The role of emotion regulation and core autism symptoms in the experience of anxiety in autism

The relationship between distress tolerance and behavioral activation on anxiety and depression symptomatology in autistic youth: Leveraging self and caregiver perspectives

Anxiety and depression are prevalent among autistic adolescents and may be difficult to accurately diagnose and treat given various factors (e.g., diagnostic overshadowing, heterogeneity). Therefore, efforts to examine transdiagnostic factors (i.e., distress tolerance, behavioral activation) may afford more parsimonious means for assessment and treatment. To our knowledge, there has been little research on distress tolerance, behavioral activation, and depressive and anxiety symptoms in autistic adolescents to guide diagnostic practices and treatment planning. In the current study, we examined the interrelationships between these transdiagnostic factors and depressive and anxiety symptoms using ratings from 100 verbally fluent autistic adolescents without intellectual disability (Mage = 13.70, SDage = 2.23, Range: 11:00-17:11 years) and 100 of their caregivers. Many adolescents reported male sex assigned at birth (61%), cisgender (87%), not Hispanic/Latinx (90%), and White (80%) identities. A series of correlational analyses were employed to examine associations between these constructs from youth and caregiver perspectives, and multiple linear regression analyses were conducted to explore the mediating roles of distress tolerance and behavioral activation. Preliminary results show that low distress tolerance and behavioral activation were associated with more severe internalizing symptoms per self- and caregiver-report. Some differences by rater emerged, which highlight the importance of multi-informant ratings in autism. Results from mediation analyses may show that behavioral activation may be more salient to assessments and treatment planning for depression than distress tolerance, while distress tolerance may be important for both anxiety and depression; however, findings are preliminary given the cross-sectional nature of the data. Findings suggest that these transdiagnostic concepts may be important to individualizing treatment approaches, including the timing of certain approaches, for anxiety and/or depression in autistic adolescents.

Autistic Symptoms, Irritability, and Executive Dysfunctions: Symptom Dynamics from Multi-Network Models

Socio-cognitive difficulties in individuals with autism spectrum disorder (ASD) are heterogenuous and often co-occur with irritability symptoms, such as angry/grouchy mood and temper outbursts. However, the specific relations between individual symptoms are not well-represented in conventional methods analyzing aggregated autistic symptoms and ASD diagnosis. Moreover, the cognitive-behavioral mechanisms linking ASD to irritability are largely unknown. This study investigated the dynamics between autistic (Social Responsiveness Scale) and irritability (Affective Reactivity Index) symptoms and executive functions (Cambridge Neuropsychological Test Automated Battery) in a sample of children and adolescents with ASD, their unaffected siblings, and neurotypical peers (N = 345, aged 6-18 years, 78.6% male). Three complementary networks across the entire sample were computed: (1) Gaussian graphical network estimating the conditional correlations between symptom nodes; (2) Relative importance network computing relative influence between symptoms; (3) Bayesian directed acyclic graph estimating predictive directionality between symptoms. Networks revealed numerous partial correlations within autistic (rs = .07-.56) and irritability (rs = .01-.45) symptoms and executive functions (rs = -.83 to .67) but weak connections between clusters. This segregated pattern converged in all directed and supplementary networks. Plausible predictive paths were found between social communication difficulties to autism mannerisms and between "angry frequently" to "lose temper easily." Autistic and irritability symptoms are two relatively independent families of symptoms. It is unlikely that executive dysfunctions explain elevated irritability in ASD. Findings underscore the need for researching other mood and cognitive-behavioral bridge symptoms, which may inform individualized treatments for co-occurring irritability in ASD.

Using Restricted Interests in Cognitive Behavioral Therapy for Children With Autism Spectrum Disorder: Results From a Preliminary Randomized Controlled Trial

Children with autism spectrum disorder (ASD) exhibit significant deficits in social communication and emotion regulation skills. While cognitive behavioral therapy (CBT) applications appear promising, trials to date have largely excluded social communication skill development and have not been designed to include a wider range of emotional challenges. To our knowledge, the present study is the first to pilot a uniquely modified CBT program targeting emotion regulation, including social communication training, and explicitly focusing on the child's areas of circumscribed interest in order to teach skills and promote generalization. Forty participants were randomly assigned to either the CBT group or a waitlist control (WLC) group, resulting in 20 school-aged children in each group. The treatment approach was determined to be feasible and acceptable, and therapy engagement and attendance were reasonably high. Caregivers expressed high satisfaction with the program, qualitatively citing gains in skills such as social problem-solving, emotion identification, and identifying and processing cognitive distortions. The primary outcome of postintervention changes was not significantly different between the groups (CBT vs. WLC). The mean Social Skills Improvement System score decreased by 0.44 points (95% confidence interval [CI]: -5.04, 4.15) in the CBT group and increased by 0.41 points (95% CI: -4.23, 5.04) in the WLC group, and the postintervention changes were not significantly different between the groups (difference: -0.85; 95% CI: -7.29, 5.60; p = .79). The estimated rate of emotional dysregulation episodes decreased by a factor of 0.94 (95% CI: 0.57, 1.56) in the CBT group and increased by a factor of 1.07 (95% CI: 0.51, 2.24) for WLC (p = .74). Among those who reported emotional dysregulation episodes, the mean duration decreased by 1.39 minutes (95% CI: -3.90, 6.67) less for CBT than waitlist (p = .60). Although satisfaction, acceptability, and emotional dysregulation outcome results from this preliminary CBT treatment for ASD are promising, sample size and measurement limitations will be important considerations to inform future trials.

