Brief transition-focused education for families of autistic youth: preliminary mixed-methods investigation

PURPOSE

The transition to adulthood is one of the most challenging and complex processes for autistic youth and their families. Few evidence-based transition support programs exist, and those that have garnered support require long-term commitments and resources that may prohibit participation by families with financial and time limitations. The current study investigated the feasibility and initial promise of a brief, caregiver-focused educational transition program for families of autistic youth delivered in the community over a single day.

METHODS

Quantitative informant-report and qualitative interview data were collected from 12 caregivers of autistic youth before and after program participation. Using a partially mixed sequential equal status design, quantitative and qualitative data were integrated to evaluate change in caregiver transition knowledge and empowerment, as well as caregivers' perceptions of program feasibility, acceptability, and usefulness.

RESULTS

Caregivers reported significant increases in knowledge of transition-related topics and sense of empowerment regarding their family life. Caregiver perceptions of the intervention suggest they found it feasible, acceptable, and useful.

CONCLUSIONS

Short-term transition programming may be a helpful option for caregivers who seek transition supports for autistic youth.

Structural, Institutional, and Interpersonal Racism: Calling for Equity in Autism Research and Practice

Disparities in autism research and practices based on race and ethnicity are evident across many outcomes and life course stages. However, most of the research has focused on outlining differences and not the underlying systemic inequities driving these disparities. In this conceptual paper, we aim to shift the focus by outlining mechanisms of structural racism within the institutions of science, healthcare, and residential segregation and educational systems in the United States (U.S.). We argue that these and other forms of institutional racism constitute structural racism that are influencing the racial and ethnic disparities we see in autism services and care. For each of these institutions, we identify institutional racism related to autism and offer an example of how it shapes interpersonal racism and adverse outcomes, including misdiagnosis, delayed diagnosis, unequal access to educational services, and differential treatment in clinical encounters. We then provide anti-racism approaches in autism research and practice for each of these institutions that addresses institutional and interpersonal racism shaping autism inequities among racial and ethnic minorities. We conclude with a call to action to clinicians, researchers, and others to prioritize and disrupt the impacts of structural, institutional, and interpersonal racism through targeted anti-racism approaches.

Improving Resident Physician History and Physical in Challenging Situations

OBJECTIVE

To educate physician trainees using simulation on best management of children with autism spectrum disorder who have neurocognitive and behavioral challenges when experiencing acute illness.

METHOD

A simulation-based curriculum including baseline assessment, communication techniques, and use of calming resources was developed to educate residents in assessing children with sensory barriers. Traditional simulation and deliberate practice were used to teach this curriculum to second- and third-year pediatric and internal medicine-pediatric residents. Using alternating assignment, residents were placed into 3 groups: deliberate practice, traditional simulation-based debriefing, and control (no simulation training). The residents were assessed on the initial visit, 2 weeks and 4 to 6 months follow-up periods with a sensory assessment tool. Assessment scores were analyzed using a general linear mixed model with random intercept based on Poisson regression to approximate distribution of the total score.

RESULTS

Forty-three residents participated: 46.5% men, 53.5% women. There were 15, 16, and 12 residents in the control, deliberate practice and traditional simulation groups, respectively. Both teaching styles showed improved performance at 2 weeks follow-up. In addition, these groups demonstrated higher performance when compared with the control group. We were able to show that resident physicians were able to learn important principles and retain them during 4 to 6 months follow-up. However, there was not a difference between 2 teaching styles both in improvement and retention.

CONCLUSION

Simulation education, both deliberate and traditional, can be used to enhance teaching of key components in assessing children with sensory and communication barriers, including those with autism spectrum disorder when presenting with acute illness.

Deep Brain Stimulation of the Nucleus Accumbens for Severe Self-Injurious Behavior in Children: A Phase I Pilot Trial

BACKGROUND

Self-injurious behavior (SIB) consists of repetitive, nonaccidental movements that result in physical damage inflicted upon oneself, without suicidal intent. SIB is prevalent among children with autism spectrum disorder and can lead to permanent disability or death. Neuromodulation at a locus of neural circuitry implicated in SIB, the nucleus accumbens (NAc), may directly influence these behaviors.

