"I wouldn't know where to start": Perspectives from clinicians, agency leaders, and autistic adults on improving community mental health services for autistic adults

A Multi-Perspective Qualitative Study About Working With Autistic Individuals in Prison-Based Interventions to Address Sexual Offending

Research suggests that sexual offending is one of the more common forms of offending behaviour committed by autistic individuals. Despite this, very little research has investigated approaches to rehabilitation for autistic individuals who have sexually offended. The small body of literature that does exist suggests that interventions to address sexual offending may not be sufficiently adapted for this group. In this paper we present an exploratory qualitative study that (i) explores how prison-based interventions to address sexual offending are experienced by autistic individuals with sexual offense convictions and the staff who work with them, and (ii) identifies and explores the features of prison-based sexual offending interventions that may be challenging or beneficial for autistic individuals, from the perspective of those involved in treatment. Semi-structured interviews were conducted with 12 autistic men serving prison sentences for sexual convictions, and 13 members of prison staff. A multi-perspective phenomenologically-informed thematic (MPT) analysis identified three themes of 'Feeling overwhelmed', 'Out of the comfort zone', and '(Dis)connected to others'. These themes highlight some of the key issues relating to the format and delivery of interventions, as well as the impact of the broader prison context on rehabilitation.

Mental Health Care Needs and Access to Care for Adults With Intellectual Disabilities

BACKGROUND

Adults with intellectual disabilities (IDs) are at greater risk for psychiatric disorders than the general population. Yet, they have limited access to mental health services.

OBJECTIVES

To examine the prevalence of psychiatric disorders in adults with ID. To describe evidence-based interventions for this population, their access to mental health care, and outline opportunities for improved access.

DESIGN

This manuscript summarizes literature regarding psychiatric disorders in adults with ID and their access to behavioral health care. We considered articles referencing mental health care for adults with ID. PubMed and a variety of search terms were used. Studies published in English from 2010 to the date of the searches were included. Quantitative and qualitative study designs, review articles, program descriptions, and opinion papers were considered for inclusion. Additional references from the selected articles were also considered.

RESULTS

We identified 2864 records. One hundred two records were included, consisting of work commenting on mental health and ID and access to care in the United States. The articles describe increased psychiatric comorbidities in adults with ID. They highlight the few evidence-based interventions for psychiatric comorbidities and the limited access to care.

CONCLUSIONS

Our mental health care providers generally have minimal training and experience with people with ID, limiting access to appropriate care for these individuals. Improved access could be created by increasing education and experiences with these populations for mental health providers. Aligning policies, financing, and adequate insurance reimbursement to develop a continuum of care will be critical for these individuals.

Where are all the Services: Mapping Community-Based Services for Canadian Autistic Youth with Co-occurring Mental Health Conditions

PURPOSE

Autistic youth are at heightened risk of mental health issues and face several barriers to accessing appropriate supports. A lack of available services is a common barrier that many autistic youth experience, with only 43% of autistic youth from the US who needed mental health services receiving them. Little is known about the availability of these mental health services in Canada, despite the high prevalence of mental health issues in autistic youth. The current study is one of very few that has reviewed the state of community-based programs and services for the support of mental health challenges in autistic people in North America, and the first such study in Canada.

METHODS

Using an environmental scan methodology, we conducted a search of resource listings on various community websites with a filter for "autism". The resulting websites were then reviewed to find what services providers offer for autistic youth (≥ 25 years) and contacted to complete a survey.

RESULTS

267 listings of mental health supports were identified in the initial search, with 94 sites that specifically mentioned serving autistic youth. 43% (n = 40) of service providers completed a survey about the services they offered, therapeutic approaches, and background training. Providers reported that neurodiversity approaches and multi-disciplinary teams were working well in their practices, yet funding access and society's views on autism were barriers they face.

CONCLUSION

Findings add to the growing body of evidence that availability of services is a systemic barrier that many autistic youth experience when accessing mental health supports.

Developing Therapeutically Attuned Relationships with Autistic Children and Their Caregivers

The purpose of this paper is to propose the Intentional and Attuned Therapeutic Relationship Model as a means to emphasize an intentional and attuned therapeutic relationship among the therapist, autistic child, and their caregiver. Neurodiversity-affirming practice is strengths-based, collaborative, and inclusive of the needs and goals of the autistic child and their caregiver. As this necessitates reevaluating occupational therapy models of care delivered to autistic children, this paper provides a brief review of sensory processing and emotional regulation; discusses the Intentional Relationship Model and the phenomenon of attunement, respectively; and proposes the Intentional and Attuned Therapeutic Relationship Model, which combines elements of the Intentional Relationship Model and attunement to develop the therapeutic relationship in alignment with the neurodiversity-affirming paradigm.

Anxiety Disorders in Autistic People: A Narrative Review

Anxiety is the most common co-occurring mental health condition across the lifespan for autistic people. The authors summarize the extant research on prevalence, correlates and predictors, measurement, and treatment of anxiety disorders in autistic people, which has rapidly expanded in the past decade. In addition to addressing gaps within each of these areas, the authors propose that there is a need for future work to center autistic perspectives, employ longitudinal designs, and expand the focus to include autistic adults and those with co-occurring intellectual disability.

An 'explosion in the mouth': The oral health experiences of autistic children

LAY ABSTRACT

In England, one in four children have tooth decay by the age of 5 years. Tooth decay affects many autistic children. Communication differences, sensory sensitivities and preferred routines can make dental care difficult. Daily toothbrushing, healthy eating and drinking, and attending the dentist may be challenging for autistic children. We do not know much about how autistic children feel about looking after their teeth. Learning from them directly is important to understand their needs and make sure their voices are heard. We interviewed 10 autistic children aged between 7 and 13 years to discover how they care for their teeth, what helped and what did not. We talked about toothbrushing, healthy eating and drinking and visiting the dentist. To support our conversations, we used Talking Mats® - a tool that can help with communication. Autistic children described a wide range of sensory issues related to looking after their teeth. This finding shows how important it is to tailor care to each child's needs. Children wanted to be included in conversations about their teeth at home and at the dentist. This was felt to make a big difference in building trust and making them feel comfortable and supported. Overall, we found Talking Mats® can be used in dental research to engage with autistic children. By understanding children's views, we can better help professionals and parents to support their dental needs. Our research showed that every child's experience is unique, so dental support must be tailored and inclusive to meet children's needs.

Mental Health Providers' Perspectives on What Helps and Hinders in Psychotherapy for Autistic Adults with Co-occurring Mental Health Problems

Autistic adults experience disproportionate rates of co-occurring mental health problems. Psychotherapy has been recognized as an appropriate treatment approach, but evidence is limited. Researchers used a qualitative research paradigm to explore the experiences of mental health providers who provide psychotherapy to autistic adults. The Enhanced Critical Incident Technique was used to interview 13 mental health providers regarding perceptions of facilitating therapy with autistic adults. This research highlights challenges to providing psychotherapy to autistic adults while also illuminating ways that mental health providers have worked to ameliorate such challenges and create positive experiences in therapy. This research also contrasts therapy for autistic adults relative to the general population. Practice recommendations and suggestions for future research are offered.