Close Relationships Despite the Challenges: Sibling Relationships and Autism

This study explores the experiences of siblings of autistic adolescents within families. Without the novel insights generated from engaging with siblings of autistic adolescents within a qualitative framework, it can be challenging to develop strategies for practicing effectively with this group or structuring interventions with these families. Using a social constructivist approach and qualitative participatory methodology, the exploratory study was conducted using in-depth interviews with ten non-autistic siblings, analyzed via a thematic analysis method. The results reveal a common feeling of uncertainty and apprehension in the relationships, leading siblings to physical and emotional detachment from their autistic brothers or sisters. The research emphasizes the caregiving roles predominantly taken up by sisters, especially when the autistic sibling is a brother with intellectual disability. These roles exert substantial demands, with unclear boundaries suggesting potential role confusion. The findings have important implications for family practice, necessitating the need to address role conflict and promote role clarity. They also underscore the gendered nature of caregiving, advocating for support to sister-siblings in these roles. This study revealed the complexities of sibling relationships in families with a member who is an autistic adolescent sibling. The study suggests interventions that promote open family dialogues for a balanced approach to family roles, providing valuable guidance to practitioners to enhance siblings and family well-being.

A qualitative exploration of an autism-specific self-compassion program: The ASPAA

LAY ABSTRACT

Autistic people often struggle to find the right support for their mental health. We wanted to change that by trying a new approach to help autistic adults with their emotions and well-being. We focused on something called "self-compassion," which is a way of being kind and understanding toward ourselves. This approach has worked well for many people, but we didn't know if it would work for autistic individuals. We invited 39 autistic adults to join an online program that taught them about self-compassion. The program lasted 5 weeks and included educational materials, meditation exercises, and self-reflection activities. We asked the participants for feedback each week and at the end of the program. From their responses, we discovered four important things. First, self-compassion had a big positive impact on the well-being of autistic adults. Second, they faced some challenges during the program. Third, they saw self-compassion as a journey that takes time and practice. Finally, they described how they valued changes to help autistic people engage with the program. Our findings show that self-compassion can really help autistic adults. We learned about the benefits they experienced and the difficulties they faced. Most importantly, we found that personalized support is crucial for autistic individuals. By creating programs that consider their specific needs, we can improve their mental health and make their lives better.

Investigating the Effects of Transdiagnostic Processes on Anxiety and Depression Symptoms in Autistic Young People: the Mediating Role of Emotion Dysregulation

Internalising symptoms are elevated in autism compared to the general population. Few studies have investigated emotional dysregulation (ED) as a potential mediator between specific transdiagnostic processes and anxiety and depression symptoms in autistic youth. In a sample of 94 autistic young people aged 5-18 years referred to a specialist clinic for an autism evaluation, we tested the effects of ED as a mediator between cognitive inflexibility (CI), intolerance of uncertainty (IU) and alexithymia with anxiety and depression symptoms, using structural equation modelling. Effect sizes were compared to a non-autistic comparison group (n = 84). CI and alexithymia did not significantly predict depression symptoms in autistic young people, directly nor via ED. Relationships between CI/alexithymia and depression were fully mediated by ED in the non-autistic sample. There was a direct effect of CI on anxiety in the non-autistic group but not in those with a diagnosis. IU predicted depression symptoms in the autism group; and ED mediated this relationship only in those who did not receive a diagnosis. IU directly predicted anxiety in both groups and this relationship did not occur via ED. The finding of a direct pathway from IU to anxiety and depression in autistic youth is consistent with the literature. The finding that CI did not predict anxiety or depression in those with autism is novel, as was the finding that ED mediated relationships between alexithymia and anxiety/depression symptoms in both samples. The findings may have important implications for the delivery of psychological interventions for autistic youth.

