repetitive behavior/interests (β=-0.06) symptoms predicted social impairment only via their shared associations with emotion dysregulation. Sensitivity analyses revealed that most relations were robust to control for item overlap across measures. In contrast, only the ADHD-inattention/social impairment link was robust to control for mono-informant bias, highlighting the importance of multi-informant methods and the potential for different determinants of social functioning across settings. Overall, this study implicates emotion regulation skills and all four ADHD/ASD symptom clusters as potential influences on children's social functioning, albeit with a more nuanced and potentially setting-specific pattern than suggested by prior work.

Effects of nonsocial and circumscribed interest images on neural mechanisms of emotion regulation in autistic adults

Introduction

Emotion dysregulation is commonly reported among autistic individuals. Prior work investigating the neurofunctional mechanisms of emotion regulation (ER) in autistic adults has illustrated alterations in dorsolateral prefrontal cortex (dlPFC) activity, as well as concurrent atypical patterns of activation in subcortical regions related to affect during cognitive reappraisal of social images. Whereas most research examining ER in autism has focused on regulation of negative emotions, the effects of regulating positive emotions has been generally understudied. This is surprising given the relevance of positive motivational states to understanding circumscribed interests (CI) in autism.

Methods

Accordingly, the purpose of this study was to use fMRI with simultaneous eye-tracking and pupillometry to investigate the neural mechanisms of ER during passive viewing and cognitive reappraisal of a standardized set of nonsocial images and personalized (self-selected) CI images.

Results

The autistic group demonstrated comparatively reduced modulation of posterior cingulate cortex (PCC) activation during cognitive reappraisal of CI images compared to viewing of CI, although no eye-tracking/pupillometry differences emerged between-groups. Further, the autistic group demonstrated increased PCC connectivity with left lateral occipital and right supramarginal areas when engaging in cognitive reappraisal vs. viewing CI.

Discussion

In autistic adults, CI may be differentially modulated via PCC. Considering the documented role of the PCC as a core hub of the default mode network, we further postulate that ER of CI could potentially be related to self-referential cognition.

Parasympathetic withdrawal indexes risk for emotion dysregulation in children with autism spectrum disorder

Children with autism spectrum disorder (ASD) experience significant difficulties with emotion regulation. Theory and empirical evidence suggest substantial biological contributions to regulatory challenges, which may be related to core ASD symptoms. Respiratory sinus arrythmia (RSA) is a measure of parasympathetic nervous system activity that serves as a putative biomarker for emotion regulation. Higher baseline RSA and more RSA reactivity (parasympathetic withdrawal; RSA-R) in response to challenge appear adaptive in non-clinical populations, but existing evidence for children with ASD remains inconclusive. The current study examined correlates of observed emotion dysregulation in 61 children with ASD between the ages of 6 and 10 years, including ASD symptom levels as well as both baseline RSA and concurrent RSA reactivity. Consistent with previous research, ASD symptom level was significantly correlated with observed dysregulation whereas additional factors such as child IQ were not. Baseline RSA was unrelated to observed dysregulation, but higher RSA reactivity predicted concurrent dysregulation above and beyond the contribution of child ASD symptoms. Findings contribute to an emerging understanding of dysregulation in these children, raise questions about the utility of traditional baseline RSA measures for this population, and clarify the functional significance of RSA reactivity as a risk factor for emotion dysregulation in children with ASD.

Prenatal metal mixture concentrations and reward motivation in children

Reward motivation is a complex umbrella term encompassing the cognitions, emotions, and behaviors involved in the activation, execution, and persistence of goal-directed behavior. Altered reward motivation in children is characteristic of many neurodevelopmental and psychiatric disorders. Previously difficult to operationalize, the Progressive Ratio (PR) task has been widely used to assess reward motivation in animal and human studies, including children. Because the neural circuitry supporting reward motivation starts developing during pregnancy, and is sensitive to disruption by environmental toxicants, including metals, the goal of this study was to examine the association between prenatal concentrations of a mixture of neurotoxic metals and reward motivation in children. We measured reward motivation by administering a PR test to 373 children ages 6-8 years enrolled in the Programming Research in Obesity, Growth, Environment and Social Stressors (PROGRESS) Study in Mexico City. Children were asked to press a response lever for a token reward; one press on the response lever was required to earn the first token and each subsequent token required an additional 10 lever presses. Maternal blood concentrations of lead, manganese, zinc, arsenic, cadmium, and selenium were measured using inductively-coupled plasma mass spectrometry during the 2nd and 3rd trimesters of pregnancy. We performed generalized Weighted Quantile Sum (gWQS) regression analyses to examine associations between the prenatal metal mixture and reward motivation; adjusting for child sex, birthweight and age; and maternal IQ, education, and socioeconomic status. The prenatal metal mixture was significantly associated with higher motivation as indicated by more lever presses (ß = 0.02, p < 0.001) and a shorter time between receiving the reinforcer and the first press (ß = 0.23, p = 0.01), and between subsequent presses (ß = 0.07, p = 0.005). Contributions of different metals to this association differed by trimester and child sex. These findings suggest that children with increased exposure to metal during the 2nd and 3rd trimesters of gestation demonstrate increased reward motivation, which may reflect a tendency to perseverate or hypersensitivity to positive reinforcement.

