Real-World Executive Functions in Adults with Autism Spectrum Disorder: Profiles of Impairment and Associations with Adaptive Functioning and Co-morbid Anxiety and Depression

Outcomes from a Driving and Community Mobility Intervention Designed for Novice Drivers with Autism from the Perspective of the Participants and Their Parents

To examine change in driving and community mobility outcomes for teens and young adults with autism as a result of participating in an occupational therapy intervention designed as a Bootcamp as perceived by the participants and their parents. Matched questionnaires were completed by novice drivers with autism as well as their parents prior to and immediately after the intervention. The intervention consisted of a 5-day (32 h) intervention using interactive driving simulators, role playing, and highly interactive learning experiences. Sixty-seven participants and their parents completed the pre and post surveys. Of these, 52 (80%) were male and 13 (20%) were female, with a mean age of 17.8 ± 3.03 years. Wilcoxon signed rank tests was used for the Likert scale questions and paired t test for ratio level data. Results demonstrated participants perceived significant improvement in knowledge, skills and abilities related to both driving and community mobility. There were also significant differences in perception from the parents' perspective, but not as evident as the participants. Only a few significant changes were perceived in terms of executive functioning, which support accuracy of the results. Findings also showed significantly improvement in anxiety and confidence.As driving and community mobility is critical for young adults with autism to be successful in adult roles, intervention for improving knowledge, skills, and abilities in this complex daily task is essential. This study demonstrates statistically significant outcomes of a driving and community mobility occupational therapy intervention from the perspective of the participants and their parents.

Characterizing Inhibitory Control Challenges Among Autistic Adults: An Examination of Demographic and Psychiatric Moderators and Associations with Anxiety Symptomatology

Autism spectrum disorder is associated with elevated rates of mental health difficulties and executive function challenges. Emerging evidence links executive function to mental health in autistic individuals. However, less is known about (a) everyday inhibitory control difficulties among autistic adults; (b) the influence of sex assigned at birth and co-occurring attention deficit/hyperactivity disorder (ADHD) features on inhibition challenges; and (c) relations between inhibition challenges and anxiety symptoms. Drawing upon data from 732 autistic adults aged 18-83, this online study examined self-reported inhibitory control in autistic adults and the influence of assigned sex and ADHD screening status (based on a positive screening score on a self-report tool) on the degree of inhibitory control challenges experienced. In addition, this research examined relations between inhibitory control challenges and anxiety symptoms, and the moderating role of assigned sex and ADHD screening status in this relationship. Autistic adults endorsed significantly more inhibitory control challenges relative to published norms. Participants assigned female reported more difficulties in inhibitory control relative to sex-adjusted normative expectations than participants assigned male. Participants who screened positive for ADHD reported more inhibitory control challenges than those who screened negative. Greater endorsement of inhibitory control challenges was associated with greater anxiety symptomatology; this relationship was moderated by ADHD screening status, but not by assigned sex. Inhibitory control is an area of difficulty in autistic adults and is associated with anxiety symptomatology, suggesting that inhibitory control may be a valuable intervention target to improve emotional well-being in autistic adults.

Autism Spectrum Disorder Across the Lifespan

Autism is a neurodevelopmental condition that affects individuals worldwide throughout their lives. Copious advances in research have enhanced our understanding of autism significantly since Dr. Leo Kanner's first description of the condition in 1943. This review aims to provide an overview of our current knowledge of autism, examining its manifestations across age, race, gender, and co-occurring conditions (e.g., intellectual disability) from childhood through adulthood. We also focus on the identification and diagnosis of autism, long-term outcomes with a spotlight on adulthood, and appropriate supports and interventions across different developmental stages for autistic individuals and their families. We stress the importance of a lifespan perspective that considers the evolving needs of individuals with autism as they age, and we highlight the role of longitudinal research.

Navigating Neurotypical Norms in Academic Research: A Perspective from an Autistic Early Career Researcher

Abstract

The academic research landscape, rich with complexity, reveals its potential for innovation when explored through a neurodiversity lens. This perspective article presents a nuanced examination of the unique strengths that autistic thinking brings to scholarly pursuits, such as enhanced pattern recognition and systematic rigor-qualities that have personally empowered my own grant writing endeavors. It also confronts the challenges that arise from the prevailing neurotypical standards within the academic milieu. Merging a scholarly review with selective personal insights, this article advocates for a redefinition of scholarly communication and mentorship that is inclusive of neurodiversity. I aim to provide insights and experiences that offer guidance to fellow autistic researchers, their mentors, research institutions, and funding bodies. Drawing from my perspective, I delve into communication complexities, the perennial struggle to conform to neurotypical writing standards, the weight of "imposter syndrome," and the pivotal role that mentors play in supporting and advocating for autistic early career researchers. The recommendations offered in this study aim to establish an academic environment that not only welcomes but also leverages the distinctive capabilities of autistic researchers. This perspective aspires to serve as a catalyst for mentors, colleagues, and funding bodies to embrace a more neuroinclusive approach in their practices.

Abstract

The purposes of this article were to highlight specific challenges and strengths of autistic researchers in academia, particularly in the context of grant writing and scholarly communication, and to offer actionable recommendations to foster a neuroinclusive academic environment. From my perspective as an autistic researcher who has navigated both the triumphs and trials of grant acquisition and publication, I offer a personal and professional vantage point. The insights drawn from these experiences shed light on the difficulties autistic researchers face and underline the need for systemic change.

Abstract

As an early career researcher, I find myself at a juncture, navigating not only the demands of the scholarly world but also life as a late-diagnosed autistic woman, who has journeyed through the labyrinthine world of grant writing. I offer a glimpse into my world, which includes successes with 2 federal grant awards, 1 foundation grant, 5 intramural grants, 14 peer-reviewed publications and unsuccessful attempts with 1 federal grant, 2 foundation grants, and 2 peer-reviewed articles. I bring a blend of personal experience and professional expertise.

Abstract

The current academic dialogue acknowledges neurodiversity but often falls short in offering the necessary structural support for the distinct communication styles and cognitive approaches of autistic researchers. Although there is a recognized benefit in mentorship and clearer communication within academia, the practical implementation varies widely.

Abstract

I propose a series of recommendations to bridge these gaps. These include the establishment of grant programs accessible to autistic researchers, the improvement of mentorship and training programs to include an appreciation for neurodiversity, and the education of grant reviewers about the strengths inherent in autistic researchers. In addition, the article suggests revising application processes to increase inclusivity, encouraging the participation of autistic researchers in peer review, promoting community engagement and networking opportunities, allocating funding specifically for research by autistic scientists, and enhancing collaboration with organizations dedicated to autism.

Abstract

The implementation of these recommendations has the potential to significantly improve the academic environment for autistic adults, not only enhancing their current academic engagement and success but also setting a foundation for inclusivity and respect for neurodiversity. Such systemic changes hold the promise of nurturing a future generation of autistic researchers, acknowledging and celebrating the unique insights we bring to the scientific community.

Gender and Autism Program: A novel clinical service model for gender-diverse/transgender autistic youth and young adults

Objective: Situated in Children's National Hospital (CNH)'s Neuropsychology Division, the Gender and Autism Program (GAP) is the first clinical service dedicated to the needs of autistic gender-diverse/transgender youth. This study describes GAP clinical assessment profiles and presents a multi-perspective programmatic review of GAP evaluation services. Method: Seventy-five consecutive gender- and neuropsychologically-informed GAP evaluations were analyzed, including demographics, gender and autism characterization, and primary domains evaluated. Three program-based Delphi studies were conducted and identify: clinician priorities and challenges in providing care, program administrator lessons learned and ongoing barriers, and considerations adapting this model for a rural academic medical center. Results: Nearly two-thirds of referrals were transfeminine. Most youth had existing autism diagnoses; of those undiagnosed, three-quarters were found to be autistic. Five goals of evaluations were identified: Mental health was always assessed, and most evaluations also assessed gender-related needs in the context of autism neurodiversity. Neuropsychological characterization of strengths and challenges informed personalized accommodations to support youth gender-related self-advocacy. Clinicians emphasized frequent youth safety concerns. Administrators emphasized the need for specialized training for working with families. Components for adaptation of the GAP in a rural academic medical center were identified. Conclusions: Since its founding, the GAP has proven a sustainable neuropsychology-based service with consistent referral flow and insurance authorizations. Capturing staff perspectives through rigorous Delphi methods, and addressing the GAP's feasibility and replicability, this study provides a road map for replicating this service. We also highlight GAP training of specialist clinicians, fundamental to addressing the desperate shortage of providers in this field.