Emotion Dysregulation Mediates the Relationship Between Sensory Processing and Behavior Problems in Young Children with Autism Spectrum Disorder: A Preliminary Study

Emotion dysregulation is one of the challenges that children with autism spectrum disorder (ASD) and their families face. It is unclear whether emotion dysregulation plays a mediating role in the relationship between sensory processing patterns and problem behaviors among these children. This study examined the relations between emotion dysregulation, behavioral problems, and sensory processing patterns among fifty-seven young children with ASD. Behavioral problems and sensory processing patterns were moderately to strongly correlated with emotion dysregulation. The relationship between sensory processing patterns and behavioral problems was significant with emotion dysregulation as a mediator. These findings help identify the relationship between emotion dysregulation, sensory processing patterns, and behavioral problems to facilitate the planning of intervention strategies for young children with ASD.

The Association of Autistic Traits on Cognitive Emotion Regulation Strategies in a Non-clinical Sample

Individuals with high autistic traits have difficulty in regulating their negative emotions. However, few studies clarify the relationship between autistic traits and cognitive emotion regulation strategies. This study examined the association between adaptive and maladaptive strategies in cognitive emotion regulation and autistic traits using a non-clinical sample. Two hundred and thirty-four participants completed the Japanese version of the Social Responsiveness Scale-2 (Adult Self-Report version) and the Japanese version of the Cognitive Emotion Regulation Questionnaire. The results showed that autistic traits were negatively associated with the use of adaptive subordinate strategies for cognitive emotion regulation. By contrast, autistic traits were positively associated with the use of maladaptive subordinate strategies of cognitive emotion regulation. The cognitive and emotional characteristics of autism spectrum disorder, such as perspective taking and executive function, contextualize these results. These findings can help guide not only our understanding of the relationship between autistic traits and cognitive emotion regulation but also develop interventions aimed at facilitating the use of adaptive cognitive emotion regulation strategies and preventing the use of maladapted strategies in individuals with high autistic traits.

Population-Based Teacher-Rated Assessment of Anxiety Among Canadian Kindergarten Children

Despite anxiety being a prevalent mental health problem in children, little data exist on the pervasiveness and levels of anxiety symptoms in kindergarteners. Data from the Early Development Instrument, a teacher-completed, population-level measure of child development, were collected across Canada from 2004 to 2015. The final analytic sample consisted of 974,319 children of whom 2.6% were classified as "highly anxious". Compared to children who exhibited "few to none" anxious behaviors, highly anxious children were more likely to be male, have English/French as a second language, and have a special needs designation. Furthermore, compared with their less anxious peers, highly anxious children had between 3.5 and 6.1 higher odds of scoring below the 10th percentile cut-off in physical, social, language/cognitive and communication domains. Our findings suggest that anxious behaviors are related to children's overall health and illustrate the consistency and extensiveness of anxiety at a very young age among Canadian children.

The interplay of supports and barriers during the transition to adulthood for youth on the autism spectrum

PURPOSE

Transition to adulthood is a complex process that involves important life domains such as education, work, independent living, community, health, and social relationships. Autistic youth face the transition with greater challenges than their peers, and there continues to have significant gaps in the services as they approach young adulthood. The study was conducted to understand the complex interplay between supports and barriers to participation in the transition process.

METHOD

Data was collected through six focus groups with 24 participants (7 parents, 11 practitioners, 6 autistic youth), digitally audio-recorded, transcribed, and analyzed using thematic analysis.

RESULTS

Four themes were reported: Inadequacy of Services, Ambivalence about Formal Services and Support, Understanding Good Partnership, and Evolving Parental Involvement. While parents and practitioners see the fragmented services and lack of comprehensive support as the most prominent challenge, autistic youth feel ambivalent about the type of services they need. Practitioners address the importance of establishing an appropriate level of engagement with parents in the transition process. Autistic youth expect their parents to set a boundary that affirms their independence.

CONCLUSIONS

Our study highlights the need to elicit input across different stakeholders to make transition services centralized, easily accessible, and individualized.Implications for RehabilitationIt is important to have a systematic road map, early preparation of families and autistic youth about the array of adult transition services, and a centralized hub of information to be disseminated.Disability service agencies should develop and implement plans for enhancing outreach and services to transition youth on the autism spectrum and their families.Practitioners need to identify locally available resources and channels for outreach and make available service more visible by producing transition-related materials with examples of current legislative information, problem solving, and best practices.Practitioners should consider how autistic youth identify their needs and wants may be different than how service providers and parents conceptualize them.It is critical to capitalize appropriate levels of caregivers/family support and engagement by provision of education about policies and guidelines for communication and collaboration.

