Cognitive Remediation Interventions in Autism Spectrum Condition: A Systematic Review

Insistence on sameness, repetitive negative thinking and mental health in autistic and non-autistic adults

LAY ABSTRACT

Autistic people are more likely to have mental health problems than non-autistic people. We know that having repetitive and negative thoughts can contribute to multiple mental health problems such as depression and obsessive-compulsive disorder. Autistic people often do the same behaviours repetitively, and they may also have more repetitive thinking styles. This could contribute to higher rates of mental health problems in autistic people. In this research, we wanted to find out if higher rates of repetitive behaviours contributed to depression and anxiety, and whether this relationship was because of repetitive negative thinking. We asked three groups of autistic adults to take part in the research. Sixty-seven autistic clinical participants were recruited from clinical settings and had moderate depression. Fifty-four autistic community participants and 66 non-autistic community participants were recruited from community settings. All participants completed measures of repetitive behaviours; a measure of anxiety and depression; and two measures of repetitive negative thinking (ruminating and obsessing). Autistic community participants had significantly higher repetitive behaviours, rumination and obsessing scores than non-autistic community participants. We found that higher rates of repetitive behaviours contributed to more repetitive thinking (obsessing and ruminating), which contributed to higher rates of depression and anxiety. The higher rates of repetitive negative thinking found in autistic individuals may contribute to higher rates of mental health problems in this group. Mental health assessments and interventions for autistic people should therefore consider the role of multiple forms of repetitive negative cognition and behaviour, which cut across diagnostic categories such as anxiety, depression and obsessive-compulsive disorder. These should be considered when aiming to understand why individuals develop mental health conditions and why these conditions persist.

Five Challenges in Implementing Cognitive Remediation for Patients with Substance Use Disorders in Clinical Settings

Many patients with substance use disorders (SUDs) present cognitive deficits, which are associated with clinical outcomes. Neuropsychological remediation might help rehabilitate cognitive functions in these populations, hence improving treatment effectiveness. Nardo and colleagues (Neuropsychology Review, 32, 161-191, 2022) reviewed 32 studies applying cognitive remediation for patients with SUDs. They underlined the heterogeneity and lack of quality of studies in this research field but concluded that cognitive remediation remains a promising tool for addictive disorders. We capitalize on the insights of this review to identify the key barriers that currently hinder the practical implementation of cognitive remediation in clinical settings. We outline five issues to be addressed, namely, (1) the integration of cognitive remediation in clinical practices; (2) the selection criteria and individual factors to consider; (3) the timing to be followed; (4) the priority across trained cognitive functions; and (5) the generalization of the improvements obtained. We finally propose that cognitive remediation should not be limited to classical cognitive functions but should also be extended toward substance-related biases and social cognition, two categories of processes that are also involved in the emergence and persistence of SUDs.

Understanding Others' Distress Through Past Experiences: The Role of Memory Engram Cells in Observational Fear

For individuals to survive and function in society, it is essential that they recognize, interact with, and learn from other conspecifics. Observational fear (OF) is the well-conserved empathic ability of individuals to understand the other's aversive situation. While it is widely known that factors such as prior similar aversive experience and social familiarity with the demonstrator facilitate OF, the neural circuit mechanisms that explicitly regulate experience-dependent OF (Exp OF) were unclear. In this review, we examine the neural circuit mechanisms that regulate OF, with an emphasis on rodent models, and then discuss emerging evidence for the role of fear memory engram cells in the regulation of Exp OF. First, we examine the neural circuit mechanisms that underlie Naive OF, which is when an observer lacks prior experiences relevant to OF. In particular, the anterior cingulate cortex to basolateral amygdala (BLA) neural circuit is essential for Naive OF. Next, we discuss a recent study that developed a behavioral paradigm in mice to examine the neural circuit mechanisms that underlie Exp OF. This study found that fear memory engram cells in the BLA of observers, which form during a prior similar aversive experience with shock, are reactivated by ventral hippocampal neurons in response to shock delivery to the familiar demonstrator to elicit Exp OF. Finally, we discuss the implications of fear memory engram cells in Exp OF and directions of future research that are of both translational and basic interest.