What underlies emotion regulation abilities? An innovative programme based on an integrative developmental approach to improve emotional competencies: Promising results in children with Prader-Willi syndrome

BACKGROUND

This study aimed to test the effect of a new training programme on emotional competencies, named EMO-T, and to show the value of an integrative developmental approach. This approach postulates that the emotion regulation disturbances commonly observed in neurodevelopmental disorders are the consequence of potential disruptions in the prerequisite emotion skills. This integrative approach is particularly suitable in the case of complex and multidimensional disorders such as Prader-Willi syndrome (PWS), a rare genetic disease.

METHODS

We examined the emotion expression, recognition, comprehension, and regulation skills in 25 PWS children aged 5-10 and 50 typically developing children (TD) aged 3-10. After a pre-test session, half of the PWS children participated in the EMO-T programme with their regular therapist for 6 weeks, while the other half continued their usual rehabilitation programme. Two post-test sessions were conducted, one at the end of the programme and one 3 months later.

RESULTS

At pre-test, PWS children displayed a deficit in the four emotional competencies (EC). PWS children who participated in the EMO-T programme showed a significant and sustainable post-test improvement regarding voluntary expression and emotion recognition abilities, such that the level reached was no longer different from the baseline level of TD children. They also tended to improve in their emotion regulation, although they received no specific training in this skill.

DISCUSSION

These results support that emotion regulation abilities require prerequisite emotion skills, which should be more fully considered in current training programmes. Because emotion regulation disorders strongly impact all areas of life, an integrative developmental approach appears crucial especially in the case of neurodevelopmental disorders. Further studies should be conducted to explore this perspective.

Co-occurring mental health symptoms and cognitive processes in trauma-exposed ASD adults

BACKGROUND

Mental health problems are common amongst adults with an Autism Spectrum Disorder (ASD). Stressful and traumatic life events can trigger or exacerbate symptoms of anxiety, depression and PTSD. In the general population, transdiagnostic processes such as suppression and perseverative thinking are associated with responses to trauma and mental health symptoms.

AIMS

This study explored the relationships between thought suppression, perseverative thinking and symptoms of depression, anxiety and PTSD in ASD adults who reported exposure to a range of DSM-5 and non-DSM-5 traumatic events.

METHODS

59 ASD adults completed a series of online self-report questionnaires measuring trauma, transdiagnostic cognitive processes, and mental health symptoms.

RESULTS

Probable PTSD rarely occurred in isolation and was associated with depression and anxiety symptoms in trauma-exposed ASD adults. All cognitive processes and mental health symptoms were positively associated with one another, regardless of whether the trauma met DSM-5 PTSD Criterion A. When accounting for both cognitive processes, only thought suppression significantly predicted PTSD and anxiety symptoms, while only perseverative thinking significantly predicted depression symptoms.

CONCLUSIONS AND IMPLICATIONS

These preliminary results suggest that different cognitive processes more strongly affect anxiety/PTSD versus depression symptom severity in trauma-exposed ASD adults, although co-occurring symptoms are common. Implications for assessment, treatment and future research are discussed.

Is a Negative Attentional Bias in Individuals with Autism Spectrum Disorder Explained by Comorbid Depression? An Eye-Tracking Study

Heightened attention towards negative information is characteristic of depression. Evidence is emerging for a negative attentional bias in Autism spectrum disorder (ASD), perhaps driven by the high comorbidity between ASD and depression. We investigated whether ASD is characterised by a negative attentional bias and whether this can be explained by comorbid (sub) clinical depression. Participants (n = 116) with current (CD) or remitted depression (RD) and/or ASD, and 64 controls viewed positively and negatively valenced (non-)social pictures. Groups were compared on three components of visual attention using linear mixed models. Both CD individuals with and without ASD, but not remitted depressed and never-depressed ASD individuals showed a negative bias, suggesting that negative attentional bias might be a depressive state-specific marker for depression in ASD.

The Role of Diagnostic Instruments in Dual and Differential Diagnosis in Autism Spectrum Disorder Across the Lifespan

The heterogeneity inherent in autism spectrum disorder (ASD) makes the identification and diagnosis of ASD complex. We survey a large number of diagnostic tools, including screeners and tools designed for in-depth assessment. We also discuss the challenges presented by overlapping symptomatology between ASD and other disorders and the need to determine whether a diagnosis of ASD or another diagnosis best explains the individual's symptoms. We conclude with a call to action for the next steps necessary for meeting the diagnostic challenges presented here to improve the diagnostic process and to help understand each individual's particular ASD profile.

A wearable heart rate measurement device for children with autism spectrum disorder

Autism spectrum disorder (ASD) is a neurodevelopmental condition characterized by early impairment in social and communication domains and autonomic nervous system unbalance. This study evaluated heart rate (HR) as a possible indicator of stress response in children with ASD as compared to children with language disorder (LD). Twenty-four patients [mean age = 42.62 months; SD = 8.14 months,12 with ASD (10 M/2F) and 12 with LD (8 M/4F)] underwent clinical [Leiter International Performance Scale-Revised, Autism Diagnostic Observation Schedule, second edition (ADOS-2)] and physiological evaluation (HR monitoring) during five interactive activities, while wearing an HR measurement device. IQ (ASD:IQ = 103.33 ± 12.85 vs. LD:IQ = 111.00 ± 8.88, p = 0.103) and fluid reasoning on the Leiter-R Scale were within the normal range in all subjects. Increased HR during the third activity (ADOS-2 bubble play) significantly correlated with autistic symptoms (r = 0.415; p = 0.044), while correlations between ADOS-2 total score and HR during the first activity (ADOS-2 free play; r = 0.368; p = 0.077), second activity (Leiter-R figure ground subscale; r = 0.373, p = 0.073), and fifth activity (ADOS-2 anticipation of a routine with objects; r = 0.368; p = 0.076) did not quite reach statistical significance. Applying a linear regression model, we found that the ADOS-2 total score significantly influenced HR variations (p = 0.023). HR monitoring may provide a better understanding of the stress-provoking situations for children with ASD. Furthermore, it could help clinicians detect the impact of the stressful condition on the autistic core and adress treatment strategy.