"He Just Wants Someone to Hear Him and Listen to Him": Barriers and Facilitators to Autistic Youth with Anxiety Receiving Quality Mental Healthcare

About half of autistic youth present with clinically interfering anxiety. Psychotherapies with exposure-focused elements are effective in academic clinical settings and controlled trials. However, there is relatively less research examining the implementation of modified interventions for autistic youth with anxiety in community mental health settings. The current study explores community members' perceptions of barriers and facilitators that impact autistic youth with anxiety's receipt of quality mental health services in their community. Semi-structured interviews were conducted with 15 autistic youth, 15 caregivers of autistic youth, 11 community mental health clinicians, and 8 community mental health clinic leaders. Interviews were analyzed thematically. Participants shared their experiences with facilitators and barriers to autistic youth with anxiety receiving quality mental healthcare. Themes that emerged include (1) characteristics of the autistic youth, (2) engagement of autistic youth and caregivers, (3) building rapport between providers, autistic youth, and caregivers, (4) access to mental health services, (5) intervention fit, and (6) provider characteristics. Based on participants' perspectives and suggestions, future directions for anxiety treatment programs tailored for autistic youth include building more time into the intervention sessions to build rapport, incorporating autistic youth's preferences into provider matches, and providing families with more psychoeducation.

Bipolar Disorder in a female with CDKL5 Deficiency Disorder: A Case Report

Background

CDKL5 deficiency disorder (CDD) is an early-onset developmental and epileptic encephalopathy. While a subset of individuals is believed to experience comorbid behavioral disorders, none have reported well-defined affective disorders. Though there is a documented association between epilepsy and mood disorders, they may go undetected in the CDD population due to difficulty assessing mood in the presence of severe/profound intellectual disability and disease-related sleep dysregulation. We aimed to identify the clinical characteristics of an individual with CDD who presented with a mood disorder falling outside this expected behavioral phenotype.

Case Presentation

We identified one 22-year-old female with CDD diagnosed with unspecified bipolar disorder at 18 years of age. Family history was noncontributory. At diagnosis, she had fluctuations in mood, characterized by periods of elated affect, increased energy and vocalizations, hypertonia, and insomnia lasting 3-4 days alternating with periods of depressed affect, irritability, hypotonia, and excessive sleep lasting for up to one month. She had experienced frequent mood swings and sleep dysregulation from early childhood, and by early adulthood the duration of "up" and "down" periods fell in the range specified in the DSM-5 bipolar disorder criteria. Trazodone and suvorexant did not alleviate sleep related symptoms. Her epilepsy was well controlled on lamotrigine monotherapy since early childhood. Though lamotrigine treatment has had no psychiatric benefit despite its known mood stabilizing properties, aripiprazole has been effective in reducing severity and frequency of fluctuations between hypomania and depression.

Conclusions

While sleep and behavioral disorders fall within the expected phenotype for CDD, this is the first report of bipolar disorder. Careful attention to patterns of sleep and behavior that may indicate mood cycling in this population is required, particularly in the setting of limited communication and functional abilities.

Community Member Views on Autism Intervention: Effects of Closeness to Autistic People with Intellectual Disabilities And Nonspeaking Autistic People

Background

Controversy regarding the neurodiversity movement (NDM), the social and medical models of disability, autism intervention goals, and causal attributions of disability contributes to divides in the autistic and autism communities. The present study investigates the views of autistic and non-autistic autistic and autism community members on these topics. We explored whether these views are shaped by having close relationships to autistic people with intellectual disabilities (ID) and nonspeaking autistic (NSA) people.

Methods

A total of 504 autistic and autism community members (278 autistic, 226 non-autistic) completed an online survey about theoretical models and intervention goals. Participants reported whether they had one or more close relationships with NSA people, autistic people with ID, neither, or both.

Results

Overall, there was considerable consensus regarding desired intervention goals: normalization goals were generally opposed, while participants generally supported well-being, societal reform, supportive environment, and adaptive skill goals. While autistic participants reported less support for normalization and adaptive skills goals than non-autistic participants, they expressed somewhat more enthusiasm for societal reform and supportive environments than non-autistic people. Autistic people supported the NDM more and the medical model less than non-autistic people. Those close to autistic people with ID gave higher ratings to adaptive skill goals. On average, participants not close to autistic people with ID saw the challenges of those without ID as being slightly more due to environmental/social factors than the challenges of those with ID; there was no such statistical difference among those close to autistic people with ID.

Conclusion

Further research investigating community views, with the inclusion of more autistic people with ID and NSA people themselves, is needed, but the results of this study suggest that the broader autistic and autism communities see NDM-consistent intervention goals as appropriate for all autistic people, including NSA people and those with ID. As autism interventions have often pursued unpopular normalization goals, this suggests directions for reform.

"Education would be step number one": Community mental health clinicians' training and support needs to treat anxiety in autistic youth

Background

Autistic youth experience high rates of anxiety, which has been treated with modified cognitive-behavioral therapy (CBT), often integrating exposure therapy. Such anxiety treatments are effective for this population; however, there remains a gap between these evidence-based mental health interventions and their implementation in community mental health (CMH) services where autistic youth receive care.

Method

This qualitative study conducted semi-structured interviews with four types of community members in the United States: 15 autistic youth with anxiety, 15 caregivers of autistic youth with anxiety, 11 CMH clinicians, and 8 CMH clinic leaders. Participants identified the training needs of CMH clinicians to support the delivery of CBT for autistic youth with anxiety.

Results

Through inductive thematic analysis, three themes were found: presentation of autism and anxiety, intervention delivery, and training format. Participants highlighted the need for clinician education to understand the varying presentations of autism and co-occurring anxiety and how to effectively deliver a personalized mental health intervention for autistic youth. Clinicians also desired a clinician training program that includes engaging components and offers individualized, ongoing support while the intervention is delivered.

Conclusions

Findings from this study will inform the development of a clinician training program to deliver CBT modified for autistic youth with anxiety in CMH contexts.

Problems with "problem behavior": A secondary systematic review of intervention research on transition-age autistic youth

LAY ABSTRACT

In a previous study, we looked at research done on strategies to support autistic people who were between 14 and 22 years old. For this study, we looked at all of the studies in our previous study that tried to decrease or stop autistic people from doing certain things-many researchers call these things "problem behavior." There were 48 studies that tried to reduce problem behavior, and most of them used strategies like prompting and reinforcement to try get autistic people to change their behavior. We found many things wrong with these studies. Most of them did not define the group of behaviors they were trying to stop autistic people from doing. None of the studies looked at whether any side effects happened when they tried the strategy they were studying. Also, most of the studies tried to stop autistic people from doing behaviors that probably were not harmful, like stereotypic behavior. Most of the studies did not say how they decided that the behaviors they tried to stop were a problem for the autistic people in the study, and most studies did not try to figure out why the autistic people in the study did the behaviors the researchers were trying to stop them from doing.