Neuroplasticity-based novel brain stimulation support intervention options for autistic population

Transcranial magnetic stimulation (TMS), introduced in 1985, has become a vital tool for investigating brain-behaviour relationships and therapeutic interventions. Repetitive TMS (rTMS) as a therapeutic tool has shown promise for various neuropsychiatric conditions, including autism, which affects approximately 1% of the global population. Evidence suggests that atypical neuroplasticity characterizes the neurobiology of autism. Recent studies using TMS paradigms like theta-burst stimulation (TBS) indicate an excessive neuroplasticity or hyper-plasticity in the form of an excessive long-term potentiation (LTP) in the motor cortex of autistic adults compared to neurotypical controls. Hyper-plasticity may negatively impact cognitive and behavioural outcomes. Our proposed neuroplasticity-based rTMS intervention protocols aim to address motor function, sensory sensitivities, and executive function difficulties in autistic adults. We present a testable framework to evaluate neuroplasticity in the motor, sensory, and dorsolateral prefrontal cortices, hypothesizing the presence of hyper-plasticity in autistic adults. We anticipate that this hyper-plasticity underpins motor, sensory, and executive function difficulties in autistic adults. Additionally, we propose investigating the efficacy of bilateral rTMS to reduce hyper-plasticity and improve these functions in autistic adults. This approach not only seeks to enhance therapeutic options but also provides biological insights into the brain mechanisms underlying some of the common autism-associated difficulties.

Simple Executive Function as an endophenotype of autism-ADHD, and differing associations between simple versus complex Executive Functions and autism/ADHD traits

Autism and ADHD are associated with difficulties with Executive Functions (EFs), but the prevalence and nature of these difficulties in early development is not well understood. In this longitudinal study, 107 children with a family history of autism and/or ADHD (FH-autism/ADHD), and 24 children with No-FH-autism/ADHD completed multiple EF tasks (5 at age 2 years, 7 at age 3 years). Parents reported on their child's autism- (Q-CHAT at age 2, SRS-2 at age 3), and ADHD-related traits (CBCL DSM-ADHD scale, both ages). Compared to the No-FH-autism/ADHD group, the FH-autism/ADHD group showed lower scores on simple EFs (involving response inhibition, and holding in mind) at ages 2 and 3. Exploratory analysis linked FH-autism specifically with lower Executive Attention (top-down attentional control) at age 2, and the combination of FH-autism and FH-ADHD with lower Complex EF (involving selectively deploying responses, or updating information) at age 3. Three-year-olds' Simple EF scores were negatively associated with ADHD-related traits. Complex EF scores were negatively associated with autism traits (before correcting for multiple comparisons). Toddlers with a family history of autism and/or ADHD may benefit from interventions to support simple EF development, whilst those already showing autistic traits may benefit from support with more-complex EF skills.

Attention-Deficit/Hyperactivity Disorder in Medicaid-Enrolled Autistic Adults

Importance

Autistic adults experience suboptimal health outcomes. Likewise, attention-deficit/hyperactivity disorder (ADHD) is linked to poor health outcomes in the general population, yet little is known about co-occurring ADHD and its links with poor health outcomes among autistic adults.

Objective

To determine the prevalence of ADHD and ADHD medication prescriptions and to examine associations between health outcomes and both ADHD co-occurrence and ADHD medication prescriptions among autistic adults.

Design, Setting, and Participants

Population-based cohort study of US Medicaid-enrolled adults aged 18 years and older, including autistic adults with and without co-occurring intellectual disability (ID), adults with ID without autism, and adults from a random sample of Medicaid-enrolled individuals from 2008 to 2019. Analyses were completed September 2023 to September 2024.

Exposures

Autism, ADHD, and ID using validated algorithms from the Chronic Conditions Warehouse.

Main Outcomes and Measures

Prevalence rates of co-occurring ADHD, ADHD medication prescriptions, substance use, cardiovascular conditions, injury in autism without ID, ID without autism, autism with ID, and the general population.

Results

The study included 3 506 661 patients (mean [SD] age, 33.5 [15.6] years; 1 854 892 [52.9%] female; 702 694 [20.0%] Black, 587 048 [16.7%] Hispanic, and 1 786 703 [60.0%] White). Compared with the general Medicaid-enrolled population (1 846 102 patients), which had 49 523 patients (2.7%) with co-occurring ADHD diagnoses, this study found elevated rates of ADHD in autism without ID (280 195 patients [26.7%]; prevalence ratio [PR], 5.1; 95% CI, 4.4-5.9), autism with ID (261 061 patients [40.2%]; PR, 6.8; 95% CI, 6.0-7.7), and ID without autism (1 119 303 patients [19.0%]; PR, 4.4; 95% CI, 4.0-5.0). A total of 117 704 adults (26.6%) with ADHD received an ADHD medication prescription. The study identified that rates of substance use were higher among clinical groups with co-occurring ADHD. For example, 9886 of 74 675 autistic adults with ADHD (13.2%) had substance use disorder, compared with 11 782 of 205 520 autistic adults with no ADHD (5.7%). ADHD diagnoses were associated with higher rates of all health outcomes, regardless of group. Substance use was higher in both ID groups with ADHD diagnoses and ADHD medications, whereas injury and cardiovascular condition rates were lower in all ADHD groups who received ADHD medications.

Conclusions and Relevance

In this cohort study of Medicaid-enrolled adults, autistic adults experienced high rates of co-occurring ADHD and were more likely to receive ADHD medication prescriptions than adults in the general population. Negative health outcome rates are higher among autistic people with co-occurring ADHD, although ADHD medication prescriptions are associated with lower rates of negative health outcomes. Treating ADHD may improve health among autistic adults.

Self-Set Goals: Autistic Adults Facilitating Their Self-Determination Through Digitally Mediated Social Stories

Background

Personalized and practical support can facilitate autistic adults' independence and agency and can enable enhanced self-determination while influencing quality of life. Notwithstanding, traditional supports or interventions for autistic adults typically seek to address perceived challenges associated with autism, rather than identify what the autistic person wants support with. In this research, we explored the potential to empower autistic people by attaining their own self-set goals with the support of digitally mediated Social Stories.

Methods

We conducted a pre/post quasiexperimental design to investigate the usefulness and effectiveness of digitally mediated Social Stories for autistic adults to support the attainment of their self-set goals. Thirty-three autistic participants self-set goals and self-developed Social Stories using a digital application. We collected closeness-to-goal measures at baseline and after 2 weeks of reading their digitally mediated Social Stories themselves and we compared them with a control condition. We then evaluated the goals participants were interested in. The autistic adults also evaluated the usefulness of the intervention for them.

Results

Over 2 weeks, the use of self-set goals, combined with a digitally mediated Social Story, elicited a statistically significant increase in closeness-to-goal ratings with a large effect size. The majority of participants reported that digitally mediated Social Stories were an appropriate and effective form of self-support. Our analysis of the participants' goals indicated that autistic adults predominantly identified a need for support with increasing nonsocial behaviors.

Conclusion

Self-developed digitally mediated Social Stories can effectively support autistic adults in reaching their self-set goals. Digitally mediated Social Stories can support reflection on one's goals, increase commitment toward goals, break down tasks into meaningful parts, as well as create meaningful predictions for autistic adults. Thus, digitally mediated Social Stories have the potential to empower autistic adults to self-support reaching self-set goals.