Pathways to Psychopathology Among Autistic Adults

PURPOSE OF REVIEW

Autistic adults frequently require treatment of mental health problems. Increased rates of suicidality and diminished quality of life among autistic people may be partially attributable to psychiatric symptoms. Some risk factors for mental health problems in autistic people are likely the same as risk factors present in neurotypical individuals, but unique factors that are specific to neurodivergent individuals, and some even more specific to autistic people, may exist. Understanding pathways from autism to mental health problems could inform intervention efforts at the individual and societal levels.

RECENT FINDINGS

We review a growing body of research identifying risk processes across the affective, cognitive, and social domains. Consistent with the principle of equifinality, different processes appear to independently and jointly lead to heightened risk for the onset of mental health problems. Autistic adults frequently utilize mental healthcare services, and experience heightened risk for chronic impairment as a result of mental health problems. Understanding causal and developmental risk processes in autism should inform personalized treatment. We synthesize extant research on these processes and offer suggestions for addressing them therapeutically and societally.

Molehill Mountain feasibility study: Protocol for a non-randomised pilot trial of a novel app-based anxiety intervention for autistic people

Up to 50% of autistic people experience co-occurring anxiety, which significantly impacts their quality of life. Consequently, developing new interventions (and/ or adapting existing ones) that improve anxiety has been indicated as a priority for clinical research and practice by the autistic community. Despite this, there are very few effective, evidence-based therapies available to autistic people that target anxiety; and those that are available (e.g., autism adapted Cognitive Behavioural Therapy; CBT) can be challenging to access. Thus, the current study will provide an early-stage proof of concept for the feasibility and acceptability of a novel app-based therapeutic approach that has been developed with, and adapted for, autistic people to support them in managing anxiety using UK National Institute for Health and Care Excellence (NICE) recommended adapted CBT approaches. This paper describes the design and methodology of an ethically approved (22/LO/0291) ongoing non-randomised pilot trial that aims to enrol approximately 100 participants aged ≥16-years with an existing autism diagnosis and mild-to-severe self-reported anxiety symptoms (trial registration NCT05302167). Participants will be invited to engage with a self-guided app-based intervention-'Molehill Mountain'. Primary (Generalised Anxiety Disorder Assessment, Hospital Anxiety and Depression Scale) and secondary outcomes (medication/ service use and Goal Attainment Scaling) will be assessed at baseline (Week 2 +/- 2), endpoint (Week 15 +/- 2) and three follow-ups (Weeks 24, 32 and 41 +/- 4). Participants will also be invited to complete an app acceptability survey/ interview at the study endpoint. Analyses will address: 1) app acceptability/ useability and feasibility (via survey/ interview and app usage data); and 2) target population, performance of outcome measures and ideal timing/ duration of intervention (via primary/ secondary outcome measures and survey/ interview)-with both objectives further informed by a dedicated stakeholder advisory group. The evidence from this study will inform the future optimisation and implementation of Molehill Mountain in a randomised-controlled trial, to provide a novel tool that can be accessed easily by autistic adults and may improve mental health outcomes.

Mental health providers' perceptions of competency when working with autistic children with co-occurring mental health diagnoses

Psychotherapy research has long focused on provider competence and treatment efficacy. Mental health providers treat diverse client populations with varying, complex needs. Though estimates vary, the rate of children diagnosed with autism and a co-occurring psychiatric disorder is relatively high. While behavioral approaches to treatment have been established as the gold standard, talk-based therapies are increasingly common, and a broader range of providers are treating this population. There are gaps in the literature regarding empirically supported, targeted approaches, and provider sense of competency in addressing complex needs. The aim of this secondary qualitative analysis was to gain further insights into mental health providers' experiences of psychotherapy with autistic children with a cooccurring diagnosis. Eleven licensed clinicians participated in semistructured interviews. The following themes emerged: perception of competency, complex needs, and family involvement. Recommendations for a collaborative approach, increased opportunities for training, and standardized, targeted assessments and treatment protocols were made.

Understanding the prevalence and manifestation of anxiety and other socio-emotional and behavioural difficulties in children with Developmental Language Disorder

BACKGROUND

It is well-documented that children with Developmental Language Disorder (DLD) have a higher likelihood of experiencing anxiety, as well as other socio-emotional and behavioural (SEB) difficulties. Despite this, there is little consensus as to how these difficulties manifest. This study aims to understand the prevalence of broader SEB difficulties and anxiety, informing intervention development by understanding the relationships between them.

METHODS

A mixed-methods, case-control study was conducted. First, an online survey was completed by 107 parents of either children with DLD ("DLD sample"; n = 57) or typically developing children ("typical sample"; n = 50), aged 6-12 years old. Binary SEB statements informed by previous qualitative work (e.g. "my child requires routine/sameness"; "my child has frequent tantrums") provided an insight into the prevalence of SEB difficulties in both DLD and typical samples. Validated measures of anxiety, emotion regulation, intolerance of uncertainty, insistence on sameness, family stress and coping mechanisms were also collected. Correlation and mediation analyses were run using these validated measures to understand the manifestation of anxiety in children with DLD in more detail. Qualitative interviews were then carried out with a select panel of survey respondents (n = 4).

