'Who Am I?': An Exploratory Study of the Relationships Between Identity, Acculturation and Mental Health in Autistic Adolescents

Should We Continue to Tell Autistic People that Their Brains are Different?

Autism is often considered to reflect categorically 'different brains'. Neuropsychological research on autism spectrum disorder (ASD) however, has struggled to define this difference, or derive clear-cut boundaries between autism and non-autism. Consequently, restructuring or disbanding the ASD diagnosis is becoming increasingly advocated within research. Nonetheless, autism now exists as a salient social construction, of which 'difference' is a key facet. Clinical and educational professionals must influence this cautiously, as changes to autism's social construction may counterproductively affect the quality of life of autistic people. This paper therefore reviews ASD's value as both neuropsychological and social constructs. Although lacking neuropsychological validity, the autism label may be beneficial for autistic self-identity, reduction of stigma, and administering support. Whilst a shift away from case-control ASD research is warranted, lay notions of 'different brains' may be preserved.

Effects of Adaptive Prompts in Virtual Reality-Based Social Skills Training for Children with Autism

The purpose of this single-case experimental design (SCED) study is to investigate how adaptive prompts in virtual reality (VR)-based social skills training affect the social skills performance of autistic children. Adaptive prompts are driven by autistic children's emotional states. To integrate adaptive prompts in VR-based training, we conducted speech data mining and endorsed micro-adaptivity design. We recruited four autistic children (12-13 years) for the SCED study. We carried out alternating treatments design to evaluate the impacts of adaptive and non-adaptive prompting conditions throughout a series of VR-based social skills training sessions. Using mixed-method data collection and analyses, we found that adaptive prompts can foster autistic children's desirable social skills performance in VR-based training. Based on the study findings, we also describe design implications and limitations for future research.

Social Skills Interventions for Adolescents with Level 1 Autism Spectrum Disorder: A Systematic Review with Meta-Analysis of Randomized Controlled Trials

Objective

Evidence on the efficacy of social skills training for adolescents with Level 1 Autism Spectrum Disorder (ASD) is unclear.

Method

We searched Pubmed, Scopus, and Web of Science until July 27th, 2023, for randomized controlled trials (RCTs) of social skills training for pre-adolescents and adolescents (aged 9-18) with Level 1 ASD. We then pooled data on efficacy from individual RCTs by conducting multivariate mixed-effects meta-analyses in R. We estimated possible bias in the retained RCTs using the RoB2 tool.

Results

We retained 36 RCTs (encompassing 2796 participants), including 18 RCTs comparing an experimental treatment to a waiting list, and 18 RCTs comparing it to standard care/control treatment. Meta-analyses showed that experimental treatments were significantly more efficacious than waiting list or standard care/ control treatments in improving social skills (SMD = 0.3745; 95%CI = [0.2396; 0.5093]), as well as reducing behavioral symptoms (0.3154;0.1783, 0.4525) and anxious/depressive symptoms (0.2780; 0.0432, 0.5128). However, for some outcomes there was significant heterogeneity across studies and evidence of publication bias. Subgroup analyses and meta-regressions did not identify any specific clinical or demographic factors as significant predictors of outcome. The most common risk of bias across studies was related to deviations from intended interventions and measurement of the outcomes.

Conclusions

At the group level, social skills training for adolescents with Level 1 ASD is efficacious, with small-to-moderate effect size. Future research should focus on personalized medicine approaches, aimed at tailoring interventions to specific characteristics of adolescents with Level 1 ASD.

Autistic identity: A systematic review of quantitative research

Autism can be considered both a personal and social identity. Identifying the factors contributing to positive Autistic identity development is crucial given the potential implications for mental health and wellbeing. In this systematic review, we aimed to synthesize quantitative literature on Autistic identity to identify the (individual and environmental) factors associated with Autistic identity, and to ascertain the relationship between Autistic identity and mental health and wellbeing. A total of 3,617 studies were screened and 20 met our inclusion criteria. Results indicated that people developed a more positive Autistic identity when receiving external autism acceptance and external support. The association between individual factors and Autistic identity were largely nonsignificant or inconclusive, highlighting the need for broad support that meets the needs of a range of Autistic people, rather than specific subgroups. Importantly, positive Autistic identity was associated with improved mental health and wellbeing. Peer support and/or self-directed support resources may be valuable mechanisms for supporting Autistic people to cultivate a positive Autistic identity. The evaluation of such support, including the long-term impacts on identity development, will be a critical avenue for future research.