Learning from the community: iterative co-production of a programme to support the development of attention, regulation and thinking skills in toddlers at elevated likelihood of autism or ADHD

Programmes designed to support children with known, or increased likelihood of, autism or ADHD often focus on reducing behaviours central to a clinical diagnosis. However, supporting children to pursue their own goals and cope with everyday life through fostering executive function (EF) development, without enforcing neuro-normative assumptions, may be more acceptable to neurodivergent people, and more beneficial. The co-production process for this neurodiversity-affirming programme involved: Review of research priorities identified during published public-and-clinician consultations; iterative programme development through two pilot rounds with a general community sample; and consultation with stakeholders (parents with a connection to autism or ADHD, alongside early years specialists, psychologists and therapists) to check acceptability of the proposal, and refine the logic model and materials. The logic model for the resultant programme-Supporting Toddlers with a connection to autism or ADHD to develop strong Attention, Regulation and Thinking skills (START)-involves three mechanisms of change: The child has appropriate play-based opportunities to practise EF skills; Parenting behaviours linked to strong EFs are encouraged; Parents are empowered to improve environmental-fit for their child so that EF stressors are reduced.

Investigating Social Competence in a Pilot Randomized Clinical Trial of a Theatre-Based Intervention Enhanced for Adults with Autism Spectrum Disorder

Autism spectrum disorder (ASD) is characterized by challenges in social competence that persist in adulthood, yet few treatment options exist. A pilot randomized clinical trial (RCT) of a peer-mediated, theatre-based intervention with established efficacy in youth with ASD was examined in autistic adults. The final sample consisted of forty-seven 18-to-40-year-old participants randomized to the experimental (EXP N = 23) or waitlist control (WLC N = 24) condition. A multimodal, social interdependent model was employed to examine social competence changes in brain (incidental face memory (IFM) using event-related potentials), cognition (Wechsler Memory Scale-III), behavior (Contextual Assessment of Social Skills) and function (Social Responsiveness Scale (SRS); Adaptive Behavior Assessment Scale (ABAS) Social Composite). Using analysis of covariance in which pretest was controlled in the model, posttest between-group differences were observed on IFM (p = 0.016, η2 = 0.139, d = 0.79) and several social and adaptive functional (SRS, ABAS) outcomes in social communication and interaction (SCI) (p = 0.019, η2 = 0.121, d = -00.45), communication (p = 0.044 η2 = 0.09, d = -00.31), and motivation (p = 0.001, η2 = 0.229, d = -0.79) domains. At two-month follow-up, gains in social motivation remained (p = 0.041, η2 = 0.100, d = -0.77). The results offer preliminary support for a unique theatre-based social skills intervention for autistic adults who have few treatment options to enhance social competence. The trial was pre-registered with ClinicalTrials.gov (Identifier: NCT04349644).

Factors that Influence the Daily Living Skills of Autistic Adults: The Importance of Opportunity

While existing literature has demonstrated that Daily Living Skills (DLS) performance of autistic individuals is lower than what is expected of their age and cognitive abilities, limited studies have examined DLS in autistic adults. This study aimed to understand the influence of intellectual function (IQ) and contextual factors (i.e., provision of opportunities) on autistic individuals' DLS performance. Participants included 33 autistic individuals ranging in age from 16 to 35 years. Their caregivers were administered the Vineland Adaptive Behavior Scales, 3rd edition's (Vineland-3) caregiver interview form. A novel coding system was developed to capture the frequency of reasons for participants' non-performance of DLS tasks, based on caregiver's report. "Target" scores reflecting expected possible score if reasons for nonperformance could be addressed were computed. Qualitative analysis of parental responses indicated that, for adults with average or higher IQ, lack of opportunity to learn and/or implement the skill was the most frequent reason for not performing DLS. Lack of opportunity was also the second most common reason provided for adults with NVIQ below 85, following cognitive ability. Taking into account reasons for nonperformance, "Target" scores were, on average, 7.65 points higher for the NVIQ ≥ 85 group. These findings highlight a need for multi-dimensional assessment to go beyond individual strengths and difficulties to also include contextual factors that may influence adults' skill acquisition and performance. It is essential that clinicians ensure that adequate opportunities for learning and performance are available to promote acquisition of important DLS.

Effects of Difficulties in Executive Functions on Behavioral and Adaptive Problems in Italian Autistic Preschoolers

Objective

To describe the relationship between executive functions (EF) and symptom's severity, behavioral problems, and adaptive functioning in autistic preschoolers.

Method

Seventy-six autistic preschoolers (age-range: 37-72 months; SD: 8.67 months) without intellectual disability were assessed. Executive functions were measured by both performance-based (Battery for Assessment of Executive Functions -BAFE-) and indirect measures (Behaviour Rating Inventory of Executive Function - Preschool Version -BRIEF-P); adaptive skills were assessed using the Vineland Adaptive Behavior Scales Second Edition (VABS-II); ASD severity was evaluated through the ADOS-2 and the SCQ; the Child Behavior Checklist (CBCL ½-5) questionnaire was used to describe the emotional/behavioral profile.

Results

A considerable rate of autistic preschoolers showed weaknesses in one or more measures of EF, in particular in inhibition and working memory at both performance-based and parent report measures. EF measures explained a significant proportion of variance in the emotional/behavioral profile, and in the adaptive skills, particularly in the socialization domain. Specifically, the most relevant EF predictors are Inhibition, Emotional Control and Cognitive Flexibility subscales of the BRIEF-P.

Conclusions

Assessment of EF in autistic preschoolers may identify those children at higher risk for emotional/behavioral problems and adaptive difficulties. EF are a crucial target for early intervention in preschoolers with autism with the potential to improve child outcomes.

Understanding cognitive flexibility in emotional evaluation in autistic males and females: the social context matters

BACKGROUND

Autistic individuals often have difficulty flexibly adjusting their behavior. However, laboratory experiments have yielded inconsistent results, potentially due to various influencing factors, which need to be examined in detail. This study aimed to investigate the hypothesis that the social content of stimuli could play a specific role in some of the flexibility challenges faced by autistic individuals. The second aim was to explore sex differences in this context.

METHODS

We analyzed data from 256 adult participants (124 with autism), matched on age, gender, and sex, who performed an emotional shifting task involving unpredictable shifts between positive and negative stimuli. Additionally, the task included both social and non-social conditions.

RESULTS

Our results revealed a larger switch cost in the social than in the non-social condition, and this was more pronounced in autistic than in non-autistic individuals. Furthermore, we observed that autistic females differed from autistic males in the non-social condition and from non-autistic females in the social condition.

LIMITATIONS

The online nature of the study reduced the control over participant conditions. In addition, further studies are needed to investigate whether these results apply to the broader autism spectrum.

CONCLUSIONS

Building on previous research demonstrating a greater switch cost in autistic than non-autistic individuals for socio-emotional stimuli, our study further extends these findings by highlighting that the social context, rather than the emotional nature of the stimuli alone, may play a significant role in the flexibility challenges faced by autistic individuals. Our findings also contribute to the literature on sex differences in autism.

Adaptive behavior in primary agenesis of the corpus callosum

BACKGROUND AND AIMS

Primary agenesis of the corpus callosum (ACC) is a congenital neurological disorder characterized by the absence, either partial or complete, of the corpus callosum in individuals who do not have intellectual disability and are otherwise neurologically asymptomatic. While mild to moderate neurocognitive deficits have been observed in individuals with primary ACC using neuropsychological assessments, the impact of this syndrome on adaptive behavior remains insufficiently understood.

METHODS

This study used self- and informant-ratings on the Adaptive Behavior Assessment System, Second Edition (ABAS-II) to evaluate adaptive behavior in 35 adults diagnosed with primary ACC.

RESULTS

While adults with primary ACC reported adaptive functioning comparable to an age-adjusted normative sample, family informants rated their adaptive ability below norms in several skill domains, particularly social skills.

CONCLUSIONS

This pattern of lower ratings by informants than self-ratings suggests adults with ACC may have poor understanding of their own behavior and its consequences. This study demonstrates that informants observe significant deficiencies in the conceptual, social, and practical aspects of adaptive behavior in persons with primary ACC, and that these deficiencies are not seen as clearly by the persons themselves.