RESULTS

The DLD sample scored significantly higher on all binary SEB statements than the typical sample: experiencing anxiety (80.7%, p < .05), requiring routine and sameness (75.4%, p < .001) and emotional dysregulation (75.4%; p < .001) were the most common difficulties reported for children with DLD. Using the validated scales, family stress and coping mechanisms were found to only correlate with the manifestation of anxiety in the typical group, not the DLD group. "Intolerance of uncertainty" and "insistence on sameness" were found to fully mediate the relationship between DLD diagnosis and symptoms of anxiety. Parent's interviews provided contextual support for the analysis, as well as highlighting sensory sensitivities as a focus for future research.

CONCLUSIONS

Parents of children with DLD appear to cope well with their children's complex SEB needs. Intervention focussing on intolerance of uncertainty may help the management of difficulties with anxiety. Behaviours such as insistence on sameness should be investigated further, as potential indicators for anxiety amongst children with DLD.

Childhood Executive Function Predicts Internalizing and Externalizing Symptoms in Emerging Adults With and Without Autism: A 10-Year Longitudinal Study

Individuals with autism spectrum disorder (ASD) and typically developing individuals were assessed on three neuropsychological tests of executive function (EF) and on scales of autism symptoms and co-occurring internalizing and externalizing symptoms at baseline (T1; N = 88, M_age = 11.8 years, 73% males), 2-year (T2; 99% retention, M_age = 13.9 years), and 10-year follow-ups (T3; 75% retention, M_age = 21.4 years). An EF composite score from T1 significantly predicted internalizing symptoms at T2 (β = .228) and internalizing and externalizing symptoms at T3 (β = .431 and .478, respectively), when controlling for age and autism symptoms. OThe findings suggest that EF difficulties are a long-term risk factor for more co-occurring symptoms. .

Emotion Regulation and Executive Function: Associations with Depression and Anxiety in Autism

Background

Adolescents and young adults with autism spectrum disorder (ASD) are prone to experience co-occurring mental health conditions such as mood or anxiety disorders, as well as impairments in emotion regulation and executive functioning. However, little research has examined inter-relationships among these constructs, despite evidence of additional stressors and increased risk of internalizing disorders at this age, relative to non-autistic individuals. If either emotion regulation or executive functioning are shown to have patterns of association with mental health, this can inform mechanism-based intervention.

Method

Fifty-seven autistic adolescents and adults (16-25 years) with ASD in a transition intervention completed questionnaires and clinician-administered measures at baseline. Analyses assessed whether executive functioning impairment, above and beyond emotion regulation impairment, were associated with depression and anxiety symptoms.

Results

ASD characteristics, emotion regulation, anxiety, and depression were significantly correlated. ASD characteristics was a significant contributor to depression and emotion regulation impairments were significant contributors to anxiety and depression. Findings indicated that inhibition difficulties did not uniquely contribute to depression or anxiety above emotion regulation impairment. Difficulties in cognitive flexibility were associated with depression above and beyond ASD characteristics, IQ, and emotion regulation, but not associated with anxiety.

Conclusions

Although preliminary, findings suggest that inflexibility and regulatory impairment should be considered in depression remediation approaches. Improving ER, on the other hand, may have broader transdiagnostic impact across both mood and anxiety symptoms in ASD.

Investigating associations between cognitive empathy, affective empathy and anxiety in adolescents with autism spectrum disorder

Autism spectrum disorder (ASD) is strongly associated with socio-cognitive impairments that may result in vulnerability to other mental health conditions, particularly anxiety disorders. This study examined the relationship between anxiety disorders and two key socio-cognitive impairments (cognitive empathy, affective empathy) in 60 adolescents (aged 11-18 years) with and without ASD. Adolescents with ASD showed cognitive empathy was negatively associated with separation anxiety disorder, whereas positive associations between affective empathy and generalized anxiety disorder, and positive marginal associations between affective empathy, social phobia, total anxiety, and separation anxiety disorder were observed. These findings suggest that cognitive and affective empathy show different patterns of associations with anxiety-related issues in ASD, and these differences should be considered for interventions and treatment programs.