Examining normative values using the Cambridge neuropsychological test automated battery and developmental traits of executive functions among elementary school-aged children in Japan

The Cambridge Neuropsychological Test Automated Battery (CANTAB) is a computerized and child-friendly neuropsychological assessment battery that includes subtests aimed at evaluating some aspects of executive functions. Using the CANTAB, this study aims to establish normative values based on the aspects of executive functions among school-aged children in Japan. The participants included 234 children (135 boys and 99 girls aged 6-12 years) enrolled in regular classes, without any clinical records of developmental disorders or educational support. The participants were grouped according to age (6-7, 8-9, and 10-12 years). Four CANTAB subtests, including spatial working memory (SWM) to assess spatial working memory, Stockings of Cambridge (SOC) to evaluate planning, intra/extradimensional set shift (IED) to evaluate attentional set shifting and flexibility, and stop signal task (SST) to evaluate inhibition, were administered to each participant. The results showed that performance in all the CANTAB subtests administered changed with age. Among the subtests, compared with performances in the SOC and IED, those in the SWM and SST improved earlier, thereby indicating that spatial working memory and inhibition develop earlier than planning as well as attentional set shifting and flexibility. Additionally, in the SST subtest, girls made fewer errors than boys did in the 6-7 years group. This study presents normative data of four CANTAB subtests according to age and sex among school-aged children in Japan. We expect that the findings will be used to develop effective tools for the early detection of and support for children with executive dysfunction.

Inhibition functions can be improved in children with autism spectrum disorders: An eye-tracking study

Cognitive remediation therapy interventions could improve cognitive functioning in subjects with autism. To investigate the benefit of a short cognitive training rehabilitation in children with autism spectrum disorder (ASD) on pursuit and fixation performances. We recruited two groups (G1 and G2) of 30 children with ASD, sex-, IQ- and age-matched (mean 11.6 ± 0.5 years), and pursuit and fixation eye movements were recorded twice at T1 and T2. Between T1 and T2, a 10-min cognitive training was performed by the G1 group only, whereas the G2 group had a 10-min of rest. For all children with ASD enrolled in the study, there was a positive correlation between restricted and repetitive behaviour scores of both Autism Diagnostic Interview-Revised (ADI-R) and the Autism Diagnostic Observation Schedule (ADOS) and the number of saccades recorded during the fixation task at T1. At T1, oculomotor performances were similar for both groups of ASD children (G1 and G2). At T2, we observed a significant reduction in the number of saccades made during both pursuit and fixation tasks. Our findings underlined the importance to promote cognitive training rehabilitation for children with ASD, leading to a better performance in inhibitory and attention functioning responsible for pursuit and fixation eye movement's performance.

Virtual Reality Training of Social Skills in Adults with Autism Spectrum Disorder: An Examination of Acceptability, Usability, User Experience, Social Skills, and Executive Functions

Poor social skills in autism spectrum disorder (ASD) are associated with reduced independence in daily life. Current interventions for improving the social skills of individuals with ASD fail to represent the complexity of real-life social settings and situations. Virtual reality (VR) may facilitate social skills training in social environments and situations similar to those in real life; however, more research is needed to elucidate aspects such as the acceptability, usability, and user experience of VR systems in ASD. Twenty-five participants with ASD attended a neuropsychological evaluation and three sessions of VR social skills training, which incorporated five social scenarios with three difficulty levels. Participants reported high acceptability, system usability, and user experience. Significant correlations were observed between performance in social scenarios, self-reports, and executive functions. Working memory and planning ability were significant predictors of the functionality level in ASD and the VR system's perceived usability, respectively. Yet, performance in social scenarios was the best predictor of usability, acceptability, and functionality level. Planning ability substantially predicted performance in social scenarios, suggesting an implication in social skills. Immersive VR social skills training in individuals with ASD appears to be an appropriate service, but an errorless approach that is adaptive to the individual's needs should be preferred.

Fully Immersive Virtual Reality-Based Cognitive Remediation for Adults with Psychosocial Disabilities: A Systematic Scoping Review of Methods Intervention Gaps and Meta-Analysis of Published Effectiveness Studies

BACKGROUND

Cognitive Remediation (CR) programs are effective for the treatment of mental diseases; in recent years, Virtual Reality (VR) rehabilitation tools are increasingly used. This study aimed to systematically review and meta-analyze the published randomized controlled trials that used fully immersive VR tools for CR programs in psychiatric rehabilitation. We also wanted to map currently published CR/VR interventions, their methods components, and their evidence base, including the framework of the development intervention of CR in fully immersive VR.