Probing heterogeneity to identify individualized treatment approaches in autism: Specific clusters of executive function challenges link to distinct co-occurring mental health problems

LAY ABSTRACT

Many autistic people struggle with mental health problems like anxiety, depression, inattention, and aggression, which can be challenging to treat. Executive function challenges, which impact many autistic individuals, may serve as a risk factor for mental health problems or make treating mental health conditions more difficult. While some people respond well to medication or therapy, others do not. This study tried to understand if there are different subgroups of autistic young people who may have similar patterns of executive function strengths and challenges-like flexibility, planning, self-monitoring, and emotion regulation. Then, we investigated whether executive function subgroups were related to mental health problems in autistic youth. We found three different types of executive function subgroups in autistic youth, each with different patterns of mental health problems. This helps us identify specific profiles of executive function strengths and challenges that may be helpful with identifying personalized supports, services, and treatment strategies for mental health conditions.

Behavioural interventions to treat anxiety in adults with autism and moderate to severe intellectual disabilities: the BEAMS-ID feasibility study

Background

Interventions for anxiety need to be adapted to meet the needs of autistic people with moderate to severe learning disabilities and successfully modelled before evidence about efficacy can be generated from clinical trials.

Objectives

The objectives were to: (1) adapt a behavioural intervention for anxiety, develop an intervention fidelity checklist and logic model, and appraise candidate outcome measures, together with carers, autistic people, and clinicians, (2) characterise treatment-as-usual, (3) model the adapted intervention to determine the acceptability and feasibility for all stakeholders, judge the appropriateness of outcome measures, examine the feasibility and acceptability of consent and associated processes and (4) describe factors that facilitate or challenge intervention delivery.

Design

This study had two phases. Phase 1a: using consensus methods, an intervention adaptation group was formed who met to adapt the intervention, appraise candidate outcome measures, and contribute to the development of the intervention fidelity checklists and logic model. Phase 1b: a national online survey was conducted with professionals to characterise treatment-as-usual. Phase 2: this was a single-group non-randomised feasibility study designed to model the intervention to test intervention feasibility and acceptability, outcome measures, and aspects of the research process.

Setting

Participants were recruited from National Health Service community adult learning disabilities teams in England.

Participants

Participants aged 16 and over with a diagnosis of autism, moderate to severe learning disabilities, an anxiety disorder, and a carer who was available to take part in the intervention. For those who lacked capacity to make a decision about taking part, a consultee had to provide advice that the participant should be included in the study.

Interventions

The intervention comprised 12 sessions alongside treatment-as-usual.

Main outcome measures

The feasibility and acceptability of the intervention and research processes, outcome measure completion rates, and intervention adherence.

Results

The intervention was successfully adapted and modelled with 28 autistic participants with moderate to severe learning disabilities. The intervention was judged to be feasible and acceptable by autistic adults with learning disabilities, carers, and therapists. Carers and therapists suggested minor intervention revisions. Carers completed 100% of outcome measures and the missing data rate was low; however, they indicated that some of the questions were repetitive and said they had difficulty responding to some items. The use of the Mental Capacity Act, 2005, led to an average 5-week delay to participant enrolment. The accrual rate was affected by the COVID-19 pandemic and improved during the summer and early autumn of 2022.

Limitations

Randomisation was not modelled within this feasibility study, although carers and therapists indicated that this would be acceptable.

Conclusions

The BEAMS-ID intervention and associated study processes were judged to be feasible and acceptable. The intervention required minor revision.

Future work

The BEAMS-ID intervention should be tested further within a trial.

Study registration

This study is registered as ISRCTN12637590.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: NIHR129804) and is published in full in Health Technology Assessment; Vol. 28, No. 72. See the NIHR Funding and Awards website for further award information.

Refining our Understanding of Anxiety in Autistic Youth: Examining the Role of Behavioral Inflexibility

Prior research has demonstrated that cognitive inflexibility is associated with anxiety in autistic individuals. Everyday patterns of behavioral inflexibility (e.g. observable inflexible behavior in the context of the need to change or adapt and that is manifested in real-world everyday settings) is common in autism and can be distinguished from performance on discrete cognitive tasks that tap flexible attention, learning, or decision-making. The purpose of this study was to extend this prior work on inflexibility in autism but with measures specifically developed with input from stakeholders (caregivers and clinicians) for autistic youth designed to measure everyday behavioral inflexibility (BI). We characterized anxiety in a large sample of autistic (N = 145) and non-autistic youth (N = 91), ages 3 to 17 years, using the Parent Rated Anxiety Scale for Autism Spectrum Disorder (PRAS-ASD). Further, we sought to understand how BI, measured via the Behavioral Inflexibility Scale (BIS), predicted anxiety compared to other variables known to increase anxiety in youth (chronological age, IQ, autism diagnosis, assigned sex at birth). Autistic youth had higher parent-related anxiety and BI compared to non-autistic youth. BI was the strongest predictor of anxiety scores, irrespective of diagnosis. Overall, our findings highlight the importance of BI to the understanding of anxiety in autistic youth.

An Examination of Perceived Stress and Emotion Regulation Challenges as Mediators of Associations Between Camouflaging and Internalizing Symptomatology

Background

Camouflaging involves the masking of autism traits, potentially creating an outer impression of "non-autisticness." Although associations of camouflaging with anxiety and depression in autistic adults are widely reported, factors that mediate these associations are unclear. We examined two potential mediators of the association between camouflaging and anxiety/depression: perceived stress and emotion regulation (ER) challenges.

Methods

Seven hundred eighty-seven autistic adults (18.2-78.2 years) recruited through Simons Powering Autism Research (SPARK) Research Match completed questionnaires, including the Camouflaging Autistic Traits Questionnaire (CAT-Q), and measures of autistic traits, depressive and anxious symptomatology, perceived stress, and ER challenges. Four moderated mediation models were tested. In all models the independent variable was CAT-Q total score, and the moderator variable was sex designated at birth. The dependent variable was depressive or anxious symptomatology, and the mediator variable was perceived stress or ER challenges.

Results

We found that more camouflaging, increased ER challenges, and higher levels of perceived stress were associated with greater depressive and anxious symptomatology. We also found that perceived stress and ER challenges significantly mediated the associations between camouflaging and both depression and anxiety. In the model with perceived stress and anxiety, sex moderated the mediation, with females showing a stronger mediation. There was no significant moderation in any of the other models.

Conclusion

We contextualize the findings within the broader literature on camouflaging as a response to stigma and other facets of minority stress. We discuss how the results of this study support the idea that the day-to-day stress of living in a neurotypical world, the cognitively demanding nature of camouflaging, and the constraints that camouflaging place on autistic people's behaviors in social contexts (e.g., contributing to suppressing ER strategies such as stimming), create a cycle that contributes to elevated rates of anxiety and depression in autistic people.

Autistic Adults Avoid Unpredictability in Decision-Making

Decision-making under unpredictable conditions can cause discomfort in autistic persons due to their preference for predictability. Decision-making impairments might furthermore be associated with a dysregulation of sex and stress hormones. This prospective, cross-sectional study investigated decision-making in 32 autistic participants (AP, 14 female) and 31 non-autistic participants (NAP, 20 female) aged 18-64 years. The Iowa Gambling Task (IGT) and the Cambridge Risk Task (CRT) were used to assess decision-making under ambiguity and under risk with known outcome probabilities, respectively. Cortisol, estradiol, and testosterone serum levels were related to decision-making performance. Groups did not differ in overall IGT and CRT performance, but compared with NAP, AP preferred less profitable card decks with predictable outcomes while avoiding those with unpredictable outcomes. AP required more time to reach decisions compared to NAP. Additionally, AP without comorbid depression performed significantly worse than NAP in the IGT. Estradiol and cortisol concentrations were significant predictors of CRT scores in NAP, but not in AP. The study results imply that AP are 'risk-averse' in decision-making under ambiguity as they avoided choice options with unpredictable losses in comparison to NAP. Our findings highlight the intolerance for uncertainty, particularly in ambiguous situations. Thus, we recommend being as transparent and precise as possible when interacting with autistic individuals. Future research should explore decision-making in social situations among individuals with ASD, factoring in person-dependent variables such as depression.