Social Decision Making in Autistic Adolescents: The Role of Theory of Mind, Executive Functioning and Emotion Regulation

Social decision making is often challenging for autistic individuals. Twenty autistic adolescents made decisions in the socially interactive context of a one-shot ultimatum game, and performance was compared to a large matched typical reference sample. Theory of mind, executive functioning and emotion regulation were measured via direct assessments, self- and parent report. Relative to the reference sample, autistic adolescents proposed fewer fair offers, and this was associated with poorer theory of mind. Autistic adolescents responded similarly to the reference sample when making decisions about offers proposed to them, however they did not appear to down regulate their negative emotion in response to unfair treatment in the same way. Atypical processes may underpin even apparently typical decisions made by autistic adolescents.

The Role of Diagnostic Instruments in Dual and Differential Diagnosis in Autism Spectrum Disorder Across the Lifespan

The heterogeneity inherent in autism spectrum disorder (ASD) makes the identification and diagnosis of ASD complex. We survey a large number of diagnostic tools, including screeners and tools designed for in-depth assessment. We also discuss the challenges presented by overlapping symptomatology between ASD and other disorders and the need to determine whether a diagnosis of ASD or another diagnosis best explains the individual's symptoms. We conclude with a call to action for the next steps necessary for meeting the diagnostic challenges presented here to improve the diagnostic process and to help understand each individual's particular ASD profile.

Neural features of sustained emotional information processing in autism spectrum disorder

LAY ABSTRACT

Many individuals with autism spectrum disorder struggle with emotions that are intense and interfering, which is referred to as emotion dysregulation. Prior research has established that individuals with autism may be more likely than individuals who are not autistic to have repetitive thoughts. It is possible that persistent thoughts about negative or distressing stimuli may contribute to emotion dysregulation in autism spectrum disorder. This study aimed to identify areas of the brain with evidence of persistent processing of negative information via functional magnetic resonance neuroimaging. We used a task that alternated between emotional processing of personally relevant negative words, neutral words, and a non-emotional task. Criteria were developed to define heightened and persistent emotional processing, and analyses were conducted to identify all brain regions satisfying these criteria. Participants included 25 adolescents with autism spectrum disorder and 23 typically developing adolescents who were similar to the autism spectrum disorder group in IQ, age, and gender ratios. Brain regions identified as having greater and continued processing following negative stimuli in the autism spectrum disorder group as compared with the typically developing group included the salience network and the prefrontal dorsolateral cortex. These areas have been previously implicated in emotion dysregulation outside of autism spectrum disorder. Collectively, brain activity in the identified regions was associated with parent-reported emotion dysregulation in the autism spectrum disorder group. These results help to identify a potential process in the brain associated with emotion dysregulation in autism spectrum disorder. This information may be useful for the development of treatments to decrease emotion dysregulation in autism spectrum disorder.

Respiratory sinus arrhythmia, parenting, and externalizing behavior in children with autism spectrum disorder

Children with autism spectrum disorder exhibit significant difficulties with emotion regulation. Respiratory sinus arrhythmia is a biomarker for processes related to emotion regulation, with higher baseline rates linked to beneficial outcomes. Although reduction in respiratory sinus arrhythmia in response to challenge can index adaptive processes in community samples, excessive withdrawal may suggest loss of regulatory control among children with clinical concerns. Psychophysiological risk for problems may be protected against or exacerbated by parenting environments more or less supportive of the development of children's regulatory competence. Respiratory sinus arrhythmia was examined in 61 children with autism spectrum disorder ages 6-10 years in relation to externalizing behavior, and parenting was considered as a moderator. Respiratory sinus arrhythmia was obtained during laboratory tasks, and positive parenting, negative parenting, and children's externalizing behaviors were each indexed through multiple methods. Respiratory sinus arrhythmia reactivity interacted with negative, but not positive parenting. Higher respiratory sinus arrhythmia reactivity was associated with more externalizing behavior under conditions of higher negative parenting, but with lower externalizing behavior at lower levels of negative parenting. Similarly, negative parenting was only associated with externalizing behaviors in the context of high child respiratory sinus arrhythmia reactivity. Implications for our understanding of emotion regulation in children with autism spectrum disorder, and for related interventions, are discussed.