Acceptance and commitment therapy for autistic adults: A randomized controlled pilot study in a psychiatric outpatient setting

LAY ABSTRACT

Autistic adults are often stressed and feel depressed or anxious. However, mental health programs that are suited for autistic adults are few. Acceptance and commitment therapy is a psychotherapy method that seems to help people feel better, although not thoroughly evaluated in autistic individuals. In this study, 20 autistic adults had 14 weeks of acceptance and commitment therapy group treatment suited for autism (NeuroACT), while 19 autistic adults had ordinary care. The acceptance and commitment therapy group treatment program seemed logical and reasonable to the participants. Also, when comparing the participants in the NeuroACT group with those in the ordinary care group, the NeuroACT participants reported less stress and higher quality of life. Compared to the ordinary care group, they could also manage distressing thoughts better, perceived themselves as more flexible, and did not avoid stressful situations as much as before. However, there was no significant difference between the groups in depression, anxiety, sleep problems, social aspects of autism, everyday functioning, or executive challenges. Slightly more NeuroACT participants did not finish the treatment than ordinary care participants. In conclusion, the NeuroACT program may be a treatment for autistic adults who feel stressed and have reduced quality of life. More studies are needed to see how helpful the NeuroACT program is for autistic adults.

Management of Emotion Dysregulation and Outbursts in Children and Adolescents

PURPOSE OF REVIEW

Emotion dysregulation and outbursts are very common reasons for referral to child and adolescent mental health services and a frequent cause of admission to hospitals and residential programs. Symptoms of emotion dysregulation and outburst are transdiagnostic, associated with many disorders, have the potential to cause severe impairment and their management presents a major challenge in clinical practice.

RECENT FINDINGS

There are an increasing number of psychosocial interventions that demonstrate promise in improving emotion dysregulation and outbursts. Acute care systems to manage the most severely ill patients have limited best practice guidelines but program advancements indicate opportunities to improve care models. Pharmacotherapy may be of assistance to psychosocial interventions but must be used with caution due to potential adverse effects. Much remains to be discovered however evidence informed, targeted treatments for specific populations show potential for future improvements in outcomes.

Effects of Square-Stepping Exercise on Motor and Cognitive Skills in Autism Spectrum Disorder Children and Adolescents: A Study Protocol

Individuals with autism spectrum disorder (ASD) diagnoses present not only cognitive, emotional, communicative, and social challenges but also movement issues that affect their everyday activities, learning, and leisure. The use of the square-stepping exercise (SSE), a motor program initially created to strengthen the lower limbs of older adults, is spreading because of its advantages (e.g., balance and lower limb strength improvements). A study protocol to assess the SSE effects on motor, sensory, and cognitive skills in Spanish children and adolescents between 6 and 12 years old with ASD diagnoses is presented. A randomised clinical will be performed, recruiting 52 children and adolescents with ASD who will be distributed into two groups: an experimental (n = 26) and a control (n = 26) group. The SSE sessions will be held for 9 weeks (two times per week). The main variable will be balance, which will be measured with the Movement Assessment Battery for Children 2 (MABC2), and secondary outcomes will include sensory processing, attention, and executive functions. Assessments will be carried out before and at the end of the program implementation, including an additional follow up one month later. If this program obtains positive results, it should be implemented in different settings (schools, clinics, associations, etc.) to improve the quality of movement and development in children and adolescents with ASD, as it is an easy-to-use and structured tool.

The Anxiety Caused by Secondary Schools for Autistic Adolescents: In Their Own Words

Secondary schools are increasingly becoming inclusive of all students whatever their individual needs, but we question whether teachers understand enough about specific needs in order to effectively support all their students. Research indicates that autistic students often struggle with aspects of school (conformity; social communication; sensory challenges; bullying) but very few studies ask autistic adolescents about their experiences. One of the key elements of the school experience for autistic adolescents is the levels of anxiety experienced by many students on a daily basis. This research set out to explore the extent to which autistic students in secondary schools in the UK were able to recognise and reflect on their own anxiety. The eighteen participants in this co-produced qualitative study took part in semi-structured interviews planned by a team of autistic and non-autistic researchers. The themes that emerged from this study, in terms of triggers for anxiety, included other people’s behaviour, fear of the unknown, and sensory sensitivities. A theoretical view of their difficulties concurs with the concept of intolerance of uncertainty. Our data suggest that autistic students continue to experience high levels of anxiety throughout their secondary education, despite supports put in place by some schools. Strategies are highlighted that could be implemented by all schools to promote truly inclusive settings.

A Systematic Review on the Impact of the Social Confinement on People with Autism Spectrum Disorder and Their Caregivers during the COVID-19 Pandemic

The COVID-19 pandemic had imposed a variety of containment measures on the general population for prolonged periods. Confinement has had, and still has, social, economic, educational, health, and psychological consequences on the entire population.

OBJECTIVE

In this article, a systematic search has been performed based on studies carried out since the beginning of the pandemic, regarding the impact of these containment measures on the autism spectrum disorder (ASD) population and their caregivers.