Aging Well and Autism: A Narrative Review and Recommendations for Future Research

With autism first recognized in the 1940s, the early cohorts of autistic children are beginning to enter older adulthood. Little is known about the experiences and outcomes of autistic older adults. In the general population, "successful aging" is a dominant model among gerontologists and is used to evaluate outcomes in older adulthood. This narrative review aims to provide a framework for understanding and supporting successful aging in older autistic adults. Using Fernández-Ballesteros' four-domain model of "aging well" we review knowledge on aging and autism by examining outcomes in health and functioning, cognitive and physical functioning, positive affect and control, and social participation and engagement. Findings indicate that outcomes in autistic older adults are generally poor, marked by increased medical conditions, low adaptive skills, elevated risk of cognitive decline, limited physical activity, high rates of mental health conditions, low quality of life, and reduced social or community participation. Patterns of challenges are similar across cognitive abilities and profiles of autistic traits. Challenges and next steps in aging and autism research are identified, and future directions for the field are discussed.

App-based meditation habits maintain reductions in depression symptoms among autistic adults

LAY ABSTRACT

Existing research has identified an increased risk of depression among autistic adults, which can negatively impact their adaptive functioning abilities and socioeconomic outcomes. Mobile app-based meditation is a feasible, accessible, and effective self-care solution for depression among neurotypical adults, but there is limited evidence for the long-term benefits of app-based meditation among autistic adults. Habits are a key behavioral strategy for maintaining behavior change, and anchoring is one effective habit formation intervention that has yet to be tested among autistic adults. This study demonstrates that it is both feasible and effective to integrate the anchoring habit formation strategy into an app-based meditation intervention for establishing meditation habits among autistic adults. In addition, the study shows that app-based meditation habits were successful at maintaining reductions in depressive symptoms over 6 months. These results demonstrate the power of anchoring-based habit formation interventions for establishing healthy habits among autistic adults, which offers a promising behavioral intervention technique for establishing other healthy habits among autistic adults. The study also shows that app-based meditation habits are an effective long-term self-care solution for managing depressive symptoms among autistic adults that should be used by mental health providers and policymakers. Future research should test this combined anchoring and app-based meditation intervention technique among larger samples of autistic adults and over longer durations to better understand the mechanisms underlying the success of this intervention.

Central Executive and Default Mode Networks: An Appraisal of Executive Function and Social Skill Brain-Behavior Correlates in Youth with Autism Spectrum Disorder

Atypical connectivity patterns have been observed for individuals with autism spectrum disorders (ASD), particularly across the triple-network model. The current study investigated brain-behavior relationships in the context of social skills and executive function profiles for ASD youth. We calculated connectivity measures from diffusion tensor imaging using Bayesian estimation and probabilistic tractography. We replicated prior structural equation modeling of behavioral measures with total default mode network (DMN) connectivity to include comparisons with central executive network (CEN) connectivity and CEN-DMN connectivity. Increased within-CEN connectivity was related to metacognitive strengths. Our findings indicate behavior regulation difficulties in youth with ASD may be attributable to impaired connectivity between the CEN and DMN and social skill difficulties may be exacerbated by impaired within-DMN connectivity.

Implementation of Peer-Assisted Physical Activity Via Telehealth for Adults on the Autism Spectrum: A Mixed Methods Feasibility Study

OBJECTIVE

Adults on the autism spectrum are at risk for physical inactivity, obesity, and related health conditions. Physical activity provides physical, social, and mental health benefits across the lifespan. Previous research examined feasibility and effectiveness of physical activity intervention in autistic children, but very few studies target autistic adults. This study examined the feasibility and acceptability of Physical Activity Connections via Telehealth, implemented during the coronavirus disease 2019 (COVID-19) pandemic lockdown as an alternative to in-person programming for autistic adults aged 18 to 32.

METHODS

The 10-week intervention utilized telehealth and remote technologies to deliver a theoretically grounded program to improve physical activity. Strategies included peer-guidance, coaching, individualized wellness goals, customized exercise programs, and wearable activity trackers. Feasibility and acceptability were examined using a mixed-methods design including observational and survey data collection, as well as participant interviews. Data were analyzed using descriptive statistics and content analysis.

RESULTS

Findings support feasibility and acceptability of telehealth to promote physical activity among autistic adults who have cognitive capacity and ability to utilize remote technology, with applicability beyond pandemic-imposed challenges.

CONCLUSION

Telehealth delivery of physical activity interventions is a viable alternative to in-person programs and may enable autistic adults to overcome barriers to physical activity participation and access.

IMPACT

As the rate of autism continues to rise globally, rehabilitation professionals will play a significant role in promoting health and wellness for autistic individuals across the lifespan. Findings promote informed practice based on the health needs of this growing segment of society.

The mediators for the link between autism and real-world executive functions in adolescence and young adulthood

LAY ABSTRACT

Childhood factors that predict real-world executive function in autism spectrum disorder during the transition into adulthood are largely unknown. This study aimed to identify the predictors for the behavioral and cognitive aspects of real-world executive function in late adolescent and young adult autistic populations. We followed up 289 autistic youth (mean age 11.6 years) and 203 non-autistic controls (10.7 years) to their ages of 16.9 and 15.8, respectively. The Behavior Rating Inventory of Executive Function scale was used to measure the real-world executive function at late adolescence and young adulthood at follow-up. Potential predictors such as autistic symptoms, inattention or hyperactivity symptoms, peer relationship, emotional symptoms, and parenting styles were assessed in childhood at first enrollment. The results showed that childhood inattention, withdrawn behaviors, social communication difficulties, and child-reported emotion and inattention/hyperactivity may predict real-world lower executive function in late adolescence and young adults with autism. When separating executive function into behavioral and cognitive aspects, we found that oppositional behaviors and peer problems were specific predictors for behavioral regulation and cognitive function, respectively. Our findings suggested that treating common predictors in childhood, such as inattention, may potentially improve real-world executive function in autism during the transition into adulthood.

Contrasting Views of Autism Spectrum Traits in Adults, Especially in Self-Reports vs. Informant-Reports for Women High in Autism Spectrum Traits

There is uncertainty among researchers and clinicians about how to best measure autism spectrum dimensional traits in adults. In a sample of adults with high levels of autism spectrum traits and without intellectual disability (probands, n = 103) and their family members (n = 96), we sought to compare self vs. informant reports of autism spectrum-related traits and possible effects of sex on discrepancies. Using correlational analysis, we found poor agreement between self- and informant-report measures for probands, yet moderate agreement for family members. We found reporting discrepancy was greatest for female probands, often self-reporting more autism-related behaviors. Our findings suggest that autism spectrum traits are often underrecognized by informants, making self-report data important to collect in clinical and research settings.

Adaptive behaviour deficits in individuals with 3q29 deletion syndrome

BACKGROUND

3q29 deletion syndrome (3q29del) is associated with a significantly increased risk for neurodevelopmental and neuropsychiatric phenotypes. Mild to moderate intellectual disability (ID) is common in this population, and previous work by our team identified substantial deficits in adaptive behaviour. However, the full profile of adaptive function in 3q29del has not been described nor has it been compared with other genomic syndromes associated with elevated risk for neurodevelopmental and neuropsychiatric phenotypes.

METHODS

Individuals with 3q29del (n = 32, 62.5% male) were evaluated using the Vineland Adaptive Behaviour Scales, Third Edition, Comprehensive Parent/Caregiver Form (Vineland-3). We explored the relationship between adaptive behaviour and cognitive function, executive function, and neurodevelopmental and neuropsychiatric comorbidities in our 3q29del study sample, and we compared subjects with 3q29del with published data on fragile X syndrome, 22q11.2 deletion syndrome and 16p11.2 deletion and duplication syndromes.

RESULTS

Individuals with 3q29del had global deficits in adaptive behaviour that were not driven by specific weaknesses in any given domain. Individual neurodevelopmental and neuropsychiatric diagnoses had a small effect on adaptive behaviour, and the cumulative number of comorbid diagnoses was significantly negatively associated with Vineland-3 performance. Both cognitive ability and executive function were significantly associated with adaptive behaviour, and executive function was a better predictor of Vineland-3 performance than cognitive ability. Finally, the severity of adaptive behaviour deficits in 3q29del was distinct from previously published data on comparable genomic disorders.