METHODS

Level 1 of evidence. This study followed the PRISMA extension for Scoping Reviews and Systematic Review. Three electronic databases (Pubmed, Cochrane Library, Embase) were systematically searched, and studies were included if they met the eligibility criteria: only randomized clinical trials, only studies with fully immersive VR, and only CR for the adult population with mental disorders.

RESULTS

We found 4905 (database) plus 7 (manual/citation searching articles) eligible studies. According to inclusion criteria, 11 studies were finally reviewed. Of these, nine included patients with mild cognitive impairment, one with schizophrenia, and one with mild dementia. Most studies used an ecological scenario, with improvement across all cognitive domains. Although eight studies showed significant efficacy of CR/VR, the interventions' development was poorly described, and few details were given on the interventions' components.

CONCLUSIONS

Although CR/VR seems to be effective in clinical and feasibility outcomes, the interventions and their components are not clearly described. This limits the understanding of the effectiveness and undermines their real-world implementation and the establishment of a gold standard for fully immersive VR/CR.

Social cognition training improves recognition of distinct facial emotions and decreases misattribution errors in healthy individuals

Facial emotion recognition is a key component of social cognition. Impaired facial emotion recognition is tied to poor psychological wellbeing and deficient social functioning. While previous research has demonstrated the potential for social cognition training to improve overall facial emotion recognition, questions remain regarding what aspects of emotion recognition improve. We report results from a randomized controlled trial that evaluates whether computerized social cognition training can improve recognition of distinct facial emotions in healthy participants. This investigation was designed to better understand the therapeutic potential of social cognition training for individuals with neuropsychiatric disorders. Fifty-five healthy adult participants were randomly assigned to an internet-based intervention during which they either completed social cognition training (SCT) or played control computer games (CON) for 10.5 h over 2-3 weeks. Facial emotion recognition was measured with the Penn ER-40, which was conducted before and after training. The following variables were collected and analyzed: facial emotion recognition accuracy for each emotion (i.e., anger, fear, happy, neutral (no emotional expression), and sad), reaction times for each emotion, and response error types (i.e., frequency of an emotion being chosen incorrectly, frequency of an emotion being missed, and frequency of an emotion being confused for another particular emotion). ANOVAs and t-tests were used to elucidate intervention effects both within and between groups. Results showed that the SCT group improved their accuracy for angry and neutral faces. They also improved their reaction times for neutral, fearful, and sad faces. Compared to the CON group, the SCT group had significantly faster reaction times to neutral faces after training. Lastly, the SCT group decreased their tendency to confuse angry faces for no emotional expression and to confuse no emotional expression for sad faces. In contrast, the CON group did not significantly improve their accuracy or reaction times on any emotional expression, and they did not improve their response error types. We conclude that social cognition training can improve recognition of distinct emotions in healthy participants and decrease response error patterns, suggesting it has the potential to improve impaired emotion recognition and social functioning in individuals with facial emotion recognition deficits.

Contrasting the Social Cognitive and Metacognitive Capacities Among Patients With Schizophrenia and Autism Spectrum Disorders Enrolled in Psychiatric Rehabilitation

ABSTRACT

Unique deficits in synthetic metacognition have been found in schizophrenia when compared with other psychiatric conditions and community controls. Although persons with autism spectrum disorders (ASD) display similar deficits in social cognition relative to those with schizophrenia, to date no study has compared metacognitive function between these groups. We aimed to compare the metacognitive capacities of persons with schizophrenia and ASD and their associations with other outcomes (neurocognition, social cognition, depression, and quality of life). Fifty-six outpatients with schizophrenia or ASD (mean age, 32.50 [9.05]; 67.9% male) were recruited from two French Centers of Reference for Psychiatric Rehabilitation of the REHABase cohort. Evaluation included the Indiana Psychiatric Illness Interview, Metacognition Assessment Scale-Abbreviated, Movie for the Assessment of Social Cognition, and a large cognitive battery. Compared with those with schizophrenia, participants with ASD had higher self-reflectivity ( p = 0.025; odds ratio, 1.38 [1.05-1.86]) in univariable analyses. Metacognitive deficits may be found in ASD with a profile that varies from what is found in schizophrenia. It is possible that methods for enhancing metacognitive abilities during psychiatric rehabilitation may be refined to assist adults with ASD to better manage their own recovery.