Community-guided, autism-adapted group cognitive behavioral therapy for depression in autistic youth (CBT-DAY): Preliminary feasibility, acceptability, and efficacy

LAY ABSTRACT

Depression in youth is a significant public health problem worldwide, particularly for autistic youth who are over twice as likely to experience depression than their non-autistic peers. Although pathways to depression are complex, emotional reactivity and negative self-esteem are two risk factors for depression in autistic and non-autistic youth. Although autistic youth are more likely to experience depression than their non-autistic peers, psychotherapy options for autistic youth are very limited; community guidance in the development and testing of psychotherapy programs is a promising approach in autism. Therefore, in this study, we designed an autism-adapted CBT-DAY, in collaboration with autistic community members. Specifically, CBT-DAY combined neurodiversity-affirming and cognitive behavioral approaches to target emotional reactivity and self-esteem in youth to improve depressive symptom severity in a group setting across 12 weeks. We examined the preliminary feasibility, acceptability, and efficacy of CBT-DAY in a pilot non-randomized trial. In addition, we implemented a rigorous protocol for assessing, monitoring, and addressing potential harms in this intervention. Results from 24 autistic youth (11-17 years old) suggest that CBT-DAY may be feasible to use in an outpatient clinical setting and generally acceptable to youth and their caregivers. Participation in CBT-DAY may be associated with significant improvements in youth emotional reactivity and self-esteem, as well as depressive symptom severity per self-report only. Exploratory analyses showed that participation in CBT-DAY may also be associated with significant improvements in internalizing symptoms. Findings demonstrate the potential promise of neurodiversity-affirming and cognitive behavioral approaches to treating depressive symptoms in some autistic youth.

"There is No Help:" Caregiver Perspectives on Service Needs for Adolescents and Adults with Profound Autism

The underrepresentation of individuals with profound autism (who require 24/7 access to care) in autism research has resulted in limited knowledge about their service needs and a lack of evidence-based practices tailored to those needs. This study explored caregiver perspectives on service needs, barriers to accessing care, and treatment priorities to guide treatment development and improvement of service delivery. A sequential mixed-methods design integrated quantitative survey data (n = 423; Mage = 18.89 years; 26.7% female) with qualitative interviews (n = 20) with caregivers of adolescents and adults with profound autism. Quantitative findings indicated regular socialization opportunities were the most frequently endorsed unmet service need (60.3% of caregivers), followed by primary health care with autism-trained staff (59.3%), social skills instruction (55.8%), life skills instruction (51.3%), and behavioral support (47.3%). Higher likelihood of needing social activity groups was associated with elevated emotional reactivity, higher language level, minoritized ethnicity, and lower household income. Greater need for specialized primary health care was associated with lower income, while the need for social and life skills instruction was associated with increased age and elevated dysphoria. Qualitative analysis identified 10 themes that converged and expanded quantitative findings by highlighting a pervasive shortage of individualized, goal-oriented services, common barriers to care, and the priority of developing centralized treatment settings that coordinate care throughout adulthood. This study identified pressing service needs for adolescents and adults with profound autism in the United States. These insights are crucial for improving the accessibility and quality of clinical care.

Mental Health Professionals' Experiences of Adapting Mental Health Interventions for Autistic Adults: A Systematic Review and Thematic Synthesis

Autistic adults experience high rates of metal health difficulties and face significant barriers to accessing appropriate mental health care. Empirical research and recent professional guidelines emphasise the importance of modifying standard mental health interventions to best meet the needs of autistic adults. This systematic review explored mental health professionals' experiences of adapting mental health interventions for autistic adults. A systematic search was conducted on CINAHL, PsychINFO, PubMed, Scopus, and Web of Science in July 2022. The findings from 13 identified studies were synthesised using thematic synthesis. Three major analytical themes were generated, the unique experience of adapting interventions for autistic clients, factors which facilitate successful adaptations, and challenges to adapting interventions. Each theme contained a number of subsequent sub-themes. Professionals view the process of adapting interventions to be a highly individualised process. A range of personal traits, professional experiences, and systemic, service-based issues were identified in facilitating or challenging this individualised process. Further research regarding adaptations with different intervention models and increased supportive resources are required to enable professionals to successfully adapt interventions for autistic adult clients.

Approaches to improving mental health care for autistic children and young people: a systematic review and meta-analysis

Autistic children and young people (CYP) experience mental health difficulties but face many barriers to accessing and benefiting from mental health care. There is a need to explore strategies in mental health care for autistic CYP to guide clinical practice and future research and support their mental health needs. Our aim was to identify strategies used to improve mental health care for autistic CYP and examine evidence on their acceptability, feasibility, and effectiveness. A systematic review and meta-analysis were carried out. All study designs reporting acceptability/feasibility outcomes and empirical quantitative studies reporting effectiveness outcomes for strategies tested within mental health care were eligible. We conducted a narrative synthesis and separate meta-analyses by informant (self, parent, and clinician). Fifty-seven papers were included, with most investigating cognitive behavioral therapy (CBT)-based interventions for anxiety and several exploring service-level strategies, such as autism screening tools, clinician training, and adaptations regarding organization of services. Most papers described caregiver involvement in therapy and reported adaptations to communication and intervention content; a few reported environmental adjustments. In the meta-analyses, parent- and clinician-reported outcomes, but not self-reported outcomes, showed with moderate certainty that CBT for anxiety was an effective treatment compared to any comparison condition in reducing anxiety symptoms in autistic individuals. The certainty of evidence for effectiveness, synthesized narratively, ranged from low to moderate. Evidence for feasibility and acceptability tended to be positive. Many identified strategies are simple, reasonable adjustments that can be implemented in services to enhance mental health care for autistic individuals. Notable research gaps persist, however.

Bias in assessment of co-occurring mental disorder in individuals with intellectual disabilities: Theoretical perspectives and implications for clinical practice

Influence from bias is unavoidable in clinical decision-making, and mental health assessment seems particularly vulnerable. Individuals with intellectual disabilities have increased risk of developing co-occurring mental disorder. Due to the inherent difficulties associated with intellectual disabilities, assessment of mental health in this population often relies on a different set of strategies, and it is unclear how these may affect risk of bias. In this theoretical paper, we apply recent conceptualisations of bias in clinical decision-making to the specific challenges and strategies in mental health assessment in intellectual disabilities. We suggest that clinical decision-making in these assessments is particularly vulnerable to bias, including sources of bias present in mental health assessment in the general population, as well as potential sources of bias which may be specific to assessments in this population. It follows that to manage potential bias, triangulating information from multi-informant, multi-method, interdisciplinary assessment strategies is likely to be necessary.

Improving Emergency Department Care for Suicidality in Autism: Perspectives from Autistic Youth, Caregivers, and Clinicians

ABSTRACT: Purpose: Emergency department (ED) visits for suicidal ideation and self-harm are more prevalent in autistic than non-autistic youth. However, providers are typically offered insufficient guidance for addressing suicide risk in autistic youth, likely impacting confidence and care.