METHODS

We completed a phase I, open-label clinical trial of deep brain stimulation (DBS) of the NAc in children with severe, treatment-refractory SIB (ClinicalTrials.gov identifier NCT03982888). Participants were monitored for 12 months following NAc-DBS to assess the primary outcomes of safety and feasibility. Secondary outcomes included serial assessments of SIB and SIB-associated behaviors, ambulatory actigraphy, and changes in brain glucose metabolism induced by DBS.

RESULTS

Six children (ages 7-14 years) underwent NAc-DBS without serious adverse events. One child was found to have a delayed asymptomatic intracranial hemorrhage adjacent to a DBS electrode that did not require intervention, and 3 children experienced transient worsening in irritability or SIB with titration of stimulation parameters. NAc-DBS resulted in significant reductions in SIB and SIB-associated behaviors across multiple standardized scales, concurrent with clinically meaningful improvements in quality of life. Ambulatory actigraphy showed reductions in high-amplitude limb movements and positron emission tomography revealed treatment-induced reductions in metabolic activity within the thalamus, striatum, and temporoinsular cortex.

CONCLUSIONS

This first-in-children phase 1 clinical trial demonstrates the safety and feasibility of NAc-DBS in children with severe, refractory SIB at high risk of physical injury and death and supports further investigations.

The Transition to Adulthood: A Qualitative Study of Autism Spectrum Disorder From Military and Veteran Parents and Military-Dependent Young Adults

INTRODUCTION

Given the unique experiences of military service members and their families, military-dependent young adults (18-25 years old) with autism spectrum disorder (ASD) and their military or veteran families experience unique barriers to accessing quality mental health care during the transition to adulthood. In fact, developing services to address ASD challenges for military families is a burgeoning area of interest for the department of defense. However, there is a limited knowledge on the specific needs of military families as the young adult's transition outside of high school and lose supports.

MATERIALS AND METHODS

The present study conducted 3 focus groups with 16 military and veteran parents, and 3 focus groups with 10 military-dependent young adults to evaluate the needs of military-dependent young adults (17-25 years old) with ASD and military/veteran parents with a young adult with ASD.

RESULTS

Parents reported several key topics, including barriers to services (e.g., permanent change of station, recently moving to a state and lacking awareness of the available resources), defining adulthood in terms working in a cohesive family structure, and therapy recommendations for parents and young adults with ASD transitioning to adulthood. Young adults provided key information, including describing experiences with having a parent in the military, difficulty accessing services during the transition to adulthood, and recommendations on therapy for military-dependent young adults with ASD.

CONCLUSION

Military and veteran families with autistic dependents lack access to important mental-health resources. When developing programs for military families and military-dependent autistic young adults, mental health providers should consider the frequent relocations, lack of access to important transition resources, and common military values. The presence of advocates at military bases should be encouraged to help military families navigate autism services in their local community.

"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.

'We have so much to offer': Community members' perspectives on autism research

LAY ABSTRACT

Autism research is changing. Autistic activists and researchers want Autistic people in the community to have more of a say about what is researched and how. But we haven't asked people in the community what they think. This study used the information obtained from 55 community members, including Autistic people, their families, and professionals working with Autistic people, from an existing study on their priorities for autism research. We re-looked at what was said to see if we could understand community members' views and experiences of autism research. People agreed strongly that research can play a powerful role in shaping good Autistic lives. They also felt that big changes were needed for research to do this. Some of these changes were that researchers should stop thinking about autism narrowly and in a negative way, where Autistic people are seen as the problem. Researchers need to think more about how to improve systems, experiences and how other people respond to Autistic people. They also want the autism community to be more involved in what is researched and how it is researched. The findings from our study here highlight the potential for research to be positive when Autistic people and their families are listened to, approached with understanding, and are respected and valued as individuals in the research process.