The association between social camouflage and mental health among autistic people in Japan and the UK: a cross-cultural study

BACKGROUND

To examine the relationship between social camouflage and mental health in Japanese autistic adults and make an international comparison with a sample from the UK.

METHODS

This study analysed secondary data of participants with a self-reported diagnosis of autism from Japan (N = 210; 123 men and 87 women) and the UK (N = 305; 181 women, 104, men, and 18 nonbinary). The relationships between the quadratic term of the Camouflaging Autistic Traits Questionnaire and mental health scales, including depression and anxiety, were assessed.

RESULTS

The UK sample showed linear relationships, whereas the Japanese sample showed significant nonlinear relationships. The quadratic terms of the Camouflaging Autistic Traits Questionnaire slightly explained generalised anxiety (β = .168, p = .007), depression (β = .121, p = .045), and well-being (β = - .127, p = .028). However, they did not explain the association between social anxiety and the Camouflaging Autistic Traits Questionnaire.

LIMITATIONS

Participants had self-reported diagnoses, and while the autism-spectrum quotient provides a cut-off value for screening, it does not enable confirming diagnoses. Mean scores of the Japanese version of the Camouflaging Autistic Traits Questionnaire were lower as compared to the original CAT-Q, which implies that the social camouflage strategy types used by autistic people in Japan and the UK could differ. The cross-sectional design limits causal inferences.

CONCLUSION

In the UK, more social camouflage was associated with poorer mental health scores, whereas too little or too much social camouflage was associated with a low mental health score in Japan. The Japanese population is seemingly less aware of and educated on autistic characteristics and considers 'average' behaviour a good thing. This could influence Japanese autistic people's social camouflage use, differing from that of autistic people in the UK. The differences in the relationship between social camouflage and mental health between Japan and the UK could be associated with national-level divergence regarding the culture of autism.

Negative first impression judgements of autistic children by non-autistic adults

Introduction

Although autism inclusion and acceptance has increased in recent years, autistic people continue to face stigmatization, exclusion, and victimization. Based on brief 10-second videos, non-autistic adults rate autistic adults less favourably than they rate non-autistic adults in terms of traits and behavioural intentions. In the current study, we extended this paradigm to investigate the first impressions of autistic and non-autistic children by non-autistic adult raters and examined the relationship between the rater's own characteristics and bias against autistic children.

Method

Segments of video recorded interviews from 15 autistic and 15 non-autistic children were shown to 346 undergraduate students in audio with video, audio only, video only, transcript, or still image conditions. Participants rated each child on a series of traits and behavioural intentions toward the child, and then completed a series of questionnaires measuring their own social competence, autistic traits, quantity and quality of past experiences with autistic people, and explicit autism stigma.

Results

Overall, autistic children were rated more negatively than non-autistic children, particularly in conditions containing audio. Raters with higher social competence and explicit autism stigma rated autistic children more negatively, whereas raters with more autistic traits and more positive past experiences with autistic people rated autistic children more positively.

Discussion

These rapid negative judgments may contribute to the social exclusion experienced by autistic children. The findings indicate that certain personal characteristics may be related to more stigmatised views of autism and decreased willingness to interact with the autistic person. The implications of the findings are discussed in relation to the social inclusion and well-being of autistic people.