METHODS

In this pilot study, we conducted semi-structured interviews with 17 key members of the autism community (i.e., autistic youth with a history of suicidality, caregivers of autistic youth with a history of suicidality, autism specialist clinicians, ED clinicians) to inform the development of recommendations for modifying ED care for autistic patients, with a focus on suicide risk screening and management.

RESULTS

Participants reported on challenges they encountered receiving or providing care and/or recommendations for improving care. Participant perspectives were aligned, and four main categories emerged: accounting for autism features, connection and youth engagement in care, caregiver and family involvement, and service system issues.

CONCLUSION

As research continues in the development of autism-specific suicide risk assessment tools and management strategies, it is essential we better equip providers to address suicide risk in autistic patients, particularly in ED settings.

Parent-Led Cognitive Behavioral Teletherapy for Anxiety in Autistic Youth: A Randomized Trial Comparing Two Levels of Therapist Support

Parent-led cognitive behavioral therapy (CBT) is an efficient, promising form of therapy that may be well suited for autistic youth with anxiety disorders, though to date it has been minimally tested. In this study, 87 autistic youth (7 to 13 years old) with anxiety disorders and their parents were randomized to two forms of parent-led CBT in which parents led their child through a guided CBT workbook across 12 weeks: one with low therapist contact (four 30-minute telehealth calls), and one with standard therapist contact (ten 60-minute telehealth calls). Anxiety, functional impairment, and autism features significantly declined across therapy, without differences between groups. High satisfaction was reported in both groups, though significantly higher satisfaction ratings were reported in standard-contact CBT. Responder rates were 69% of completers at posttreatment (70% in standard contact, 68% in low contact) and 86% at 3-month follow-up (86% in standard contact, 87% in low contact). Low-contact CBT was estimated to incur an average cost of $755.70 per family compared with $1,978.34 in standard-contact CBT. Parent-led CBT with minimal or standard therapist contact both appear to be effective CBT delivery formats for autistic youth with anxiety disorders, with significant cost savings for low-contact CBT.

Randomized Feasibility Pilot of an Executive Functioning Intervention Adapted for Children's Mental Health Settings

The critical role of executive functioning in autism as well as the co-occurring mental health challenges common among autistic youth support to the immense value of interventions targeting executive functioning for enhancing mental health services for autistic children. The goal of the present study was to conduct a randomized feasibility trial of Unstuck and On Target, an executive functioning intervention, adapted for delivery in children's community mental health setting. Mental health therapists (n = 26) enrolled with participating autistic clients (n = 32) were randomized to receive training in and deliver the adapted Unstuck intervention or to deliver care as usual. We completed masked observational measures of Unstuck strategy use (fidelity) during recorded sessions of participating therapist-client dyads and collected measures of acceptability from participating clients and their caregivers. We also collected measures of pre-post changes in executive functioning and mental health symptoms. Therapists trained in Unstuck demonstrated significantly higher use of Unstuck strategies compared to usual care therapists. Caregivers and autistic clients perceive adapted Unstuck as highly acceptability and helpful. Autistic clients whose therapists were trained in adapted Unstuck demonstrated larger pre-post changes in executive functioning compared to usual care. Across all participating clients, changes in executive functioning were significantly related to changes in mental health symptoms. Finally, clients of therapists trained in adapted Unstuck demonstrated moderate improvements in overall mental health symptoms. The current study provides preliminary evidence of the feasibility and impact of Unstuck and On Target for children's community mental health settings.

"…in the middle of nowhere…" Access to, and quality of, services for autistic adults from parents' perspectives: a qualitative study

Introduction

Adequate education, employment, and services for autistic individuals contribute significantly to their and their parents' quality of life. Services and support for adults are dramatically more limited than those for children. The main purpose of this study was to explore how parents perceive factors supporting/hindering access to services, and how they assess the quality of services.

Methods

Qualitative data provided by 12 parents via a semi-structured interview with a broader focus on parental quality of life and its factors were analyzed. Their autistic children were between 20 and 34 years of age. A thematic analysis was performed on parts of the narratives on their adult periods of life.

Results

A complex pattern of parental perception of supportive and hampering factors influencing access to services unfolded. The sparsity of services/activities and reliable information on them made the space for autonomous decisions on service take highly limited. Parents have modest expectations on quality of services, evaluating them along two key aspects: a safe, positive atmosphere, and communication between parents and professionals. Other aspects of individualized autism-specific support were not or just rarely mentioned.

Discussion

Parents perceive themselves as investing a lot of effort and resources in getting some form of regular service and/or activity for their adult child. However, these parental efforts often fail, their child becoming inactive, and dependent on their presence. This suggests system-level problems with services for autistic adults in Hungary, with literature showing it is not specific to this country.

Heightened Anxiety and Depression Among Autistic Adolescents with ADHD: Findings From the National Survey of Children's Health 2016-2019

Data from the National Survey of Children's Health 2016-2019 was used to examine the co-occurrence of autism and ADHD and the impact on anxiety and depression among adolescents age 12-17. Rates of anxiety and depression were up to ten-fold the prevalence of adolescents not diagnosed with autism or ADHD. Over half of autistic females (57%) and nearly half of autistic males (49%) are also diagnosed with ADHD. Autistic females with ADHD had the highest co-occurrence of anxiety at 72% followed by autistic males with ADHD at 69%. The prevalence of depression was highest among autistic adolescents with ADHD yet was consistent across genders (male/female) at 38-39%. Adolescents diagnosed with autism and/or ADHD are at heightened risk for anxiety and depression.

A cluster randomized controlled trial comparing the effectiveness of two school-based interventions for autistic youth with anxiety

BACKGROUND

Recent systematic reviews have indicated that cognitive behavioral therapy (CBT) is effective in reducing anxiety symptoms for autistic and non-autistic children. However, the vast majority of CBT research for autistic youth has been implemented within university settings and primarily by mental health providers. Schools hold great promise to equitably manage the mental health symptoms of autistic youth. Although preliminary research evaluating CBT within schools has been promising, CBT has not yet been compared to another readily available school mental health program. The goal of this protocol paper is to describe a multi-site study comparing two school-based interventions, Facing Your Fears-School Based (FYF-SB) and Zones of Regulation (ZOR) via a cluster randomized controlled type 1 hybrid effectiveness-implementation trial to determine which of the two interventions will best support autistic youth with anxiety in schools.

METHODS

Up to 100 elementary and middle schools will be randomized into FYF-SB or ZOR. Once schools are randomized, a minimum of two interdisciplinary school providers at each school will be trained to deliver either FYF-SB or ZOR over the course of 12 weeks to groups of 2-5 autistic students ages 8-14 years. Over the course of two years, a total of 200 autistic students will receive either ZOR or FYF-SB. The primary outcome of this trial is child anxiety, as rated by masked evaluators and via caregiver- and student-report, which will be measured at baseline, post-treatment, and 6-month follow-up. Semi-structured interviews will also be conducted with a purposive sample of students, caregivers, and school providers to understand the acceptability, appropriateness, and feasibility of either ZOR or FYF-SB. Stakeholder engagement is a central component of this project via two stakeholder advisory boards that will directly inform and oversee the project.