Sympathetic-Parasympathetic Interaction and Externalizing Problems in Children with Autism Spectrum Disorder

Children with autism spectrum disorder (ASD) exhibit significant difficulties with emotion regulation and reactivity, which may be linked to underlying psychophysiology. The present study examined associations between autonomic nervous system activity and individual differences in externalizing behavior problems in children with ASD. A multisystem approach was adopted to consider the interplay between markers of sympathetic (electrodermal reactivity-EDA-R) and parasympathetic reactivity (respiratory sinus arrhythmia reactivity-RSA-R) in relation to behavioral challenges. Fifty-two children with ASD ages 6-10 years contributed complete psychophysiological data. Measures of EDA-R and RSA-R (RSA withdrawal) were obtained in response to a laboratory challenge task and parents reported on child externalizing behavior problems using a standardized questionnaire and a structured clinical interview. An equifinality model was supported, with two distinct psychophysiological pathways linked to heightened externalizing behavior problems. Greater RSA-R was associated with more externalizing problems in the context of higher levels of EDA-R, and lower EDA-R was associated with increased externalizing problems at lower levels of RSA-R. Findings underscore the importance of considering the role of psychophysiology in the unfolding of comorbid externalizing problems in children with ASD. Potential implications for tailoring coregulatory supports are discussed. Autism Res 2019, 12: 1805-1816. © 2019 International Society for Autism Research, Wiley Periodicals, Inc. LAY SUMMARY: Children with autism spectrum disorder (ASD) exhibit elevated rates of challenging behavior. This study identified specific psychophysiological profiles (low sympathetic-low parasympathetic reactivity, and high sympathetic-high parasympathetic reactivity) that may place these children at greater risk for behavior problems. Findings have implications for better understanding behavioral challenges in children with ASD, and for tailoring supports to address underlying psychophysiology.

Anger Rumination is Associated with Restricted and Repetitive Behaviors in Children with Autism Spectrum Disorder

Children with autism spectrum disorder (ASD) are reported to have greater levels of anger rumination than typically developing children. This study examined anger rumination in children with ASD in comparison to children with disruptive behavior disorder without ASD. We also tested if anger rumination is associated with aggression and the core ASD symptoms of restricted and repetitive behaviors (RRBs). This study included three groups of children aged 8-16 years: 63 had ASD (ASD group), 79 had disruptive behavior disorder (DB group), and 40 healthy controls (HC). ASD and DB groups showed greater anger rumination relative to the HC group. Anger rumination was associated with RRBs in children with ASD, suggesting the link to core ASD symptoms.

Emotion regulation and intervention in adults with autism spectrum disorder: a synthesis of the literature

Purpose

Emotion regulation is an ongoing multiprocess phenomenon and is a challenging developmental task to acquire in individuals with autism spectrum disorder (ASD) who have different neurobiological profiles and emotion regulation problems. The purpose of this paper is to review recent literature to understand the neurobiological and psychological perspective of emotion regulation in ASD, while converging themes of psychosocial interventions and existing best practices on emotion regulation within this heterogeneous population are reviewed and discussed in consideration of intellectual disability (ID).

Design/methodology/approach

Review of recent literature and common empirically supported interventions addressing emotional regulation implemented in individuals with and without ASD, and with and without ID were included in the electronic database search through PubMed, EBSChost, Science Direct, Wiley Online Library, GALE and SAGE. Search terms used included autism, ID, cognitive control, executive function, sensory processing/intervention, emotion regulation, cognitive behavior therapy, mindfulness, social stories, positive behavior support and behavior therapy.

Findings

Neural systems governing emotion regulation can be divided into “top-down” and “bottom-up” processing. Prefrontal cortex, cognitive and attentional control are critical for effective emotion regulation. Individuals with ASD, and with ID show impairments in these areas have problems with emotion regulation. Targeted psychosocial intervention need to consider bottom-up and top-down processes of emotion regulation, and that standardized interventions require adaptations.

Originality/value

There are limited studies looking into understanding the neurobiological and psychological perspective of emotion regulation in ASD and linking them to interventions. This review highlights psychosocial interventions that are important for further research, investigation and development as treatment in this population is limited.

Emotion Control Predicts Internalizing and Externalizing Behavior Problems in Boys With and Without an Autism Spectrum Disorder

Children and adolescents with Autism Spectrum Disorder (ASD) often show comorbid emotional and behavior problems. The aim of this longitudinal study is to examine the relation between emotion control (i.e., negative emotionality, emotion awareness, and worry/rumination) and the development of internalizing and externalizing problems. Boys with and without ASD (N = 157; age 9–15) were followed over a period of 1.5 years (3 waves). We found that baseline levels of worry/rumination was a specific predictor of later externalizing problems for boys with ASD. Furthermore, the developmental trajectory of worry/rumination predicted the development of internalizing and externalizing problems in both groups. Our findings suggest that worry/rumination may constitute a transdiagnostic factor underlying both internalizing and externalizing problems in boys with and without ASD.