Letter to the Editor: A possible threat to data integrity for online qualitative autism research

LAY ABSTRACT

Doing research online, via Zoom, Teams, or live chat, is becoming more and more common. It can help researchers to reach more people, including from different parts of the world. It can also make the research more accessible for participants, especially those with different communication preferences. However, online research can have its downsides too. We have recently been involved in three studies in which we had in-depth discussions with autistic people and/or parents of autistic children about various topics. It turns out, though, that some of these participants were not genuine. Instead, we believe they were "scammer participants": people posing as autistic people or parents of autistic children, possibly to gain money from doing the research. This is a real problem because we need research data that we can trust. In this letter, we encourage autism researchers to be wary of scammer participants in their own research.

The viability of a proposed psychoeducational neurodiversity approach in children services: The PANDA (the Portsmouth alliance's neuro-diversity approach)

People with Neurodevelopmental (ND) conditions are often unfairly stereotyped by society, without fully appreciating their strengths. As a result, their advantageous behaviours may be overlooked or ignored. Despite wide psychoeducation on ND in society there is a push from the scientific and ND community to move from a binary diagnostic system to an approach that encompasses the spectrum experienced by individuals. In view of this, we have developed the Portsmouth Alliance Neuro-Diversity Approach (PANDA), a coproduced method which helps facilitate understanding, communication and early support for individuals who may be Neuro-Diverse. 51 young people, their parents and attached professionals participated in the approach's feasibility to improve wellbeing and symptom management measured by quantitative and qualitative means. Results showed a significant improvement in the child's wellbeing, but not symptom management. Overall, this indicates the PANDA could facilitate a more holistic approach for referrals, information gathering, psychoeducation and cross-system relationship building to be used in conjunction with a traditional pathway. Though, this study is limited in scope, its main purpose is to inform future development of the approach. Additionally, more research investigating the specific narrative, and separate structure of the PANDA would be required to highlight the strengths and limitations of implementation.

'If I'm just me, I doubt I'd get the job': A qualitative exploration of autistic people's experiences in job interviews

LAY ABSTRACT

When applying for a job, autistic job candidates are likely to face a number of challenges. Job interviews are one of these challenges - they require communicating and relationship-building with unfamiliar people and involve expectations about behaviour (that may vary between companies and are not made clear to job candidates). Given autistic people communicate differently to non-autistic people, autistic job candidates may be disadvantaged in the interview process. Autistic candidates may not feel comfortable or safe sharing with organisations their autistic identity and may feel pressure to hide any characteristics or behaviour they feel might indicate they are autistic. To explore this issue, we interviewed 10 autistic adults about their job interview experiences in Australia. We analysed the content of the interviews and found three themes that related to the individual person and three themes that related to environmental factors. Participants told us that they engaged in camouflaging behaviour during job interviews, feeling pressure to conceal aspects of themselves. Those who camouflaged during job interviews reported that it took a lot of effort, which resulted in increased stress, anxiety and exhaustion. The autistic adults we spoke to reported a need for inclusive, understanding and accommodating employers to help them feel more comfortable disclosing their autism diagnosis in the job application process. These findings add to current research that has explored camouflaging behaviour and barriers to employment for autistic people.

Combating stigma in autism research through centering autistic voices: a co-interview guide for qualitative research

As autism has gained increased attention in the past few decades, autistic advocates have adopted the phrase "Nothing about us without us," illustrating the idea that autistic people should be centered in all conversations regarding autism. However, in a large portion of autism research, autistic people are still not meaningfully engaged throughout the research process, leading to continued stigma in research through biased methods. Thus, stigma about autism influences not only the content of autism research, but the ways in which neurotypical people conduct research alongside (or without) autistic people, ultimately resulting in less valid conclusions or research that actively harms the autistic community. One way to address this stigma is through involving autistic individuals as equal partners in the research process, such as by including autistic co-interviewers in qualitative studies of autistic people. In this perspectives piece, we will highlight the benefits of participatory research practices within qualitative research. Furthermore, we will outline methods for conducting co-interviews with autistic research partners and share insights from our experiences implementing this practice. We hope this piece provides researchers the practical resources and inspiration to continue working toward decreasing the stigma surrounding autism in research spaces.