DISCUSSION

Results of this study will provide evidence about the relative impact of two school-based mental health interventions on outcomes reported as meaningful by caregivers and school providers. The additional focus on evaluating factors that support the implementation of FYF-SB and ZOR will allow future studies to test targeted implementation strategies that support mental health programming uptake and implementation within public schools.

TRIAL REGISTRATION

This trial is registered with clinicaltrials.gov (NCT05863520).

Psychotropic Medication and Psychosocial Service Use Among Transition Age Youth With Autism Spectrum Disorder

People with autism spectrum disorder (ASD) experience high rates of psychotropic medication utilization and barriers to psychosocial services, yet limited literature explores use of these services and the association between a mental health condition (MH) and use. Using national multipayer claims data, this study estimates a multinomial logistic regression model to discern psychotropic medication and psychosocial service use among transition age youth (TAY) with ASD (12-26 years; N = 52,083) compared to a matched cohort of those without ASD (12-26 years; N = 52,083). Approximately one-third of TAY with ASD and no MH condition receive only psychotropic medication and the likelihood of using both psychosocial services and medication is higher only when TAY with ASD have a co-occurring MH condition.

University-Community Mental Health Training Collaboration: Teaching Criminal Legal Stakeholders About Autism

Individuals with autism spectrum disorder (ASD) are disproportionately represented in the criminal legal system, yet ASD-specific training is rarely provided to frontline clinical staff or legal professionals. This column describes a collaboration between university researchers and a state mental health department to promote ASD awareness, knowledge, and intervention skills among clinical and legal professionals working with autistic individuals with criminal legal involvement. Descriptions of how specific needs were identified, how tailored educational workshops were developed, and how workshop efficacy was assessed are provided. Lessons learned and recommendations for researchers and health care systems interested in similar collaborations are offered.

Promoting Quality of Life: Suggestions for Mental Health Care Providers Working with Young Autistic Adults

There is a growing population of autistic adults in need of supports from a service delivery system that, at present, fails to accommodate their needs adequately and equitably. Unfortunately, there is a shortage of trained behavioral health service providers to meet the needs of young autistic adults. Quality of life (QoL), or one's perception of, and satisfaction with, life in relation to held goals and expectations, has been identified as a key outcome of interest by autistic self-advocates. By supporting autistic clients to hone their strengths and interests, integrate various aspects of their identity, identify goals, and connect to appropriate resources, providers can promote clients' self-knowledge and self-determination, in the service of improving QoL. In this Perspectives article, we offer concrete recommendations to mental health providers, including those who do not specialize in autism, with the goal of supporting implementation of evidence-based strategies that improve QoL and promote self-determination among young autistic clients.

Facilitators and barriers in psychotherapy from the perspective of autistic adults: an enhanced critical incident study

PURPOSE

A significant portion of autistic adults experience mental health challenges. Currently, the literature is incomplete when it comes to understanding the needs and preferences of autistic adults who receive therapy. This study elicited the perspectives of autistic adults, focusing on the facilitators, barriers and ways to enhance psychotherapy based on receiving this care for mental health problems.

METHODS

Using the qualitative, exploratory approach of the Enhanced Critical Incident Technique, eight autistic adults took part in interviews.

RESULTS

A total of 147 critical incidents were extracted from participant interviews and categories salient to therapeutic practice. The study identified key factors influencing therapy, such as trust and respect, practical approaches, client factors, structure of sessions, knowledge about autism, support for individualized needs, access to mental health services, and involvement of family/advocate. These factors were categorized into eight main areas relevant to therapeutic practice.

CONCLUSIONS

Findings from this research reveal that psychotherapy with autistic adults is analogous to performing this work with non-autistic adults, in the sense that this work too entails elements of individually tailored treatment and the reliance on common therapeutic factors. There are also differences in this work that necessitate providers having foundational knowledge about autism. Learning directly from autistic adults' insights may help to improve upon the delivery of mental health care for autistic adults.

Transitioning to college during COVID-19: A brief report on incoming students' self-reports of mental health from 2020 to 2022

Objective: Depression and anxiety have been identified as growing concerns for many populations in the United States, including young adults. We investigated how internalizing symptoms may have changed throughout the COVID-19 pandemic among students transitioning to college.Participants: Participants were incoming undergraduates in Fall 2020, 2021, and 2022 at Northeastern Universities (N = 263).Methods: Participants completed self-reports of mood, repetitive thinking, and social satisfaction within two weeks of beginning their first college semester.Results: Depression and anxiety symptoms appear to differ by year, such that both have increased over time. These results seem to be co-occurring with an increase in repetitive negative thinking - a known predictor of depression and anxiety.Conclusions: These preliminary results suggest that mental health concerns in young adults may be worsening despite the resumption of in-person activities post-initial pandemic onset. This highlights the need to monitor and intervene on mental health in students transitioning to college.

Mechanisms of change in Behavioral Activation: Adapting depression treatment for autistic people

Despite high rates of co-occurring depression, few studies have developed or adapted treatments targeting depressive symptoms for autistic adults. Behavioral activation is widely accepted as an empirically-supported approach for treating depression in other populations. Careful attention to the mechanisms targeted by behavioral activation is an essential step toward adapting behavioral activation protocols for use with autistic adults. We consider the mechanisms targeted by behavioral activation and provide a framework for research to explore the facilitators and barriers to the use of behavioral activation to treat depression in autistic adults. Drawing upon clinical experience and extant literature, the suggestions presented are aimed at highlighting considerations for clinicians wanting to use behavioral activation programs in their clinical practices with autistic adults and to promote the research needed to establish behavioral activation as an evidence-based practice for treating depression in adults on the autism spectrum.

Community-based care for autistic youth: community providers' reported use of treatment practices in the United States

Introduction

To illustrate the landscape of community-based care for autistic youth in the United States, we identified transdisciplinary psychosocial intervention practice sets that community providers report utilizing to care for this population, and examined characteristics associated with provider-reported utilization.

Methods

The Usual Care for Autism Study (UCAS) Survey assessed provider demographics and provider-reported use of transdisciplinary practices for common ASD co-occurring problems: social difficulties, externalizing behaviors, and anxiety. Community practitioners (N = 701) from allied health, behavioral, education, medical, mental health and other disciplines who treat or work with autistic youth (7-22 years) participated.

Results

Exploratory factor analysis yielded four factors: Consequence-Based Strategies (CBS), Cognitive-Behavioral and Therapy Strategies (CBTS), Antecedent-Based Strategies (ABS), and Teaching Strategies (TS). Providers across disciplines reported utilizing ABS more often than other sets. Providers from behavioral disciplines, with less than 4-year or Master degrees, or with more experience reported the most use of ABS, CBS and CBTS. Medical and behavioral providers reported the most use of TS. Setting and child characteristics were associated with practice set use, indicating variability by disability and client socioeconomic status.