CONCLUSIONS

Individuals with 3q29del have significant deficits in adaptive behaviour, affecting all domains assessed by the Vineland-3. Executive function is a better predictor of adaptive behaviour than cognitive ability in this population and suggests that interventions targeting executive function may be an effective therapeutic strategy.

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

BACKGROUND

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

METHODS

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

DISCUSSION

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

TRIAL REGISTRATION

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

Challenges and opportunities for conceptualizing intuitive eating in autistic people

Although intuitive eating (IE) has become an increasingly adopted intervention target, current conceptualisations of IE have yet to pivot away from (neuro)normative physiology and phenomenology. Autistic individuals commonly report disordered eating behaviours and/or poorer well-being but appear to benefit from adaptive interventions using an affirmative approach. This article uses autism as a case example to summarise challenges related to IE's prevailing conceptualisation, before proposing how future research and current practice can be extended to the autistic population. Scholars are encouraged to evaluate the full 10-principal IE framework while utilising a participatory-led approach. We argue that research using a mixed methods design is urgently needed to comprehensively explore the (re)conceptualisation of IE in autistic people. While IE shows promise for producing positive outcomes in the autistic population, we discuss the potential challenges for research and practice due to its current emphasis on accurate interoception, emotional awareness and processing, and executive functioning. This suggests the need for research and practice to integrate autistic needs and experiences into future developments with an affirmative approach. Public Significance: IE is an effective intervention for reducing disordered eating behaviours. Autistic individuals commonly present disordered eating behaviours and have unique nutritional needs which often require intervention. However, there is limited understanding of IE among the autistic population. Research-informed definitions involving autistic perspectives will support translating the IE framework to this underrepresented population.

Measuring flexibility in autistic adults: Exploring the factor structure of the flexibility scale self report

Cognitive flexibility differences are common for autistic individuals and have an impact on a range of clinical outcomes. However, there is currently a lack of well validated measurement tools to assess flexibility in adulthood. The Flexibility Scale was originally designed as a parent-report measure of real-world flexibility challenges in youth. The original Flexibility Scale provides a total score and five subscales: Routines and Rituals, Transitions and Change, Special Interests, Social Flexibility, and Generativity. In this study, we evaluate the factorial validity of the Flexibility Scale as a self-report (Flexibility Scale Self Report) measure of cognitive flexibility, adapted from the original Flexibility Scale, for use by autistic adults. This study includes both a primary sample (n = 813; mean age = 40.3; 59% female) and an independently recruited replication sample (n = 120; mean age = 32.8; 74% female) of individuals who completed the Flexibility Scale Self Report. The analysis consisted of an initial confirmatory factor analysis (CFA) of the original Flexibility Scale structure, followed by exploratory factor analysis (EFA) and factor optimization within a structural equation modeling framework to identify the optimal structure for the questionnaire in adults. The identified structure was then replicated through CFA in the replication sample. Our results indicate an alternative optimal scale structure from the original Flexibility Scale, which includes fewer items, and only three (Routines/Rituals, Transitions and Change, Special Interests) of the five subscales contributing to the flexibility total score. Comparisons revealed no structural differences within the scale based on sex assigned at birth. Here the Generativity and Social Flexibility scales are treated as independent but related scales. The implications for measurement of cognitive flexibility in clinical and research settings, as well as theoretical underpinnings are discussed.

The Relations Between an Inventory-Based Measure of Executive Function and Impulsivity Factors in Alcohol- and Cannabis-Relevant Outcomes

OBJECTIVE

While the lack of relation between performance- and inventory-based executive function (EF) measures is well documented, there remains ambiguity between self-report EFs and closely related constructs (e.g., impulsivity) assessed via the same method. The degree of convergence between purported EF measures with similar yet distinct constructs contain important theoretical implications for available EF assessment strategies and their construct validity. A newer measure of EF, the Behavior Regulation Inventory of Executive Functions-Adult (BRIEF-A), allows for more direct comparisons to self-reported measures of impulsivity, such as the commonly used Urgency, Planning, Perseverance, Sensation Seeking-Positive Urgency (UPPS-P) assessment.

METHOD

The present study used factor analysis and hierarchical regression to explore the associations between the BRIEF-A and UPPS-P, using alcohol and cannabis consumption across various outcomes (i.e., quantity-frequency and consequences) as an external criterion. Participants were 339 undergraduate students (Mage = 19.35; Female = 63%) from a large southwestern university.

RESULTS

The BRIEF-A and UPPS-P demonstrated strong correlations at both higher- and lower order facets. While the BRIEF-A was a significant correlate to many substance use outcomes, these relations were generally weaker than those seen with the UPPS-P. Hierarchical regression suggested limited contributions of the BRIEF-A over and above the UPPS-P.

CONCLUSIONS

Overall, this study suggested substantial overlap between impulsigenic factors and EFs when measured by self-report, and limited utility of EF measures to account for unique variance with substance use outcomes in this sample.

Common Intersection of Autism and Gender Diversity in Youth: Clinical Perspectives and Practices

Autism and gender diversity often intersect. Many transgender youth seeking gender-related medical interventions are autistic. Clinicians serving these youth lack an autism-specific evidence base to guide gender care decisions. At present, care decisions are based on extrapolation of care models from transgender youth samples, generally. At this point, there is no evidence to suggest that autistic youth are likely to experience shifts in gender or gender-related medical requests, although this has been insufficiently studied. In this article, cowritten by expert clinicians and autistic gender-diverse collaborators, an overview of clinical care considerations and the current evidence base is provided.

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.

Early and stable difficulties of everyday executive functions predict autism symptoms and emotional/behavioral problems in preschool age children with autism: a 2-year longitudinal study

Introduction

Longitudinal studies of autistic children show that autism symptoms and emotional/behavioral problems vary and change over time. However, the factors that affect this variability remain far from certain and very little is known about what take place in the preschool period and the role of executive functions (EF).

Methods

Here, we test the influence of stable difficulties in everyday executive functioning (EEF) during early childhood across 2 years on autistic symptoms and emotional and behavioral problems. Twenty-nine autistic children (24 males and 5 females) were assessed twice within the space of 2 years. At baseline (M = 29 months, SD =5.6 months), participants were assessed for EEF, cognitive development, autistic symptoms, and emotional/behavioral problems. At follow-up, we repeated the same assessment except for cognitive development.

Results

The group with stable difficulties (across 2 years) in EEF during early childhood showed a worsening in the severity of autistic symptoms and emotional and behavioral problems compared with children without EEF difficulties (p < 0.05), and these effects cannot be attributable to cognitive development.

Discussion

Our results suggest that early and stable EEF plays the role of a modifier by interacting with the core domains of autism, in particular with the social affect domain (SA CSS), influencing social cognition and exacerbating or lessening symptom expression and emotional behavioral problems. These short-term longitudinal and preliminary findings underscore the importance of EEF as necessary target for early intervention in children with autism.

Leisure Participation of Autistic Adults: An Ecological Momentary Assessment Feasibility Study

Autistic adults participate less and express lower satisfaction in leisure activities than nonautistic adults, although literature is limited. The multifaceted nature of leisure participation makes it challenging to measure, with most measures being retrospective. Ecological momentary assessments (EMA) can reduce recall bias. This pilot study assessed the feasibility and acceptability of EMA among autistic adults. Participants (N = 40) were recruited via email and online. After completing a baseline interview, participants were asked to complete a once-daily survey for 30 days, in which they received survey links through a text messaging smartphone app. Surveys asked participants to report whether they participated in any leisure activities during the day, their level of enjoyment, with whom they interacted, and where they participated. The EMA appeared feasible in this sample, as participants completed the daily survey on average 27.05 (SD = 3.92) days. Regarding acceptability, most agreed that survey timing was convenient, that it was easy to enter responses and answer questions daily, and that they had enough response time. Overall, this study supports the use of EMA methodology among autistic adults. Future research should follow and improve upon these EMA data collection practices to examine daily behavior and well-being among autistic adults.