The Intersection of Autism and Transgender and Nonbinary Identities: Community and Academic Dialogue on Research and Advocacy

Many transgender people are autistic. Community expressions of the autism transgender intersection abound. Some commentators have questioned the proportional overrepresentation of autism among gender-diverse people, suggesting these individuals may not be truly autistic or truly transgender. However, increasing evidence challenges assertions that deny the authenticity of co-occurring autistic and transgender identities. Specifically, research by authors of this article indicates autistic transgender people show neurophenotypes generally consistent with cisgender autistic people and implicit gender phenotypes consistent with nonautistic transgender people. This article features a dialogue between eight leading experts in the field of intersectional autism and gender diversity, including clinicians, researchers, community advocates, and experts who are themselves autistic transgender. Key topics of discussion included: how research findings on autism and gender diversity inform respectful and supportive responses to autistic transgender people; the benefits and harms of increased societal attention toward the autism transgender intersection; and research and advocacy priorities. The expert panel concluded the following: (1) it is important to respect transgender autistic people's wellness and resilience, while also acknowledging the pathologization and stigmatization they face; (2) autistic gender-diverse people are experts of their own identity and should be involved in all aspects of research and clinical care; (3) research is needed to understand the disparities autistic transgender people face; (4) attempts to restrict autistic transgender people's access to gender care are unsupported by existing research; (5) adult gender care may benefit from incorporating universal design principles and neurodiversity-affirming strategies to reduce barriers to care and improve clinician-client communication in treatment delivery and the informed consent process; (6) cross-cultural and cross-societal research will improve best care practices in diverse contexts; (7) research and advocacy must be inclusive across ethnoracial identities, including in leadership and perspectives represented; and (8) a life span developmental framework is needed for adult research in this field.

Factors influencing the mental health of autistic children and teenagers: Parents' observations and experiences

LAY ABSTRACT

Autistic people are more likely to experience mental health difficulties compared to neurotypical people. It is very important that we understand what increases the risk for mental health difficulties, and what helps to protect against them. So far, research on this for children and young people has only investigated a small number of factors and these have been chosen by researchers and clinicians. This study took a different approach in which parents' expertise in their children was recognised. Parents were asked to tell the story of their autistic teenagers' mental health from diagnosis in early childhood through to the present, and to explain the 'theories' they developed about what affected their child's mental health - positively and negatively - and how. Parents believed a wide range of factors played a role. These include: (1) aspects of their child (e.g. their autistic traits, intelligence); (2) aspects of their surroundings (e.g. the efforts parents make to prevent and respond to their child's difficulties, features of the school they attend, availability of social activities); (3) changes their child experienced growing up (e.g. puberty, awareness of being autistic); and (4) life events involving loss and separation. Many of the factors parents identified as important have received little or no research attention to date. The findings suggest issues that should be considered in future research and reveal ways that support for parents and autistic children and teenagers can be improved.

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

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

Resilience and Coping Strategies in Adults with Autism Spectrum Disorder

Individuals with Autism spectrum disorder (ASD) are prone to stress and anxiety affecting their mental health. Although developing coping and resilience are key to cope with stressors of life, limited research exists. We aimed to explore stakeholders' experiences related to the coping and resilience of adults with ASD. We interviewed 22 participants, including 13 adults with ASD, five parents, and four service provides of adults with ASD from various Canadian provinces. Using thematic analysis, three themes emerged including: (a) societal expectations and conformity, (b) adjusting daily routines, and (c) learning overtime. This study highlights the importance of coping and informs the development of services to help enhance resilience among adults with ASD.

'Someone like-minded in a big place': Autistic young adults' attitudes towards autistic peer support in mainstream education

LAY ABSTRACT

Autistic young people may struggle in mainstream schools and feel disconnected from their peers and their school. We know that autistic adults can benefit from spending time with other autistic people, but we don't know if this is the case for younger autistic people. We conducted interviews with 13 autistic young adults in the United Kingdom who recently left mainstream schooling. We asked them if they would have been interested in being involved in autistic peer support when they were at school, and if so, what that peer support should look like. Results indicated that autistic young people were enthusiastic about the idea of peer support. They thought it was important that peer support was flexible to suit their needs at different times, as well as inclusive, positive, and embracing neurodiversity. They also discussed the potential benefits and difficulties of having a peer support system within a school setting. This adds to the growing body of research on the potential benefits of autistic-autistic interactions on autistic people's well-being and sense of belonging. Findings can be used to help design pilot peer support projects in schools that can be tested to see how effective they are.