Discussion

Findings reflect the complexity and inconsistency of the service landscape for autistic youth across the U.S. Only by understanding the service landscape and predictors of practice utilization, can researchers, policymakers, provider groups, and the autistic community facilitate effective implementation strategy development and use to ultimately improve community-based care.

Autism, Discrimination and Masking: Disrupting a Recipe for Trauma

Outcomes of discrimination for autistic people include masking, social isolation and exclusion, trauma, and mental health problems. This discursive paper discusses the discrimination experienced by autistic people in health, education, employment, and media settings; and considers how to reduce the impact of discrimination. Addressing the impact of discrimination requires an improved understanding of the lived experience of the autistic person, the embedding of inclusive practices in communities, developing the person's life skills and supports, and enabling the person to work through their psychological trauma. Further research can aid in minimizing and preventing discrimination against people with autism.

Co-Occurring Mental Illness and Behavioral Support Needs in Adults with Intellectual and Developmental Disabilities

People with intellectual and developmental disabilities (IDD) have higher incidences of mental health conditions and behavioral support needs than people without IDD but may not receive needed care from community providers. We examined rates of co-occurring conditions in a representative sample of adults with IDD who use state funded services in Virginia. Using data from two datasets, we identified four categories of mental health and behavioral conditions. We used these categories to examine differences in individual- and system-level factors in people with and without co-occurring conditions. We found high rates of co-occurring conditions in our sample. We found important disability factors and system-level characteristics that were associated with having a diagnosed mental health condition or behavioral support needs. Differing patterns of diagnosis and treatment for co-occurring conditions suggests more work needs to be done to support people with IDD and co-occurring mental health conditions living in the community.

Community-guided measurement-based care for autistic youth and adults receiving psychotherapy: A conceptual overview and pilot implementation study of MBC-AUT

LAY ABSTRACT

Autistic youth and adults are more likely to experience psychiatric symptoms (e.g. depression, anxiety) and to use psychiatric services than non-autistic people, yet research on evidence-based approaches to enhance psychiatric care for autistic people is limited. Measurement-based care is an evidence-based approach to psychotherapy that improves outcomes for clients, clinicians, and organizations by routinely administering and evaluating measures to clients. Despite this, research on measurement-based care systems for autistic clients is sparse. To address this gap, we developed an autism-adapted measurement-based care (MBC-AUT) system for and with autistic people and pilot tested the system in an outpatient psychiatry clinic to investigate the preliminary feasibility, acceptability, benefits, and barriers to this system for clients and clinicians. Findings suggested that the MBC-AUT system was a feasible and acceptable system for the first 18 autistic youth, their caregivers, and autistic adults to use the system. In semi-structured interviews, clients and clinicians discussed the benefits of the MBC-AUT system to various therapeutic processes, as well as several important barriers to the use of the system. We offer potential solutions to address these barriers and to reduce client and clinician burden, and propose future directions for this line of research to increase access to more autistic people. As autistic clients continue to seek psychological services amid social landscapes of increasing complexity (e.g. COVID-19 pandemic), efforts to enhance the delivery of psychotherapy for this population are critical.

Barriers and needs in mental healthcare of adults with autism spectrum disorder in Germany: a qualitative study in autistic adults, relatives, and healthcare providers

BACKGROUND

Autism refers to a neurodevelopmental condition with characteristic impairments in social interaction and communication, restrictive and repetitive behaviors, as well as difficulties in sensory information processing and daily living skills. Even though symptoms persist from early childhood throughout the lifespan and often require long-term support, there is a lack of mental health services that sufficiently meet the needs of autistic adults. Previous evidence suggested individual, professional and structural barriers to healthcare for autistic adults. Here, using a peer research approach, we sought to systematically investigate barriers and needs in mental healthcare of autistic adults in Germany at the three relevant levels (individual, professional, structural) and from three relevant perspectives (autistic adults, relatives and healthcare providers), in order to obtain specific recommendations for optimized healthcare.

METHODS

Maximum variation sampling was used to account for the complexity of the research field. Semi-structured, open-ended interviews were conducted with autistic adults (n = 15) and focus groups with relatives/partners (n = 12), and healthcare providers of several professions (n = 15). Data analysis was performed using the codebook approach of thematic analysis.

RESULTS

Poor mental healthcare of autistic adults in Germany was characterized by six central and overarching themes: (i) lack of knowledge about autism, (ii) a need for increased participation/involvement, (iii) consideration of autism-specific needs in treatment, (iv) lack of services, (v) limited access to services, and (vi) improvement of stakeholder collaboration. Themes were similarly reported across participants, emphasizing dissatisfaction in all stakeholders.

CONCLUSIONS

We identified major barriers to mental healthcare for autistic adults in Germany that affect autistic adults, but are also of concern to relatives and healthcare providers. Our results point to specific and generic areas for improvement, independent of stakeholder perspectives, which could guide future development of needs- and evidence-based services, recommendations and guidelines of mental healthcare for people with autism across the lifespan.

TRIAL REGISTRATION

This study protocol was preregistered at the Open Science Framework ( https://osf.io/5x8pg ).

Psychiatry training in autism spectrum disorder and intellectual disability: Ongoing gaps and emerging opportunities

LAY ABSTRACT

Children, adolescents, and adults with autism spectrum disorder and intellectual disability experience high rates of co-occurring psychiatric conditions throughout their lifetime. However, there is a shortage of psychiatrists to treat these populations. We evaluated how much education psychiatrists-in-training receive on how to care for individuals with autism spectrum disorder/intellectual disability. We found that in many psychiatry programs, residents receive limited training experiences in autism spectrum disorder/intellectual disability involving lectures and patient contact and that psychiatry program directors would benefit from more resources to strengthen education in autism spectrum disorder/intellectual disability.

Mental health service availability for autistic youth in New York City: An examination of the developmental disability and mental health service systems

LAY ABSTRACT

Autistic children and adolescents experience high rates of co-occurring mental health conditions, including depression and suicidality, which are frequently identified by stakeholders as treatment priorities. Unfortunately, accessing community-based mental health care is often difficult for autistic youth and their families. The first obstacle families confront is finding a provider that offers mental health treatment to autistic youth within the many service systems involved in supporting the autism community. The mental health and developmental disability systems are two of the most commonly accessed, and previous work has shown there is often confusion over which of these systems is responsible for providing mental health care to autistic individuals. In this study, we conducted a telephone survey to determine the availability of outpatient mental health services for autistic youth with depressive symptoms or suicidal thoughts or behaviors in New York City across the state's mental health and developmental disability systems. Results showed that while a greater percentage of clinics in the mental health system compared with in the developmental disability system offered outpatient mental health services to autistic youth (47.1% vs 25.0%), many more did not offer care to autistic youth and there were very few options overall. Therefore, it is important that changes to policy are made to increase the availability of services and that mental health care providers' knowledge and confidence in working with autistic youth are improved.