A Transdiagnostic Examination of Self-Regulation: Comparisons Across Preschoolers with ASD, ADHD, and Typically Developing Children

The purpose of the current study was to identify profiles of self-regulation across executive functioning (EF) and emotion regulation (ER) and examine profiles's impact on treatment outcomes. Participants included 100 preschoolers (M_age = 4.73, 75% Male, 79% Hispanic) including 37 with autism spectrum disorder and attention-deficit/hyperactivity disorder (ASD+ADHD), 32 with ADHD-only, and 31 typically developing children. Parents and teachers reported on children's EF, ER, ASD, and ADHD symptoms. Children were administered an EF battery and observed for ER during a frustration task. Children participated in an intensive behavioral summer treatment program (STP-PreK) aimed at improving school readiness across behavioral, academic, and self-regulation domains. Latent profile analyses produced 4 profiles: (a) Low ER and EF Deficits, (b) High ER Deficits, (c) High EF Deficits, and (d) Moderate ER and EF Deficits. ASD and ADHD symptoms predicted lower membership probability within the Low ER and EF Deficits Profile and higher membership probability within the Moderate ER and EF Deficits Profile. However, only ASD symptoms predicted membership within the High EF Deficits Profile. Only ADHD symptoms predicted membership within the High ER Deficits Profile. Even after accounting for diagnostic symptoms, profile membership was predictive of treatment response across behavioral and academic domains. Children in the High EF Deficits Profile experienced the largest gains. Results highlight the specificity of self-regulation deficits within and across diagnoses. Self-regulation profiles demonstrated clinical utility in predicting treatment response above traditional symptom based classifications, providing evidence for the use of transdiagnostic approaches.

Emotion Regulation Intensive Outpatient Programming: Development, Feasibility, and Acceptability

Individuals with Autism Spectrum Disorder (ASD) and/or intellectual and developmental disabilities (DD) often struggle with behavior management and emotion-regulation (ER). In this manuscript, we describe the results of a chart review examining a group treatment program designed to address ER deficits in youth with ASD and/or DD. The intensive 5 week program utilizes cognitive behavior, applied behavior analysis, and mindfulness techniques and includes biweekly child and parent groups. Results indicate that this program is feasible and associated with high caregiver satisfaction. Pre-and-post outcome results indicate statistically significant improvement on behavioral measures, but did not demonstrate significant improvment on the Pediatric Quality of Life Family Impact Module. Based on overall positive outcomes, a randomized controlled trial of the program is indicated.

Increased psychiatric symptoms in university students with autism spectrum disorder are associated with reduced adaptive behavior

High variability in adaptive behavior in cognitively-able adults with autism spectrum disorder has been previously reported, and may be caused by the high prevalence of psychiatric comorbidity in this population. This study's goals were to examine self-reported psychiatric symptoms in students with ASD, and to identify their relative contribution to the variance in adaptive behaviors. The study population included 95 students: 55 diagnosed with ASD (4 females; age range 18-34) who participated in a university integration program (ASD group), and 40 regularly matriculated students (non-ASD group, 7 females; age range 20-36). The ASD group showed a lower adaptive skill level than the non-ASD group as measured by the Adaptive Behavior Assessment System (GAC-ABAS). Significantly higher scores for the ASD group were found for social anxiety, trait anxiety, obsessive-compulsive symptoms, and depression symptoms. The level of adaptive skills correlated negatively and significantly with the severity of social anxiety symptoms in both groups and with severity of obsessive-compulsive symptoms only in the ASD group. Additionally, in a regression model, significant contributions of having an ASD diagnosis and severity of social anxiety explained 41.7% of the variance in adaptive skills. Adequate evaluation and treatment, if needed, are recommended in this population.

Delay of gratification in preschoolers with and without autism spectrum disorder: Individual differences and links to executive function, emotion regulation, and joint attention

This study examined delay of gratification behaviors in preschool-aged children with and without autism spectrum disorder. Recent research has found that elementary-aged children with autism spectrum disorder showed challenges with delay of gratification and that there were individual differences in terms of children's behaviors during the wait. We extend this work to a younger sample of children with autism spectrum disorder to understand whether these difficulties emerge by the preschool years. Moreover, we assessed whether individual differences in other key self-regulatory capacities (i.e. effortful control, emotion regulation, executive function, and joint attention) were related to delay of gratification wait durations or behavioral strategies. Findings revealed that preschoolers with autism spectrum disorder waited for a shorter duration, demonstrated more temptation-focused behaviors, and expressed less positive affect than their typical peers during the delay of gratification task. At the full-sample level, individual differences in children's temptation-focused behaviors (i.e. visual attention and verbalizations focused on the temptation) were related to children's executive function, joint attention, and parents' ratings of emotion regulation. When we examined associations within groups, the associations were not significant for the autism spectrum disorder group, but for typically developing children, there was a positive association between temptation-focused behaviors and emotion regulation.

Neuromodulation and a Reconceptualization of Autism Spectrum Disorders: Using the Locus Coeruleus Functioning as an Exemplar

The Autism Spectrum Disorders (ASD) are a heterogeneous group of developmental disorders. Although, ASD can be reliably diagnosed, the etiology, pathophysiology, and treatment targets remain poorly characterized. While there are many atypical findings in anatomy, genetics, connectivity, and other biologic parameters, there remains no discreet hypothesis to explain the core signs as well as the very frequent comorbidities. Due to this, designing targets for treatments can only be done by assuming each symptom is a result of a discreet abnormality which is likely not the case. Neuronal circuity remains a major focus of research but rarely taking into account the functioning of the brain is highly dependent on various systems, including the neuromodulatory substances originating in the midbrain. A hypothesis is presented which explores the possibility of explaining many of the symptoms found in ASD in terms of inefficient neuromodulation using the functioning of the locus coeruleus and norepinephrine (LC/NE) as exemplars. The basic science of LC/NE is reviewed. Several functions found to be impaired in ASD including learning, attention, sensory processing, emotional regulation, autonomic functioning, adaptive and repetitive behaviors, sleep, language acquisition, initiation, and prompt dependency are examined in terms of the functioning of the LC/NE system. Suggestions about possible treatment directions are explored.