Looking through rainbow-rimmed glasses: Taking neurodiversity perspective is related to subjective well-being of autistic adults

Finding new ways of supporting the well-being of autistic adults is an essential goal for research and practice. We tested the predictive value of attitudes towards autism (as neurodiversity or as a disorder) and identification with other autistic people, on the psychological distress and self-esteem of autistic adults ( n = 109). Adopting a neurodiversity attitude not only predicted higher self-esteem but also served as a protective factor against the negative impact of identification with other autistic people on psychological distress. These findings show that clinicians should be sensitive to the way autistic people understand autism and the extent to which they identify with the autism community, as these factors relate to their well-being.

Lay abstract

Autistic adults experience a high level of distress. Finding new ways to support their well-being is an important goal for researchers and clinicians. We assessed the way autistic adults view their autism, as a disorder or as a type of mind (neurodiversity), and the level they integrate with other autistic people, and we checked how those factors contribute to their well-being. People who see autism rather as a type of mind than as a disorder had higher self-esteem. People who view themselves as more similar to other autistic people felt more stressed, but this result was not accurate for people who view autism as a type of mind. Clinicians should be sensitive to the way autistic people understand autism and to what extent they identify with the autism community, because it may relate to their well-being.

Autism Spectrum Disorder, Extremism, and the Role of Developmental-Behavioral Pediatric Clinicians

ABSTRACT

Extremism is a global phenomenon, with an increasing domestic and international presence. Extremists recruit persons to their causes through online forums that spread hate-filled narratives and promote violence. Individuals with autism spectrum disorder may be vulnerable to recruitment through these online forums, and clinicians who work with autistic adolescents, young adults, and their families should familiarize themselves with the risk and identify strategies based on a multidisciplinary approach in the early identification, holistic prevention, and care-based intervention strategies of at-risk adolescents. This special article, representing an international collaboration between developmental-behavioral pediatrics, law enforcement, and psychology, hopes to shed light on the issue for clinicians.

A systematic review on autistic people's experiences of stigma and coping strategies

Autism can be understood as a concealable stigmatized identity. This is the first systematic review to synthesize the literature on autistic people's experiences of stigma and coping strategies. 2877 studies were screened and 27 were included in this review. The reviewed literature demonstrates that autistic individuals are acutely aware of being stereotyped, judged, and discriminated by others. Autistic people also show signs of internalizing stigma, rendering them more vulnerable to low self-worth and poorer mental health. To manage the impact of stigma, the included studies suggest that autistic individuals may use these strategies: concealment and camouflaging, selective disclosure and self-advocacy, as well as positive reframing and reconstructing identity. However, the evidence is limited and mixed in terms of how helpful and effective these strategies are. Future studies should include autistic populations with a wider range of intellectual abilities and explore interventions that can support autistic people in managing stigma to supplement interventions that seek to reduce stigma towards autistic people. The power of language in perpetuating and challenging stigma also has important implications for research and practice, underscoring the need for researchers and practitioners to reflect carefully on the messages they are communicating about autism.

Sex/Gender Differences in CARS2 and GARS-3 Item Scores: Evidence of Phenotypic Differences Between Males and Females with ASD

Growing evidence suggests that autistic females are more likely to be diagnostically overlooked than males, perhaps due to differences in ASD presentations (van Wijngaarden-Cremers in JAMA 44:627-635, 2014). To investigate specific behaviours in which differences lie, we analysed profiles of 777 children using the Childhood Autism Rating Scale (Scholper in JAMA 29:489-493, 2010) or Gilliam Autism Rating Scale (Gilliam, 2014). Males demonstrated greater difficulty in six CARS2-ST items and seven behaviours on the GARS-3, mostly reflecting restricted and repetitive behaviours. Across all instruments, the only area in which females showed greater difficulty was fear or nervousness (CARS2-ST). No meaningful differences emerged from the CARS2-HF analysis. Where males showed greater difficulty, females were more likely to present with developmentally typical behaviour.