"I'm the Family Ringmaster and Juggler": Autistic Parents' Experiences of Parenting During the COVID-19 Pandemic

Background

Little is known about autistic parenthood. The literature that exists suggests that autistic parents can find it difficult to manage the everyday demands of parenting and domestic life. While emerging research has also highlighted more positive parenting experiences, greater understanding of autistic parenthood is needed.

Objective

This study sought to understand autistic parents' parenting experiences during the initial phase of the COVID-19 pandemic.

Methods

Thirty-five Australian autistic parents (95% women) of autistic children (aged 4-25 years) took part in semi-structured interviews designed to elicit their experiences of life during lockdown. We used reflexive thematic analysis using an inductive (bottom-up) approach to identify patterned meanings within the data set.

Results

Autistic parents repeatedly spoke of how the lockdown brought some initial relief from the intensity of their usual lives caring for their children. Nevertheless, most autistic parents felt that the "cumulative stress" of trying to juggle everything during lockdown proved very challenging, which eventually took its toll on parents' mental health. Parents were aware that they needed support but found it difficult to reach out to their usual social supports (including autistic friends) for help, and formal supports were virtually nonexistent. Consequently, they felt "very much forgotten." Nevertheless, they described how their connections with their children grew stronger over lockdown as they focused on nurturing their children's "mental health ahead of everything else."

Conclusions

Our analysis shows how challenging conventional life can be for autistic parents. Parenting requires grappling with a distinctive set of demands, which are usually partially manageable through the informal supports many autistic parents draw upon. The relative absence of informal supports during the pandemic, however, left them reliant on more formal supports, which were not forthcoming. Research is urgently needed to identify the most effective formal supports for autistic parents, ideally in partnership with autistic parents themselves.

A Systematic Review of Therapeutic Process Factors in Mental Health Treatment for Autistic Youth

Understanding the role of therapeutic process factors in treatment change may prove useful for discerning why some autistic youth benefit from psychosocial interventions that target emotional and psychological aspects of mental health, while others do not. The aim of the current study was to synthesize what is currently known about therapeutic process factors in mental health treatment of emotional and psychological challenges for autistic youth, regarding how process factors have been measured in past research, and the relation between process factors and treatment outcome. A systematic review of the literature was conducted to narratively synthesize all articles published up until June 2021. Methodological quality of included studies was appraised. Twenty-five studies met inclusion criteria. Process factors assessed across studies included relational factors; treatment expectations, readiness, and satisfaction; and treatment engagement from youth and their parents. Process-outcome associations were reported for a limited number of constructs. There is a limited, albeit growing, body of high-quality research evaluating the role of process factors in the treatment of mental health issues for autistic youth. Future research should continue to examine process factors in relation to treatment outcome, and validate measures to accurately capture process-related constructs in mental health treatment for this population. Greater understanding of therapy processes can lead to developing evidence-informed strategies that clinicians can implement to promote positive expectations, relationships, and engagement.

Clinician factors related to the delivery of psychotherapy for autistic youth and youth with attention-deficit hyperactivity disorder

LAY ABSTRACT

Autistic children and youth often experience mental health problems, such as anxiety, depression and behavioural challenges. Although there are therapy programmes that have been found helpful in reducing these issues, such as cognitive behaviour therapy, autistic children often struggle to receive adequate mental health care. Clinicians' knowledge, attitudes, confidence and beliefs about treating mental health problems in autistic people may be related to their choices in providing psychotherapy. Across Ontario, Canada, 611 mental health clinicians, working in publicly funded agencies, completed an online survey about their experiences and opinions on delivering therapy for autistic clients compared to those with attention-deficit hyperactivity disorder. Clinician knowledge was associated with their intention to treat autistic clients or clients with attention-deficit hyperactivity disorder, partly because of their attitudes and the social pressures or values they felt. Clinicians reported feeling less intent on providing therapy to autistic youth compared to youth with attention-deficit hyperactivity disorder because of differences in their attitudes, social pressures and knowledge. This research can inform the training and educational initiatives for mental health practitioners.

'The key to this is not so much the technology. It's the individual who is using the technology': Perspectives on telehealth delivery for autistic adults during the COVID-19 pandemic

LAY ABSTRACT

The COVID-19 pandemic meant that a lot of healthcare services had to move online, such as to video-calls, or to telephone. However, not many studies have looked at how autistic adults feel about this kind of service delivery. It is important to know this, as autistic people may have poorer health than non-autistic people, and they may also struggle to access services more than non-autistic people. This study asked 11 autistic adults (aged 27-67 years), seven family members/carers (aged 44-75) reporting about autistic adults and six service providers about their experiences of accessing or providing a telehealth service. These experiences were collected through interviews, which were then analysed through thematic analysis. Two main themes were: technology aids communication and access - except when it doesn't, and in/flexibility. The themes pointed out some positive aspects of telehealth delivery, including improved communication and decreased stress. The themes also pointed out negative aspects of telehealth, such as increased rigidity of the healthcare system, amplifying pre-existing barriers. Because autistic people have many barriers to accessing healthcare, this study encourages researchers and healthcare providers to think about how such barriers could be addressed through telehealth, and about the possible limitations of telehealth for some autistic people.

Two Halves of the Same Whole: A Framework to Integrate Autism and Mental Health Services

Given the higher rates of co-occurring mental health issues experienced by autistic people, there is a pressing need to implement an effective framework that integrates autism services with appropriate mental health services. This paper discusses the impact of mental illness on the person with autism and their families, and the current challenges they face when accessing mental health support. A framework for service providers is proposed to support the mental health needs and preferences of autistic people. The paper concludes by highlighting the importance of health professionals utilising mental health interventions appropriate for autistic people, including autism-specific suicide prevention and awareness programs.

Examining subjective understandings of autistic burnout using Q methodology: A study protocol

BACKGROUND

Early research indicates that autistic burnout is a chronic, debilitating condition experienced by many autistic people across the lifespan that can have severe consequences for their mental health, wellbeing, and quality of life. To date, studies have focused on the lived experiences of autistic adults, and findings suggest that a lack of support, understanding, and acceptance by others can contribute to the risk of autistic burnout. The study outlined in this protocol will investigate how autistic people with and without experience of autistic burnout, their families, friends, healthcare professionals and non-autistic people understand the construct of autistic burnout to identify commonalities and gaps in knowledge.

STUDY AND DESIGN

Q methodology will be used to investigate participants' subjective understandings of autistic burnout. Q methodology is a mixed-methods design that is well-suited to exploratory research and can elucidate a holistic and comprehensive representation of multiple perspectives about a topic. Participants will complete a card sorting activity to rank how strongly they agree or disagree with a set of statements about autistic burnout and participate in a semi-structured interview to discuss their responses. A first-order factor analysis will be conducted for each participant group, followed by second-order factor analysis to compare the groups' viewpoints. The interview data will provide additional insights into the factors.