Social difficulties in youth with autism with and without anxiety and ADHD symptoms

Social difficulties inherent to autism spectrum disorder are often linked with co-occurring symptoms of anxiety and attention deficit hyperactivity disorder (ADHD). The present study sought to examine the relation between such co-occurring symptoms and social challenges. Parents of adolescents with autism (N = 113) reported upon social challenges via the social responsiveness scale (SRS) and anxiety and ADHD symptomatology via the Child Behavior Checklist. Results revealed differences in SRS scores across co-occurring symptom subgroups (Anxiety, ADHD, Both, Neither)-namely, adolescents with autism and anxiety as well as those with autism, anxiety, and ADHD showed greater scores on the SRS than the other groups. Implications for research and clinical practice are discussed and recommendations are offered. Autism Research 2018, 11: 1679-1689. © 2018 International Society for Autism Research, Wiley Periodicals, Inc. LAY SUMMARY: Anxiety and attention deficit hyperactivity disorder (ADHD) symptoms are related to greater social challenges for adolescents with autism spectrum disorder. The present study found that autism with anxiety and autism with anxiety and ADHD, was related to greater social difficulties than autism alone. Findings provide further support for the intertwined nature of anxiety and ADHD symptoms in autism. What this may mean for research and clinical practice is considered and recommendations are suggested.

Resistance to temptation in toddlers at genetic risk for autism spectrum disorder

Children with autism spectrum disorder often demonstrate difficulties with self-regulation, although studies of this construct in young children with autism spectrum disorder are limited. In this study, developmental changes were examined using a measure of self-regulation appropriate for young children, resistance to temptation. At 22, 28, and 34 months, toddlers with an older sibling with autism spectrum disorder (high risk) and toddlers with typically developing older siblings (low risk) were presented with an appealing toy and instructed not to touch it. Observers coded whether or not children touched the toy and the strategies they used to resist touching it. At 36 months, children were assessed for autism spectrum disorder, yielding three groups: high risk children with autism spectrum disorder, high risk children without autism spectrum disorder, and low risk children. At 22 months, most children, regardless of group, touched the forbidden toy; at 28 and 34 months, many high risk children without autism spectrum disorder and low risk children resisted the temptation to touch the toy, whereas most of the children with autism spectrum disorder did not. Differences in delay strategies were also evident. Some, but not all group differences, were accounted for by differences in language ability. Results highlight one early index of impulse control that differentiates children with emerging autism spectrum disorder from age-mates prior to the third birthday.

Pupil response to social-emotional material is associated with rumination and depressive symptoms in adults with autism spectrum disorder

BACKGROUND

Autism spectrum disorder (ASD) is marked by repetitive thinking and high rates of depression. Understanding the extent to which repetitive negative thinking in ASD reflects autistic stereotypy versus general depressive thinking patterns (e.g., rumination) could help guide treatment research to improve emotional health in ASD. We compared associations between rumination, depressive symptoms, and pupil response to social-emotional material in adults with ASD and typically developing (TD) adults with and without depression.

METHODS

N = 53 verbally fluent young adults were recruited to three cohorts: ASD, n = 21; TD-depressed, n = 13; never-depressed TD-controls, n = 19. Participants completed Ruminative Response Scale and Beck Depression Inventory self-reports and a passive-viewing task employing emotionally-expressive faces, during which pupillary motility was assessed to quantify cognitive-affective load. Main and interactive effects of cohort, emotion condition, and time on pupil amplitude were tested via a linear mixed effects analysis of variance using restricted maximum likelihood estimation. Similar procedures were used to test for effects of rumination and depressive symptoms on pupil amplitude over time within ASD.

RESULTS

Responsive pupil dilation in the ASD cohort tended to be significantly lower than TD-depressed initially but increased to comparable levels by trial end. When viewing sad faces, individuals with ASD who had higher depression scores resembled TD-depressed participants' faster, larger, and sustained pupil response. Within ASD, depressive symptoms uniquely predicted early pupil response to sad faces, while rumination and depression scores each independently predicted sustained pupil response.

CONCLUSIONS

People with elevated depressive symptoms appear to have faster and greater increases in pupil-indexed neural activation following sad stimuli, regardless of ASD status, suggesting the utility of conceptualizing rumination as depression-like in treatment. Ruminative processes may increase more slowly in ASD, suggesting the potential utility of interventions that decrease reactions before they are uncontrollable. Findings also reinforce the importance of testing for effects of internalizing variables in broader ASD research.

Intrinsic and Extrinsic Predictors of Emotion Regulation in Children with Autism Spectrum Disorder

Difficulties regulating emotion have been linked to comorbid psychopathology in children with autism spectrum disorder (ASD), but little empirical work has examined predictors of dysregulation in this population. Forty-six families of children with ASD participated in a laboratory visit that included direct measurement of children's IQ, ASD symptoms, and psychophysiological reactivity. Child emotion regulation was observed during independent and co-regulatory tasks, and parental scaffolding was rated in the dyadic context. ASD symptom severity emerged as the strongest predictor of child emotion dysregulation across contexts. Child age and parental scaffolding also uniquely predicted child dysregulation in the dyadic task. Implications for conceptualizing intrinsic and extrinsic influences on emergent emotion regulation in children with ASD are discussed, as are applications to intervention.