Comparing executive functions profiles in anorexia nervosa and autism spectrum disorder in adolescence

Objective

Executive functions (EFs) inefficiencies in anorexia nervosa (AN), especially in set‐shifting and central coherence, suggest a link between AN and autism spectrum disorders (ASDs). This study aimed at comparing EF profiles in AN and ASD, and investigating clinical variables associated with the identified EF difficulties.

Method

One hundred and sixty‐two adolescents with AN or ASD completed self‐report questionnaires assessing depression, anxiety and autism symptoms. Parents completed the behaviour rating of executive functions parent‐form (BRIEF‐P). Besides comparing EFs in AN and ASD, we also analysed clinical variables scoring below and above the mean age score across the all sample. We additionally examined the relationship between clinical variables and the BRIEF‐P indexes in AN.

Results

Participants with ASD had greater EF difficulties than participants with AN on all BRIEF‐P scales. In the whole sample, higher autistic features were related to poorer EF. In AN, lower body mass index and particularly higher autism‐spectrum quotient (BRI: Beta = 0.55; p < 0.001 and GEC: Beta = 0.50; p < 0.001) were most strongly associated with poorer EF.

Conclusion

Although participants with ASD showed greater difficulties, autistic traits were related to alter EFs in AN. Exploring further this dimension can undeniably allow better adaptive cognitive remediation programs.

Participants with autism spectrum disorder (ASD) had greater executive function (EF) difficulties than participants with anorexia nervosa (AN) on all behaviour rating of executive functions parent‐form scales

In AN, lower body mass index and particularly higher autism‐spectrum quotient were most strongly associated with poorer EF

Our study highlights the importance of autistic features in the alteration of EF in AN

Cognitive deficits in children with autism spectrum disorders: Toward an integrative approach combining social and non-social cognition

Autism spectrum disorder (ASD) is associated with neurocognitive impairment, including executive dysfunctioning and social cognition (SC) deficits. Cognitive remediation (CR) is a behavioral training-based intervention aiming to improve cognitive processes. Its first use in psychiatry interested patients with schizophrenia, in whom promising results have been shown. Integrated CR programs targeting both social and non-social cognition have demonstrated to be effective in improving both cognitive domains and functional outcomes. CR studies in children and adolescents with ASD are still new, those regarding CR approaches combining social and executive functioning remediation are scares. One study examining the efficacy of cognitive enhancement therapy (CET) for improving cognitive abilities in ADS adults, showed significant differential increases in neurocognitive function and large social-cognitive improvements. Therefore, taking into account the overlap between ASD and schizophrenia, and considering the close link between executive functions (EF) and SC, we suggest that integrative approach in ASD could result in better outcomes. The present perspective aimed to highlight cognitive remediation (CR) programs contributions in ASD (especially in children and adolescents), and to discuss the value of combining social and non-social programs.

Neuropsychological and clinical findings of Cognitive Remediation Therapy feasibility randomised controlled trial in young people with anorexia nervosa

OBJECTIVE

Randomised controlled trial (RCT) in adults with anorexia nervosa (AN) showed that Cognitive Remediation Therapy (CRT) enhances cognitive flexibility, abstract thinking and quality-of-life. Despite inconsistent findings, CRT has the potential as an adjunct treatment for young people (YP) with AN. A feasibility RCT was conducted in an inpatient setting. The study will also consider the effect of CRT in YP with AN and autistic symptoms.

METHODS

Participants were randomly allocated to the Immediate or Delayed condition to receive individual CRT sessions, in addition to standard treatment. A repeated measures design was conducted.

RESULTS

Eighty participants were recruited. The neuropsychological measures were feasible for evaluating individual CRT in YP. Significant improvements in set-shifting and central coherence were found, with no main effect between immediate and delayed condition. Significant interactions were found between the condition, and autism spectrum condition (ASC) and No-ASC subgroup, with significant positive impact of CRT on set-shifting in the No-ASC subgroup. There was some evidence that for the No-ASC subgroup, CRT was more effective if delivered at the start of the treatment; and for the ASC subgroup, that CRT was more effective if delivered at the later stage of treatment.