CONCLUSION

Q methodology has not previously been used to examine autistic and non-autistic people's perspectives about autistic burnout. Projected study outcomes include enhanced understanding of the characteristics, risks, and protective factors of autistic burnout. The findings will have practical implications for improving detection of autistic burnout and identifying strategies to support autistic adults with prevention and recovery. The results may also inform the development of a screening protocol and identify potential avenues for future research.

Improving Cognitive Behaviour Therapy for Autistic Individuals: A Delphi Survey with Practitioners

There is emerging evidence of the effectiveness of individual and group cognitive behaviour therapy (CBT) for autistic individuals, in particular to address anxiety, obsessive compulsive disorder and depression. Many CBT studies have incorporated relatively stringent standards, with regards to participant inclusion/exclusion criteria, delivery of manualised approaches and assurance of therapist training and oversight. We know less about what happens in routine CBT practice and, importantly, how service provision can be improved for autistic individuals. The present study recruited 50 CBT practitioners to a three round Delphi survey. The aims were to elicit professionals' perspectives regarding barriers to the acceptability and effectiveness of CBT for autistic individuals, and to generate consensus, both about ways of enhancing service provision, as well as the autism-relevant training needs of CBT practitioners. Study findings indicated six barriers to accessible and effective CBT for autistic individuals, relating to service provision, practitioner-related factors, client-related factors, CBT-related factors, national guidelines, and systemic considerations. There was participant consensus that changes in five domains (specifically relating to process issues, service provision, practitioners, techniques and therapeutic approach) could improve the CBT care pathway. Consensus was generated about the training needs of CBT practitioners: training about autism, CBT-specific issues, co-occurring conditions and engagement, were deemed fundamental for enhancing practice. Participants also identified autism-relevant issues for clinical supervision. Further sustained research is needed to determine the effects of adapted service provision and improved practitioner knowledge and skills on the outcomes of autistic individuals who have CBT.

Using eye movement desensitisation and reprocessing (EMDR) with autistic individuals: A qualitative interview study with EMDR therapists

OBJECTIVES

Eye Movement Desensitisation and Reprocessing (EMDR) is an evidence-based psychological therapy that targets distress associated with trauma and affective disturbance. Few studies have examined EMDR for autistic individuals who have co-occurring mental health conditions, but there is preliminary evidence of effectiveness. The current study explored EMDR therapists' experiences of working with autistic individuals, and adaptations incorporated into clinical practice to make this more accessible and effective.

DESIGN

A qualitative interview design was used. Data were thematically analysed.

METHOD

Twenty-three UK-based EMDR therapists attended one-off semi-structured qualitative interviews.

RESULTS

Four main themes emerged: (1) the experience of being autistic; (2) factors around accessing EMDR; (3) adapting EMDR; and (4) supervision and support for EMDR therapists. Participants described offering a nuanced and tailored approach; one that retained the integral components of the eight phases of EMDR, while also being flexible and responsive to each client.

CONCLUSIONS

Findings reinforce the importance of offering formulation-based psychological therapy that flexes in an evidence-informed way, according to the preferences and needs of autistic individuals. Further research should establish factors influencing accessibility and effectiveness of EMDR for autistic individuals, and the impact of autism-relevant training on the knowledge, skills and confidence of EMDR therapists and clinical supervisors working with this client group.

How People with Autism Access Mental Health Services Specifically Suicide Hotlines and Crisis Support Services, and Current Approaches to Mental Health Care: A Scoping Review

For people with autism spectrum disorder (ASD), the risk of mental illness, including suicidality, has a higher prevalence than the general population. This scoping review explored how people with ASD access suicide hotlines/crisis support services; and current approaches to delivering mental health services (MHS) to people with ASD. A search identified 28 studies meeting the selection criteria with analysis revealing four key findings. The support received by the person with ASD influenced how they accessed MHS; people often encounter barriers to accessing MHS; a separation exists between autism and MHS; and no studies on accessing or delivering MHS through crisis hotlines. The presence of such autism-specific crisis hotlines and the dearth of studies suggest a void in the existing research.

Associations between co-occurring conditions and age of autism diagnosis: Implications for mental health training and adult autism research

Adult autism studies are increasingly comprised of later-diagnosed adults, yet little is known about how these adults compare to those diagnosed earlier in life. The present study examines medical and psychiatric conditions endorsed by autistic adults and documents differences between those diagnosed with ASD in childhood versus adulthood, as well as across age groups and sex at birth. 4657 legally independent adults (ages 18-85, M = 33.4 years) with professional ASD diagnoses who completed a medical questionnaire were drawn from the Simons Powering Autism Research Knowledge (SPARK) study. Chi square analyses, t-tests, and logistic regressions were used to compare medical and psychiatric conditions between age groups, sex at birth and adults diagnosed in childhood (before age 21) versus adulthood (at or after 21 years). Overall number of conditions endorsed as being diagnosed by a professional was high, with an average of 1.69 (SD = 2.01) medical or developmental and 2.98 (SD = 2.29) psychiatric conditions reported across the sample. Females were more likely to endorse psychiatric conditions (OR = 1.68). Adult-diagnosed adults were more likely to endorse psychiatric conditions (OR = 2.71) and reported more lifetime psychiatric diagnoses (M = 3.15, SD = 2.23) than their childhood-diagnosed counterparts (M = 2.81, SD = 2.33). These findings underscore the need for research to better understand and treat co-occurring psychiatric conditions in autistic adults and report and consider the age of diagnosis in adult autism samples. Moreover, results suggest it is imperative that mental health professionals receive autism training to promote accurate differential diagnosis and equitable access to mental health care for autistic adults with co-occurring psychiatric conditions.

A survey of autistic adults, relatives and clinical teams in the United Kingdom: And Delphi process consensus statements on optimal autism diagnostic assessment for adults

LAY ABSTRACT

Living with undiagnosed autism can be distressing and may affect mental health. A diagnosis of autism can help self-awareness and self-understanding. However, it can be difficult for adults to access an autism assessment. Clinicians also sometimes find it hard to identify autism in adults. This may mean an autism diagnosis is delayed or missed. In this study, we asked autistic adults, relatives and clinicians how to improve this. The study was in two stages. In the first stage (stage 1), 343 autistic adults and 45 relatives completed a survey. In the survey, we asked questions about people's experiences of UK autism assessment services for adults. Thirty-five clinicians completed a similar survey. Clinicians reported that some autism assessment teams lacked key professionals, for example, psychologists and occupational therapists. We used the information from the three separate surveys to create 13 statements describing best autism assessment services for adults. In stage 2, we asked clinicians for their views on the 13 statements. Clinicians agreed with 11 of the statements. Some autistic adults, relatives and clinicians were positive about autism assessment services, and many also described areas that could be improved. The study findings can be used to improve UK adult autism assessment services and may be helpful for service developments worldwide.