Physiological Arousal and Emotion Regulation Strategies in Young Children with Autism Spectrum Disorders

This study aimed to assess physiological arousal and behavioral regulation of emotion in the context of frustration in 29 children with Autism Spectrum Disorders (ASD) and 45 typically developing children (41–81 months). Heart rate was continuously measured and emotion strategies were coded, during a locked-box task. Results revealed increases in arousal followed by a decline during recovery, significant for both groups indicating that heart rate patterns between groups were identical. The ASD group deployed less constructive and more venting and avoidance strategies, which was related to language impairments. We conclude that rather than abnormal levels of emotional arousal, a key impairment in young children with ASD may be difficulties in behaviorally regulating and expressing experienced emotions to others.

Sympathetic Under-Arousal and Externalizing Behavior Problems in Children with Autism Spectrum Disorder

Children with autism spectrum disorder (ASD) commonly exhibit co-occurring externalizing behavior problems, which can impede learning opportunities and contribute significantly to caregiver stress. Substantial theory and research has linked under-arousal of the sympathetic nervous system to increased externalizing problems in children without ASD, but under-arousal has not been considered as an explanatory mechanism for individual differences among children with ASD. We tested the notion that lower electrodermal activity (EDA) would predict more externalizing problems in children with ASD, and considered the degree to which parent co-regulatory support could buffer this risk. Forty children with ASD between the ages of 4 and 11 years and their primary caregivers participated in a laboratory visit that included various play, compliance, and problem-solving regulatory tasks. EDA was measured through wireless wrist sensors, parental scaffolding was observed during a dyadic problem-solving task, and parents rated their children's externalizing behavior problems. As predicted, low EDA during the compliance-oriented tasks directly predicted higher child externalizing problems. Parental scaffolding moderated the link between under-arousal during the problem-solving regulatory tasks and externalizing problems such that the relation was observed in the context of low, but not high, support. Implications for relevant theories (e.g., fearlessness theory, stimulation-seeking theory) are discussed, and the potential for psychophysiological patterns to inform intervention with these children is considered.

A preliminary evaluation of metacognitive beliefs in high functioning children with autism spectrum disorder

Purpose

Metacognitive beliefs and processes have been found to perpetuate anxiety and depression in youth and adults. However, the presence of metacognitive beliefs in children with autism spectrum disorder is somewhat unclear and has received limited research attention to date. The purpose of this paper is to explore metacognitive beliefs in children with autism and associations with anxiety and depression.

Design/methodology/approach

In total, 23 high functioning participants (17 male and 6 female) between the ages of 8 and 12 (M=10.38) diagnosed on the autism spectrum completed the study. Participants completed the Revised Children’s Scale of Anxiety and Depression and the Metacognitions Questionnaire for Children.

Findings

Correlation analyses revealed that positive and negative metacognitive beliefs were found, as hypothesised, to be prevalent in this sample.

Originality/value

Despite methodological limitations, this is one of the first research evaluations to provide evidence for metacognitive beliefs in high functioning children with autism and comorbid anxiety or low mood.

Concordance between physiological arousal and emotion expression during fear in young children with autism spectrum disorders

This study aimed to measure emotional expression and physiological arousal in response to fear in 21 children with autism spectrum disorders (43-75 months) and 45 typically developing children (41-81 months). Expressions of facial and bodily fear and heart rate arousal were simultaneously measured in response to a remote controlled robot (Laboratory Temperament Assessment Battery). Heart rate analyses revealed a main effect of task from baseline to fear ( p < 0.001, ηp2 ), no interaction effect and no effect for group. In addition, children with autism spectrum disorder showed intact facial and bodily expressions of fearful affect compared to typically developing children. With regard to the relationship between expression and arousal, the results provided evidence for concordance between expression and arousal in typically developing children ( r = 0.45, n = 45, p < 0.01). For children with autism spectrum disorder, no significant correlation was found ( r = 0.20, n = 21, p = 0.38). A moderation analysis revealed no significant interaction between expression and arousal for children with and without autism spectrum disorder ( F(1, 62) = 1.23, p = 0.27, ηp2 ), which might be the result of limited power. The current results give reason to further study concordance between expression and arousal in early autism spectrum disorder. Discordance might significantly impact social functioning and is an important topic in light of both early identification and treatment.

Effects of Equine Therapy on Individuals with Autism Spectrum Disorder: A Systematic Review

Literature on effects of equine therapy in individuals with autism spectrum disorder (ASD) has grown in recent times. Equine therapy is an alternative multimodal intervention that involves utilizing a horse to enhance core impairments in ASD. Recent systematic reviews in this area have several limitations including inclusion of populations other than ASD, assessment of a variety of animal-assisted interventions other than equine therapy, and a failure to conduct quantitative analyses to provide accurate effect size estimates. We conducted a focused systematic review to address these limitations. Our review suggested that equine therapy has beneficial effects on behavioral skills and to some extent on social communication in ASD. The evidence for positive effects of equine therapy on perceptuo-motor, cognitive, and functional skills is currently limited.