CONCLUSIONS

These findings suggest that the overall positive effect of CRT in set-shifting and central coherence alongside standard treatment. They also indicate the importance of screening for the presence of ASC which could require tailored CRT.

Adolescents With Autism Spectrum Disorder and Anorexia Nervosa Comorbidity: Common Features and Treatment Possibilities With Cognitive Remediation Therapy and Oxytocin

Autistic traits or autism spectrum disorder (ASD) can be found in 4% to 52% of anorexic patients, which makes the treatment of these patients very challenging. In this review, possible ways to treat ASD and anorexia nervosa (AN) comorbidity in children and adolescents are summarized. Over recent years, the focus has shifted from searching for the evidence of connections between these two disorders, which have started with Gillberg's study in 1983, to searching for more effective and holistic treatment of this comorbidity. The latter is known to contribute to more severe courses and worse prognosis, which is probably related to the obstacles in both diagnosing and treating. Since AN usually starts in early adolescence and high-functioning ASD children seem to begin struggling with increased pressure in adolescence, while various comorbidities can occur, it is important to improve the treatment of this comorbidity in young patients and to tailor it specifically in terms of diagnosing. In this paper, a literature review is conducted on common features and promising treatment possibilities. We describe cognitive remediation therapy and the promising pharmacotherapeutic candidate oxytocin with a special focus on adolescents.

'It's not that they don't want to access the support . . . it's the impact of the autism': The experience of eating disorder services from the perspective of autistic women, parents and healthcare professionals

LAY ABSTRACT

This study explores autistic women's experiences of eating disorder services. About 20%-30% of people with anorexia nervosa are also autistic, and current treatments seem not to work as well for them. We interviewed 15 autistic women with experience of anorexia nervosa, 12 parents of autistic women with anorexia nervosa, and 11 healthcare professionals working in eating disorder services. We asked autistic women and parents about their experiences of eating disorder services, and we asked healthcare professionals about their experiences treating autistic women with anorexia nervosa. Participants' views were represented by three overall themes: misunderstanding autism and autistic traits, one treatment does not fit all, and improving accessibility and engagement within services. We found that autistic women face many barriers when in treatment for anorexia nervosa, often because of a lack of autism understanding within eating disorder services. Future research should look at developing anorexia nervosa treatments that can specifically help autistic individuals.

Toward a Gender-Sensitive Approach of Psychiatric Rehabilitation in Autism Spectrum Disorder (ASD): A Systematic Review of Women Needs in the Domains of Romantic Relationships and Reproductive Health

Later age of diagnosis, better expressive behaviors, increased use of camouflage strategies but also increased psychiatric symptoms, more unmet needs, and a general lower quality of life are characteristics often associated with female gender in autism spectrum disorder (ASD). Psychiatric rehabilitation has shown small to moderate effectiveness in improving patients' outcomes in ASD. Few gender differences have been found in the response to psychiatric rehabilitation. This might be related to the predominance of males in research samples, but also to the lack of programs directly addressing women's unmet needs. The objectives of the present paper were: (i) to review the needs for care of autistic women in romantic relationships and reproductive health; (ii) to review the existing psychosocial treatments in these domains; and (iii) to evaluate the strengths and limitations of the current body of evidence to guide future research. A systematic electronic database search (PubMed and PsycINFO), following PRISMA guidelines, was conducted on autistic women's needs for care relating to psychiatric rehabilitation in romantic relationships and reproductive health. Out of 27 articles, 22 reported on romantic relationships and 16 used a quantitative design. Most studies were cross-sectional (n = 21) and conducted in North America or Europe. Eight studies reported on interventions addressing romantic relationships; no published study reported on interventions on reproductive health or parenting. Most interventions did not include gender-sensitive content (i.e., gender variance and gender-related social norms, roles, and expectations). Autistic women and autistic gender-diverse individuals may face unique challenges in the domains of romantic relationships and reproductive health (high levels of stigma, high risk of sexual abuse, increased psychiatric symptoms, and more unmet needs). We discussed the potential implications for improving women's access to psychiatric and psychosocial treatment, for designing gender-sensitive recovery-oriented interventions, and for future research.