Human pluripotent stem cell (hPSC) and organoid models of autism: opportunities and limitations

Autism spectrum disorder (ASD) is a complex neurodevelopmental disorder caused by genetic or environmental perturbations during early development. Diagnoses are dependent on the identification of behavioral abnormalities that likely emerge well after the disorder is established, leaving critical developmental windows uncharacterized. This is further complicated by the incredible clinical and genetic heterogeneity of the disorder that is not captured in most mammalian models. In recent years, advancements in stem cell technology have created the opportunity to model ASD in a human context through the use of pluripotent stem cells (hPSCs), which can be used to generate 2D cellular models as well as 3D unguided- and region-specific neural organoids. These models produce profoundly intricate systems, capable of modeling the developing brain spatiotemporally to reproduce key developmental milestones throughout early development. When complemented with multi-omics, genome editing, and electrophysiology analysis, they can be used as a powerful tool to profile the neurobiological mechanisms underlying this complex disorder. In this review, we will explore the recent advancements in hPSC-based modeling, discuss present and future applications of the model to ASD research, and finally consider the limitations and future directions within the field to make this system more robust and broadly applicable.

Integrating autistic perspectives into autism science: A role for autistic autobiographies

LAY ABSTRACT

Autism science faces challenges in how to think about autism and what questions to focus on, and sometimes contributes to stigma against autistic people. We examine one way that non-autistic researchers may start to combat these challenges: by reading and reflecting on autistic people's descriptions of their personal experiences (e.g. autobiographies) of what it is like to be autistic. In this article, we review some of the advantages and challenges of this approach and how it may help combat some of the challenges currently facing autism science by focusing studies on the questions autistic people find most important, counteracting stereotypes, and increasing understanding of autistic experiences.

From ivory tower to inclusion: Stakeholders' experiences of community engagement in Australian autism research

Autistic people, and other community stakeholders, are gaining increasing recognition as valuable contributors to autism research, resulting in a growing corpus of participatory autism research. Yet, we know little about the ways in which stakeholders practice and experience community engagement in autism research. In this study, we interviewed 20 stakeholders (academics, autistic people, family members/careers, research students, and service providers) regarding their experiences of community engagement in Australian autism research. Through reflexive thematic analysis of interview data, we generated four themes. First, our participants perceived academia as an "ivory tower," disconnected from community members' lives and priorities. Second, our participants identified that different stakeholders tended to hold different roles within their research projects: academics typically retained power and control, while community members' roles tended toward tokenism. Third, our participants spoke of the need to "bridge the gap" between academia and the community, highlighting communication, accessibility, and planning as key to conducting effective participatory research. Lastly, participants emphasized the changing nature of autism research, describing participatory research as "the way of the future." Our findings reflect both the progress achieved to date, and the challenges that lie ahead, as the field advances toward genuine co-production of autism research.

Show Me the Real You: Enhanced Expression of Rogerian Conditions in Therapeutic Relationship Building with Autistic Adults

Background

Research in psychotherapy and counseling theory has shown the importance of a strong therapeutic relationship. However, in the context of working with autistic adults, the relationship appears to be de-emphasized, or "different approaches" are recommended without specifying these. Neglect of relationship building may contribute to autistic adults' negative experiences with health care professionals identified in previous studies.

Methods

I interviewed 17 autistic adults about their relationship building experiences with a wide range of professionals primarily from mental and medical health backgrounds. I also interviewed two mental health counselors and one psychologist who had experience working with this client group and had been recommended by autistic participants. I elicited best practice recommendations from all participants. I analyzed the data in an interpretive-interactionist framework and present them through creative analytic practice.