METHOD

We consulted six databases (i.e., PubMed, Medline, Embase, Scopus, Web of Science, and Science Direct) and selected ten studies that met the inclusion criteria. The chosen studies have been classified according to their theoretical focus, methodology, and target population.

RESULTS

We found an increase in stress and a decrease in psychological well-being among individuals diagnosed with ASD (i.e., parents and caregivers). Additionally, in studies focused on children, youth, and adults with ASD diagnosis, the results are contradictory depending on variables such as age, ASD severity, or type of family structure.

CONCLUSIONS

The results show that the consequences of quarantine and social confinement are quite contradictory and depend on variables such as age, ASD severity, and family features.

Exploring the impact of adolescent cognitive inflexibility on emotional and behavioural problems experienced by autistic adults

LAY ABSTRACT

Autistic people experience high levels of co-occurring mental health difficulties. To develop more effective treatments, a greater understanding of the thinking processes that may lead to these difficulties is needed. Cognitive inflexibility, defined as a rigid pattern of thoughts and subsequently behaviours, is one possible thinking trait which has previously been associated with both co-occurring mental health difficulties but also other features of autism such as restricted and repetitive behaviours. Restricted and repetitive behaviours include repetitive movements, ritualistic behaviours, and/or highly focused interests. This study investigates the relationship between, cognitive inflexibility, measured using neuropsychological tasks, and emotional and behavioural problems across adolescence and early adulthood. Eighty-one autistic people who were recruited to be representative of the wider autism population were assessed at 16 and 23 years on measures of emotional and behavioural problems, with cognitive inflexibility, restricted and repetitive behaviours and verbal intelligence measured at 16 years. We used statistical modelling to investigate the relationship between cognitive inflexibility and emotional and behavioural symptoms at both timepoints while accounting for the possible relationship with restricted and repetitive behaviours and verbal intelligence quotient. Our results suggest that cognitive inflexibility may be an important factor associated with emotional difficulties across adolescence and early adulthood. This suggests that developing intervention approaches targeting cognitive inflexibility may be an important step in improving the mental health of those with autism.

Trajectories of Dysregulation in Children with Autism Spectrum Disorder

Objective: This study determined whether child and family environment factors are associated with differences in developmental trajectories of emotional and behavioral dysregulation in children with autism spectrum disorder (ASD).Method: Participants included 186 families of a child with ASD (5-12 years old at baseline; 86% male; 83% non-Hispanic Caucasian; 35% comorbid intellectual disability). At each of the four time points (each spaced 12 months apart), mothers and fathers within each family completed well-validated measures on their own mental health, their child's dysregulation, their parent-child relationship, and their parent couple relationship. Longitudinal multi-level modeling was used to describe trajectories of dysregulation across 3 years and test whether parent depression, closeness in the parent-child relationship, and positive parent dyadic coping were associated with differences in child trajectories.Results: On average, child dysregulation decreased across time. Closer mother-child and father-child relationship quality was associated with lower baseline dysregulation. More severe child restricted and repetitive behaviors, fewer maternal depression symptoms, and more positive parent dyadic coping were associated with declines in child dysregulation over time.Conclusions: On average, children with ASD become less dysregulated across time. However, there is important variability in dysregulation trajectories of children with ASD. Children with ASD who have a high (versus low) severity of restricted and repetitive behaviors appear to be at risk for greater dysregulation. The family environment, and specifically a closer parent-child relationship, better maternal mental health, and more positive couple coping, may contribute to a pattern of improved child regulation across time in ASD.

Emergency Department Utilization of Adolescents and Young Adults with Autism Spectrum Disorder

This study examined emergency department (ED) utilization by adolescents and young adults, 12-30 years of age (AYA) with autism spectrum disorder (ASD) using the 2016 Healthcare Cost and Utilization Project/National Emergency Department Sample (HCUP/NEDS). We investigated the principal reason for an ED visit, presence of an ambulatory care sensitive condition (ACSC), and likelihood of hospital admission following ED encounter in ASD and Non-ASD cohorts. The ASD cohort had a higher proportion of ED visits for ACSC diagnoses as compared to the Non-ASD cohort. In addition, the likelihood of admission following an ED visit in the ASD cohort was 3.7 times greater than in the Non-ASD cohort.

Attunement and Paternal Characteristics in Care Relationships in the Presence of Children Diagnosed with Autism

Parents of children with autism spectrum disorder (ASD) have to address various challenges mainly due to their children’s atypia related to communication, emotion regulation and behaviors, arising also within the relationship with their caregivers. Several studies have pointed out that children with ASD can exhibit many difficulties regarding initiating and maintaining meaningful relationships with others. To date, little research has explored the interactions between children with ASD and their fathers, focusing more on mothers. In the context of parent–child interactions in the presence of autism, recent studies have highlighted the importance of parental attunement but there is little research considering solely the affective-bodily dimension. Therefore, the aim of the present study was to explore the parental attunement in fathers of children with ASD observed during play interactions and to investigate the relationship between paternal attunement and the perception of their psychological characteristics related to care relationships. The results highlight that fathers who describe themselves as better in affective care and sensitivity toward others more likely have an absence of paternal attunement during play interactions. The data presented are discussed in the light of intervention hypotheses, aimed at improving the relationship between fathers and children with autism.