Executive function as a generalized determinant of psychopathology and functional outcome in school-aged autism spectrum disorder: a case-control study

BACKGROUND

Individuals with autism spectrum disorder (ASD) are challenged not only by the defining features of social-communication deficits and restricted repetitive behaviors, but also by a myriad of psychopathology varying in severity. Different cognitive deficits underpin these psychopathologies, which could be subjected to intervention to alter the course of the disorder. Understanding domain-specific mediating effects of cognition is essential for developing targeted intervention strategies. However, the high degree of inter-correlation among different cognitive functions hinders elucidation of individual effects.

METHODS

In the Philadelphia Neurodevelopmental Cohort, 218 individuals with ASD were matched with 872 non-ASD controls on sex, age, race, and socioeconomic status. Participants of this cohort were deeply and broadly phenotyped on neurocognitive abilities and dimensional psychopathology. Using structural equation modeling, inter-correlation among cognitive domains were adjusted before mediation analysis on outcomes of multi-domain psychopathology and functional level.

RESULTS

While social cognition, complex cognition, and memory each had a unique pattern of mediating effect on psychopathology domains in ASD, none had significant effects on the functional level. In contrast, executive function was the only cognitive domain that exerted a generalized negative impact on every psychopathology domain (p factor, anxious-misery, psychosis, fear, and externalizing), as well as functional level.

CONCLUSIONS

Executive function has a unique association with the severity of comorbid psychopathology in ASD, and could be a target of interventions. As executive dysfunction occurs variably in ASD, our result also supports the clinical utility of assessing executive function for prognostic purposes.

A neuro-computational social learning framework to facilitate transdiagnostic classification and treatment across psychiatric disorders

Social deficits are among the core and most striking psychiatric symptoms, present in most psychiatric disorders. Here, we introduce a novel social learning framework, which consists of neuro-computational models that combine reinforcement learning with various types of social knowledge structures. We outline how this social learning framework can help specify and quantify social psychopathology across disorders and provide an overview of the brain regions that may be involved in this type of social learning. We highlight how this framework can specify commonalities and differences in the social psychopathology of individuals with autism spectrum disorder (ASD), personality disorders (PD), and major depressive disorder (MDD) and improve treatments on an individual basis. We conjecture that individuals with psychiatric disorders rely on rigid social knowledge representations when learning about others, albeit the nature of their rigidity and the behavioral consequences can greatly differ. While non-clinical cohorts tend to efficiently adapt social knowledge representations to relevant environmental constraints, psychiatric cohorts may rigidly stick to their preconceived notions or overly coarse knowledge representations during learning.

Improving adaptive behaviors for autistic adults without intellectual disability through executive function training

Executive functioning (EF) is a cognitive process used to perform various daily activities throughout one's lifespan. Autistic adults without intellectual disabilities (ID) also experience difficulties with EF, which is closely associated with adaptive behaviors. For this reason, it is important to improve adaptive behaviors through enhanced use of EF for autistic adults to transition into adulthood successfully. This study aims to conduct a randomized controlled trial to evaluate the effectiveness of a newly developed and modified intervention program. Thirty autistic adults without ID were randomly assigned to the treatment or waitlist group. The participants and caregivers completed various assessments and self-report questionnaires to measure everyday EF and adaptive behaviors. We performed linear mixed-effect modeling to compare the two groups. Data collected at pre-, middle, post-, and follow-up based on participants who completed the program were used to explore changes across time. While there were significant differences in the EF utility-scale (F=5.46, p = .027) between the treatment and waitlist groups, no group x time interactions were detected in other measures. Everyday EF and adaptive behaviors improved when comparing measurements at different time points (p < .001). Our program is Korea's first evidence-based intervention to improve everyday EF and adaptive behaviors for autistic adults without ID.

Adaptive behavior deficits in individuals with 3q29 deletion syndrome

Background

3q29 deletion syndrome (3q29del) is associated with a significantly increased risk for neurodevelopmental and neuropsychiatric phenotypes. Mild to moderate intellectual disability (ID) is common in this population, and previous work by our team identified substantial deficits in adaptive behavior. However, the full profile of adaptive function in 3q29del has not been described, nor has it been compared to other genomic syndromes associated with elevated risk for neurodevelopmental and neuropsychiatric phenotypes.

Methods

Individuals with 3q29del (n=32, 62.5% male) were evaluated using the Vineland Adaptive Behavior Scales, Third Edition, Comprehensive Parent/Caregiver Form (Vineland-3). We explored the relationship between adaptive behavior and cognitive function, executive function, and neurodevelopmental and neuropsychiatric comorbidities in our 3q29del study sample, and we compared subjects with 3q29del to published data on Fragile X syndrome, 22q11.2 deletion syndrome, and 16p11.2 deletion and duplication syndromes.

Results

Individuals with 3q29del had global deficits in adaptive behavior that were not driven by specific weaknesses in any given domain. Individual neurodevelopmental and neuropsychiatric diagnoses had a small effect on adaptive behavior, and the cumulative number of comorbid diagnoses was significantly negatively associated with Vineland-3 performance. Both cognitive ability and executive function were significantly associated with adaptive behavior, and executive function was a better predictor of Vineland-3 performance than cognitive ability. Finally, the severity of adaptive behavior deficits in 3q29del was distinct from previously published data on comparable genomic disorders.

Conclusions

Individuals with 3q29del have significant deficits in adaptive behavior, affecting all domains assessed by the Vineland-3. Executive function is a better predictor of adaptive behavior than cognitive ability in this population and suggests that interventions targeting executive function may be an effective therapeutic strategy.

Development and Psychometric Properties of Self-Reported Job Interview Skills and Job Interview Anxiety for Autistic Transition-Age Youth

BACKGROUND

The study of job interview training is an emerging area among transition-age autistic youth who face significant challenges when navigating job interviews. The autism field has limited measures that have undergone rigorous psychometric evaluation.

OBJECTIVE

We sought to evaluate the psychometric properties of adapted self-report measures assessing job interview skills and job interview anxiety.

METHODS

As part of two parent randomized controlled trials, eighty-five transition-age autistic youth completed measures related to the strength of their job interview skills and their level of job interview anxiety. We conducted classical test theory analyses, exploratory and confirmatory factor analyses, and Rasch model analytic and calibration analyses. Pearson correlations were used to establish concurrent, divergent, and criterion validity by correlating these scales with measures of social differences, depressive symptoms, behaviors, neuropsychological functioning, and work history.

RESULTS

Our analyses yielded two brief and reliable scales: Measure of Job Interview Skills (MOJO-iSkills) and Measure of Job Interview Anxiety (MOJO-iAnxiety), which demonstrated initial concurrent, divergent, and criterion validities when correlated with measures of depressive symptoms, social differences, internalizing and externalizing behavior, and work history.

CONCLUSIONS

This study presents initial evidence that MOJO-iSkills and MOJO-iAnxiety have acceptable psychometric properties supporting they can be used to reliably and validly assess job interview skills and interview anxiety.

Self-reported cognitive decline among middle and older age autistic adults

Very little is known about autistic adults as they age. Early evidence suggests a potentially high risk for dementia and atypical cognitive decline in autistic middle and older age adults. Research in the general population indicates that self-reported cognitive decline may predict future dementia earlier than performance-based measures. Nevertheless, self-report dementia screeners have not been used to date in autism research. In a sample of middle and older age autistic adults (N = 210), participants completed a self-rated dementia screener, the AD8, to describe the rate of cognitive decline, examine associations of cognitive decline with age, educational level, sex designated at birth, and autistic traits, and document the psychometrics of a dementia screener in autistic adults. We found high rates of cognitive decline with 30% of the sample screening positive. The most common symptoms were declining interest in leisure activities, and increases in everyday problems with thinking, memory, and judgment. There was evidence that autistic individuals designated female at birth may be more vulnerable to cognitive decline than autistic individuals designated male at birth. Notably, reports of cognitive decline did not vary by age or educational level. Modestly elevated autistic traits were found in those screening positive versus negative for cognitive decline. Finally, the dementia screener showed good psychometrics, including convergent validity with an independent measure of current memory problems. These results could signal an emerging public health crisis in autistic adults as they age, and support the potential utility of self-report measures for early screening for cognitive decline in this population.