Findings

I address one major theme in this article: the importance of Rogerian/person-centered relationship conditions. All had to be practiced in an enhanced way: (1) Enhanced congruence could be demonstrated through therapist self-disclosure and refraining from phony relationship building "techniques" such as vocal adjustments. (2) Enhanced empathy could be demonstrated through genuine listening and accurate interpretation; however, interpretation needed to be phrased tentatively. (3) Enhanced unconditional positive regard could be demonstrated through explicit verbal expression, practical demonstration, and remembering.

Conclusions

Results largely mirrored research with non-autistic populations: different approaches were not needed for relationship building. Participants emphasized the importance of Rogers' person-centered conditions and described pivotal relationship building moments associated with enhanced expression of these conditions.

"I Knew She'd Get It, and Get Me": Participants' Perspectives of a Participatory Autism Research Project

Introduction

Autistic advocates and their supporters have long argued that conventional research practices provide too few opportunities for genuine engagement with autistic people, contributing to social disenfranchisement among autistic people. We recently described one attempt to develop and implement a participatory study in which a team of autistic and nonautistic researchers worked together to gather life histories from late-diagnosed autistic people. In the current study, we sought to understand the impact of this participatory approach on the participants themselves.

Methods

We spoke to 25 Australian late-diagnosed autistic adults (aged 45-72 years), who had been interviewed by an autistic researcher using an oral history approach. We asked them about their experience of being involved in that project and the research process more broadly. We thematically analyzed participants' interviews.

Results

Participants responded overwhelmingly positively to the opportunity to tell their life history, considering it illuminating and empowering. While recounting their life history was often described as "exhausting" and "draining," participants also reported feeling "supported all the way" and agreed "it was made easier because I had an autistic researcher interviewing me." One participant went so far as to say that they "probably would have dropped out [of the project] if it was run by people who weren't autistic."

Conclusions

These findings demonstrate that the benefits of coproduction to researchers and community partners extend to study participants and to the quality of the research itself. Involving autistic partners in the research process, especially in its implementation, can play a crucial role in enhancing autism research.

Perceived Stigma and Barriers to Accessing Services: Experience of Caregivers of Autistic Children Residing in Latin America

BACKGROUND

Relationship of perceived stigma and barrier to service access among Latino populations with autism in cross-cultural settings has not been fully explored.

AIM

The present study explored the relationship between difficulty accessing services and perceived stigma among caregivers of autistic children in Latin America. Additionally, explore contextual factors that better explain the perception of stigma when accessing services.

METHODS AND PROCEDURE

Approximately 2500 caregivers from six Latin American countries completed an online survey. Descriptive inferential analysis and a pointbiserial correlation were conducted to understand direct relationship between difficulty accessing services and perceived stigma and to test their relationship. Added contextual factors contributing to this relationship were examined through a binary logistic regression.

OUTCOMES AND RESULTS

Barriers to accessing services predicted stigma. Contextual factors such as country of residence, frustration experienced by caregivers, gender of autistic child and challenging behaviours had higher odds of experiencing some form of perceived stigma.

CONCLUSIONS AND IMPLICATIONS

These results suggest experiences with stigma to be heavily influenced by environmental factors such cultural differences which in combination with contextual factors could further increase the likelihood of perceiving stigma. When observing stigma within a social-cognitive approach, it is possible that a strong-held adherence to cultural norms, in addition to negative experiences (e.g., frustration) when accessing services, could be influencing caregivers perceived stigma.