Inner Speech Moderates the Relationship Between Autism Spectrum Traits and Emotion Regulation

Inner speech processes are thought to be associated with decreases in cognitive performance in autism spectrum disorder (ASD). Although verbal thinking is also a key component in emotional responses, no studies have investigated whether inner speech is linked to emotion regulation in ASD. The aim of this study was to investigate whether inner speech moderates the relationship between ASD traits and emotion regulation strategies. Our results indicate that only the evaluative/motivational form of inner speech moderates the relationship between ASD traits and cognitive reappraisal; inner speech processes did not moderate the association between ASD traits and expressive suppression. These findings are a first step to further investigate the role of inner speech in affective and self-regulatory processes in ASD.

Reliability and validity of the Pediatric Anxiety Rating Scale modified for autism spectrum disorder

LAY ABSTRACT

Many youth with autism spectrum disorder have anxiety, but it can be difficult to assess anxiety with existing measures. We modified the Pediatric Anxiety Rating Scale for youth with autism spectrum disorder and tested the new measure in a group of 116 youth (age: 5-17 years) with autism spectrum disorder. The Pediatric Anxiety Rating Scale for youth with autism spectrum disorder is an interview that a clinician usually completes with the child and parent together. We modified the interview questions and scoring instructions based on feedback from parents of children with autism spectrum disorder and from a panel of experts in autism spectrum disorder and anxiety. Unlike many other anxiety measures, the Pediatric Anxiety Rating Scale for youth with autism spectrum disorder relies less on a child's verbal expression of anxiety and more on signs that a parent can easily observe. Training clinicians to administer and score the Pediatric Anxiety Rating Scale for youth with autism spectrum disorder was uncomplicated, and raters showed excellent agreement on video-recorded interviews. Youth who were not currently in treatment for anxiety had stable Pediatric Anxiety Rating Scale for youth with autism spectrum disorder scores with repeat measurement over a 1-month period. The Pediatric Anxiety Rating Scale for youth with autism spectrum disorder is a useful clinician-rated measure of anxiety in youth with autism spectrum disorder and fills a gap for assessing anxiety in this population.

Therapeutic Alliance Formation for Adolescents and Young Adults with Autism: Relation to Treatment Outcomes and Client Characteristics

Therapeutic alliance may influence treatment outcomes for individuals with autism spectrum disorder (ASD). The present study examined the trajectory of alliance, observationally-measured at four timepoints during a 16-week mindfulness-based treatment targeting emotion regulation problems in adolescents and young adults with ASD (n = 37, mean age = 15.28, 78.40% male). Variability in alliance as a function of client characteristics and the degree to which alliance predicted emotion regulation outcomes were assessed using parent-report forms. Results demonstrate that alliance fluctuates throughout treatment. Moreover, stronger alliance predicts decreased dysphoria at posttreatment. Results also suggest that increased ASD symptom severity and depression predict weaker alliance early and throughout treatment. Findings highlight a need for clinicians to consider the importance of developing strong alliance for clients with ASD.

PRESS-Play: Musical Engagement as a Motivating Platform for Social Interaction and Social Play in Young Children with ASD

Musical experiences are ubiquitous in early childhood. Beyond potential benefits of musical activities for young children with typical development, there has long been interest in harnessing music for therapeutic purposes for individuals with autism spectrum disorder (ASD). However, there is debate as to the effectiveness of these approaches and thus a need to identify mechanisms of change (or active ingredients) by which musical experiences may impact social development in young children with ASD. In this review, we introduce the PRESS-Play framework, which conceptualizes musical activities for young children with ASD within an applied behavior analysis framework consistent with the principles of naturalistic developmental behavioral interventions. Specifically, the PRESS-Play framework proposes that musical activities support key elements of evidence-based approaches for social engagement including predictability, reinforcement, emotion regulation, shared attention, and social play context, providing a platform for delivery and receipt of social and behavioral instruction via a transactional, developmental approach. PRESS-Play considers that these factors may impact not only the child with ASD but also their interaction partner, such as a parent or peer, creating contexts conducive for validated social engagement and interaction. These principles point to focused theories of change within a clinical-translational framework in order to experimentally test components of social-musical engagement and conduct rigorous, evidence-based intervention studies.