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.

The impact of COVID-19 pandemic on emotional and behavioral problems of children with autism spectrum disorder and developmental delay aged 1-6 years in China

Introduction

The COVID-19 pandemic outbreak have caused increased levels of emotional and behavioral problems, particularly among people with pre-existing mental health conditions. Young individuals with autism spectrum disorders (ASD) and developmental delay (DD) are particularly at risk due to their vulnerability. The purpose of this study was to look into the different effects of the COVID-19 pandemic on 1-6-year-old children with ASD and DD.

Methods

Parents and guardians of children with ASD completed an online survey that included questions about their children's socio-demographics characteristics, the effects of the COVID-19 outbreak on their health, and what they needed in order to deal with the conditions of the pandemic.

Results

This study compared 4,138 children with ASD to 711 children with DD. Children with ASD had a higher risk of having more emotional and behavioral problems than children with DD (OR 1.38, 95% CI 1.12-1.70). Compared to parent-oriented rehabilitation at home, discontinuing rehabilitation had a higher likelihood of negative emotional and behavioral change (OR 1.67, 95% CI 1.41-1.98). Having teachers' online support had a higher likelihood of negative emotional and behavioral change for ASD children (OR 1.26, 95% CI 1.03-1.54).

Conclusions

This article provided evidence that children with developmental disabilities, particularly ASD, were at risk for a variety of challenges to their emotional functioning during the COVID-19 period, and that online support was not an ideal way for children with ASD to receive effective educational intervention in China.

Cingulate-Prefrontal Connectivity During Dynamic Cognitive Control Mediates Association Between p Factor and Adaptive Functioning in a Transdiagnostic Pediatric Sample

BACKGROUND

Covariation among psychiatric symptoms is being actively pursued for transdiagnostic dimensions of psychopathology with predictive utility. A superordinate dimension, the p factor, reflects overall psychopathology burden and has support from genetic and neuroimaging correlates. However, the neurocognitive correlates that link an elevated p factor to maladaptive outcomes are unknown. We tested the mediating potential of dynamic adjustments in cognitive control rooted in functional connections anchored by the dorsal anterior cingulate cortex (dACC) in a transdiagnostic pediatric sample.

METHODS

A multiple mediation model tested the association between the p factor (derived by principal component analysis of Child Behavior Checklist syndrome scales) and outcome measured with the Vineland Adaptive Behavior Scale-II in 89 children ages 8 to 13 years (23 female) with a variety of primary neurodevelopmental diagnoses who underwent functional magnetic resonance imaging during a socioaffective Stroop-like task with eye gaze as distractor. Mediators included functional connectivity of frontoparietal- and salience network-affiliated dACC seeds during conflict adaptation.

RESULTS

Higher p factor scores were related to worse adaptive functioning. This effect was partially mediated by conflict adaptation-dependent functional connectivity between the frontoparietal network-affiliated dACC seed and the right dorsolateral prefrontal cortex. Post hoc follow-up indicated that the p factor was related to all Vineland Adaptive Behaviors Scale-II domains; the association was strongest for socialization followed by daily living skills and then communication. Mediation results remained significant for socialization only.

CONCLUSIONS

Higher psychopathology burden was associated with worse adaptive functioning in early adolescence. This association was mediated by weaker dACC-dorsolateral prefrontal cortex functional connectivity underlying modulation of cognitive control in response to contextual contingencies. Our results contribute to the identification of transdiagnostic and developmentally relevant neurocognitive endophenotypes of psychopathology.

Executive functions in daily living skills: A study in adults with autism spectrum disorder

Introduction

Adults with autism and adults with schizophrenia show difficulties in adaptive skills, especially those related to daily functioning. Some studies suggest that adaptive skills are associated with deficits in executive functions (EF), while others indicate that intelligence quotient (IQ) might also play a role. Literature suggests that autistic symptoms further affect adaptive skills. The interest of the current study, therefore, was to explore to what extent IQ, EFs as well as core autistic symptoms predict adaptive skills.

Methods

To do this, 25 controls, 24 adults with autism, and 12 with schizophrenia were assessed on IQ (Wechsler Adult Intelligence Scale), and executive functioning. The EF was measured with neuropsychological tasks (inhibition, updating, and task switching) and with the Dysexecutive-Spanish Questionnaire (DEX-Sp) which assessed everyday life EF problems. Core ASD symptoms were measured using the Autism Diagnostic Observation Schedule, the Autism Spectrum Quotient-Short version (AQ-S), and the Repetitive Behavior Questionnaire - 3 (RBQ-3).

Results

The results indicated EF difficulties in both, autism and schizophrenia. The IQ explained a high percentage of the variance found in adaptive skills, but only in the autism group. We can conclude, therefore, that high IQ is associated with low adaptive skills levels and EFs affect adaptive functioning in people with autism; however, this does not explain the difficulties in adaptive functioning in the schizophrenia group. Core features of autism assessed with self-report questionnaires (but not the ADOS-2) predicted low scores on the adaptive skills, only in the autism group.

Discussion

Both EF measures predicted adaptive skills scores in autism, but not in schizophrenia. Our results suggest that different factors affect the adaptive functioning in each disorder. For instance, the EFs should be a central focus for improvement, especially for individuals with autism.

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.

Adaptive Behavior Profiles in Autism Spectrum Disorder

PURPOSE OF REVIEW

The goal of this paper is to provide an overview of profiles of adaptive behavior in autism spectrum disorder and highlight the importance of these everyday skills in optimizing self-sufficiency throughout life.

RECENT FINDINGS

Research has clearly confirmed that adaptive deficits exist in ASD, particularly in social skills. These impairments are highly associated with co-occurring conditions such as executive functioning impairments, psychiatric conditions, and even psychosis. There tends to be a discrepancy between intellectual capacity and adaptive functioning, particularly in autistic individuals without cognitive and language delays, with this gap widening between childhood and adulthood. Although cognition and language skills are associated with good outcome in ASD, they are insufficient in the absence of intact adaptive behavior. There is a critical need to emphasize the importance of adaptive functioning in diagnostic evaluations and treatment/intervention programs to ensure that every autistic individual has the potential for success.

Self-management of daily life tasks in diploma-track youth with disabilities

PURPOSE

Youth with disabilities who graduate with a regular high school diploma often continue to have difficulties in their daily functioning that ultimately impact adulthood outcomes. To better understand these functional difficulties and determine how best to address them, it is important to distinguish deficits in discrete skills from difficulty organizing skills to self-manage complex tasks associated with adult roles. The purpose of this study was to explore the extent to which challenges in social, executive function and behavior management factors relate to these two aspects of daily functioning.

METHODS

This is a secondary analysis of the National Longitudinal Transition Study 2 funded by the United States Department of Education. The direct and indirect associations between youth underlying factors and self-management of daily life tasks (SMDLT) versus discrete functional skills were modelled using structural equation modelling.

RESULTS

A model incorporating social skills, communication, and behavior regulation explained 55% of the variance in SMDLT. In contrast, the model predicting discrete functional skills had fewer significant associations and described less variance (37%) in the outcome.

CONCLUSIONS

Findings suggest that using measures of SMDLT and designing targeted interventions for SMDLT might help improve participation in independent living and productivity for diploma-track youth with disabilities.Implications for rehabilitationSuccessful transition from high school to adult roles requires the ability to self-manage the daily life tasks required for those roles, such as employment, post-secondary education, and independent living.The ability to self-manage daily tasks is distinct from mastery of discrete functional skills and should be assessed with measures that uniquely examine this domain.Social and communication skills, executive functioning, and behavioral regulation, are important contributors to the ability to self-manage life tasks for diploma-track youth with disabilities and should be incorporated into multifaceted interventions.Interventions to improve self-management of tasks should include teaching strategies and practice coordinating underlying skills in flexible ways that meet the varying demands of tasks and diverse environments.