Toward Empathetic Autism Research: Developing an Autism-Specific Research Passport

Autistic adults sometimes report negative experiences of research participation. People have developed passports or toolkits in other areas where community members report dissatisfaction (e.g., health care, criminal justice). We created a Research Passport that autism researchers and autistic adults could use to support the inclusion of autistic adults as research participants. We designed and developed the Research Passport via an iterative design process. First, we gathered ideas for a Research Passport via focus groups with autistic adults without an intellectual disability (ID) (n = 9) and autism researchers (n = 6; one of whom was autistic). We found that the Research Passport (1) was a useful idea, but not a panacea for all issues in autism research, (2) needed to be universal and flexible, and (3) could have a broad remit (e.g., to record scores on commonly used standardized tasks that could, with permission, be shared with different researchers). Next, we conducted a preliminary evaluation of a prototype Research Passport via usability testing in three ongoing research projects. Nine autistic participants without an ID provided feedback on the Research Passport (via a survey), as did three nonautistic researchers (via interviews). We found that the Research Passport (1) promoted positive participant-researcher relationships, (2) provided a structure and framework to support existing practices, and (3) needed to be adapted slightly to facilitate usability and manage expectations. Overall, the Research Passport was useful in promoting empathetic autism research. Further design and development of the Research Passport are warranted.

Lay summary

Why was this research developed?: Autistic adults taking part in research do not always have good experiences. An autistic member on our team thought that a Research Passport could help improve people's experiences. This idea was inspired by "passports" or "toolkits" that autistic people can use when visiting professionals such as doctors (so the doctor knows about the person and how to support them).What does the Research Passport do?: The Research Passport lets autistic people tell researchers about themselves before taking part in a research study. Autistic people can decide how much, or how little, they tell the researcher. Autistic and/or nonautistic researchers can use the Research Passport to try and make sure that their autistic participants have good experiences when taking part in research.How did the researchers evaluate the Research Passport?: First, nine autistic adults (who did not have an intellectual disability) and six autism researchers took part in group discussions. We asked what they thought about our Research Passport idea and what it should include. We made a Research Passport mock-up based on these discussions. Nine autistic participants who did not have an intellectual disability used the mock-up in one of three university research projects. Autistic participants completed a survey to tell us good and not-so-good things about the Research Passport. Also, we interviewed three researchers about using the Research Passport (asking what they liked and what could have been better).What were the findings?: Autistic adults and researchers involved in designing the Research Passport thought the Research Passport (1) could be useful but could not solve all problems in autism research, (2) needed to be suitable for many different people, and (3) could have many different benefits (e.g., collecting participants' scores on tests that researchers use a lot, so participants do not have to keep doing the same tests each time they take part in a new research study).Autistic adults and researchers used the Research Passport in ongoing studies and told us that it (1) led to good relationships between participants and researchers, (2) helped researchers make sure that the way they did their research was acceptable, and (3) was useful. However, participants need to be told what the Research Passport can/cannot help them with.What were the weaknesses of this project?: This study involved a small group of autistic adults and researchers, and the results may not be the same with autistic adults and researchers who have different needs. Also, participants said the Research Passport was not very easy to complete, and a bit long. We need to change the Research Passport so that a wider range of autistic people (like those with intellectual disability) can use it.What are the next steps?: The Research Passport needs to be professionally designed so it is easier to be used by a wider range of autistic people. A bigger evaluation of the Research Passport could allow us to test it with more participants and in more research studies.How will this work help autistic adults now or in the future?: Using the Research Passport could, with some changes and alongside other supports, improve the experience of autistic adults taking part in research.

Person-Oriented Research Ethics to Address the Needs of Participants on the Autism Spectrum

Research ethics scholarship often attends to vulnerability. People with autism may be vulnerable in research, but are also vulnerable to unjust exclusion from participation. Addressing the needs of participants with autism can facilitate inclusion and honor the bioethics principle of respect for persons while accounting for risk and vulnerability. Drawing from a review of the literature and informed by a moral deliberation process involving a task force of stakeholders (including autistic people and parents of autistic people), we use the model of person-oriented research ethics to identify several practical strategies researchers can use to address these needs and foster inclusion. Strategies include using multiple means of communication, addressing the sensory environment, preparing participants in advance, and accounting for social context. These practical strategies are not just methodological or design choices; they are inherently related to ethical issues. Method and design choices fulfill ethical aspirations by facilitating inclusion, reducing discomfort, and focusing on individuals.