Putative Brain Networks Underlying Repetitive Negative Thinking and Comorbid Internalizing Problems in Autism

Many high-functioning individuals with autism spectrum disorder (ASD) also experience depression and anxiety, yet little is known about mechanisms underlying this comorbidity. Repetitive negative thinking (RNT) about self-referential information is a transdiagnostic cognitive vulnerability factor that may account for the relationship between these two classes of symptoms. We propose a model where self-referential processing and cognitive inflexibility interact to increase risk for RNT, leading to internalizing problems in ASD. Examination of interactions within and between two well-characterized large-scale brain networks, the default mode network and the salience network, may provide insights into neurobiological mechanisms underlying RNT in ASD. We summarize previous literature supporting this model, emphasizing moving towards understanding RNT as a factor accounting for the high rates of internalizing problems in ASD. Future research avenues include understanding heterogeneity in clinical presentation, and promise for identifying and treating cognitive flexibility and RNT to reduce comorbid internalizing problems in ASD.

Self-regulated compliance in preschoolers with autism spectrum disorder: The role of temperament and parental disciplinary style

Regulatory difficulties are common in children with autism spectrum disorder. This study focused on an important aspect of self-regulation—the ability to willingly comply with frustrating demands of socialization agents, termed “self-regulated compliance.” We studied compliance to parental demands in 40 preschoolers with autism spectrum disorder and 40 matched typically developing preschoolers, during separate interactions with mother and father, while engaging in two paradigms: toy pick-up and delayed gratification, which tap the “do” and “don’t” aspects of self-regulated socialization at this age. Parents’ disciplinary style was micro-coded from the two paradigms and child temperament was parent reported. Compared to their typically developing peers, children with autism spectrum disorder showed more noncompliance and less self-regulated compliance to parental demands and prohibitions and greater temperamental difficulties across several domains. No group differences were found in parental disciplinary style. Child self-regulated compliance was associated with parental supportive disciplinary style and with child attention focusing. Findings highlight the importance of parental supportive presence in structuring the development of socialization in children with autism spectrum disorder. Implications for parent–child emotion regulation interventions are discussed.

Association between anger rumination and autism symptom severity, depression symptoms, aggression, and general dysregulation in adolescents with autism spectrum disorder

Rumination has a large direct effect on psychopathology but has received relatively little attention in autism spectrum disorder despite the propensity to perseverate in this population. This study provided initial evidence that adolescents with autism spectrum disorder self-report more anger-focused rumination than typically developing controls, though there was substantial within-group variability. Anger rumination was positively correlated with autism symptom severity with both groups combined. Future studies that include measures of perseveration on special interests are needed to understand whether anger rumination is a manifestation of a perseverative type of repetitive behavior or a distinct trait. Even when controlling for autism symptom severity, however, anger-focused rumination was associated with poorer functioning, including more depression symptoms and overall emotional and behavioral dysregulation. Therefore, further inquiry regarding anger rumination in autism spectrum disorder is clinically important, and the potential impact of rumination-focused interventions should be explored.

Emotion Dysregulation and Anxiety in Adults with ASD: Does Social Motivation Play a Role?

Young adults with ASD and no intellectual impairment are more likely to exhibit clinical levels of anxiety than typically developing peers (DSM-5, American Psychiatric Association, 2013). This study tests a mechanistic model in which anxiety culminates via emotion dysregulation and social motivation. Adults with ASD (49 males, 20 females) completed self-report measures on emotion regulation, caregivers completed measures on ASD severity and both on social anxiety. Results indicated that emotion dysregulation (p < .001; p < .05) and social motivation (p < .05, p < .001) significantly predicted social anxiety as reported by caregivers and young adults respectively. However, social motivation did not appear to play a moderating role in the relationship between emotion regulation and anxiety, even when controlling for social awareness. Significant predictor variables of social anxiety varied based on reporter (i.e. caregiver versus young adult), with difficulty engaging in goal-directed behaviors during negative emotions serving as the only shared predictor.

Different brain responses during empathy in autism spectrum disorders versus conduct disorder and callous-unemotional traits

BACKGROUND

Deficits in empathy are reported in autism spectrum disorders (ASD) and also underlie antisocial behavior of individuals with conduct disorder and callous-unemotional traits (CD/CU+). Many studies suggest that individuals with ASD are typically impaired in cognitive aspects of empathy, and individuals with CD/CU+ typically in affective aspects. In the current study, we compared the neural correlates of cognitive and affective aspects of empathy between youth with ASD and youth with CD/CU+.

METHODS

Functional magnetic resonance imaging (fMRI) was used to assess boys with ASD (N = 23), boys with CD/CU+ (N = 23), and typically developing (TD) boys (N = 33), aged 15-19 years. Angry and fearful faces were presented and participants were asked to either infer the emotional state from the face (other-task; emotion recognition) or to judge their own emotional response to the face (self-task; emotional resonance).

RESULTS

During emotion recognition, boys with ASD showed reduced responses compared to the other groups in the ventromedial prefrontal cortex (vmPFC). During emotional resonance, the CD/CU+ and ASD groups showed reduced amygdala responses compared to the TD controls, boys with ASD showed reduced responses in bilateral hippocampus, and the CD/CU+ boys showed reduced responses in the inferior frontal gyrus (IFG) and anterior insula (AI).

CONCLUSION

Results suggest differential abnormal brain responses associated with specific aspects of empathic functioning in ASD and CD/CU+. Decreased amygdala responses in ASD and CD/CU+ might point to impaired emotion processing in both disorders, whereas reduced vmPFC responses suggest problems in processing cognitive aspects of empathy in ASD. Reduced IFG/AI responses, finally, suggest decreased emotional resonance in CD/CU+.