Exploring Three Core Psychological Elements When Treating Adolescents on the Autism Spectrum: Self-Awareness, Gender Identity, and Sexuality

For those growing up on the autism spectrum, adolescence is associated with unique challenges. This narrative review explores three core psychological elements for clinicians to consider when treating adolescents on the autism spectrum: self-awareness, gender identity, and sexuality. Developmental tasks of adolescence include adaptation to a maturing mind and body, increased expectations for independence, and the ability to establish satisfying interpersonal relationships. What are welcome opportunities for non-autistic peers can become nearly insurmountable hurdles for autistic teens, which, in turn, could lead to crisis, particularly if skills needed for success in managing these tasks have not yet been acquired.

Is social camouflaging associated with anxiety and depression in autistic adults?

BACKGROUND

There is inconsistent evidence for a clear pattern of association between 'camouflaging' (strategies used to mask and/or compensate for autism characteristics during social interactions) and mental health.

METHODS

This study explored the relationship between self-reported camouflaging and generalised anxiety, depression, and social anxiety in a large sample of autistic adults and, for the first time, explored the moderating effect of gender, in an online survey.

RESULTS

Overall, camouflaging was associated with greater symptoms of generalised anxiety, depression, and social anxiety, although only to a small extent beyond the contribution of autistic traits and age. Camouflaging more strongly predicted generalised and social anxiety than depression. No interaction between camouflaging and gender was found.

LIMITATIONS

These results cannot be generalised to autistic people with intellectual disability, or autistic children and young people. The sample did not include sufficient numbers of non-binary people to run separate analyses; therefore, it is possible that camouflaging impacts mental health differently in this population.

CONCLUSIONS

The findings suggest that camouflaging is a risk factor for mental health problems in autistic adults without intellectual disability, regardless of gender. We also identified levels of camouflaging at which risk of mental health problems is highest, suggesting clinicians should be particularly aware of mental health problems in those who score at or above these levels.

Understanding the Relationships Between Autistic Identity, Disclosure, and Camouflaging

Background

Camouflaging involves concealing an autistic identity, for example, by adopting nonautistic behaviors in social contexts. We currently know little about the relationship between autistic identity and camouflaging. Furthermore, other variables may mediate the relationship between camouflaging and identity, and this study examined whether disclosure (being openly autistic) might mediate the relationship. We predicted that fewer camouflaging behaviors would be associated with higher autistic identity when an individual is more open about being autistic.

Methods

One hundred eighty autistic adults (52% female, 42% male, 5% other gender identities, and 1% preferred not to say) took part in the study. They completed an online survey with measures of camouflaging, autistic identity, and disclosure of autistic status.

Results

We found a significant mediation effect such that autistic identity had an indirect negative effect on camouflaging mediated via disclosure. In other words, higher autistic identity linked to more disclosure, which in turn linked to fewer camouflaging behaviors. However, there was evidence for competitive mediation, such that the direct effect (the relationship between identity and camouflaging ignoring disclosure) was significant, with higher autistic identity linking directly to more camouflaging.

Conclusions

The initial hypothesis was confirmed, with higher autistic identity linked to less camouflaging via disclosure. This finding indicates that camouflaging can reduce when there is high autistic identification, and someone has openly disclosed that they are autistic to others. However, the direct effect between identity and camouflaging suggests that there may be conflicts for someone who identifies strongly with being autistic but continues to camouflage. Other variables may play a role in the relationship between identity and camouflaging, such as fear of discrimination, self-awareness, timing of diagnosis, age, ethnicity, or gender. The findings indicate the importance of safe nondiscriminatory environments where individuals can disclose and express their autistic identity, which may in turn reduce camouflaging.

Lay summary

Why was this study done?: Camouflaging involves hiding or masking being autistic or using strategies to appear as though nonautistic. Past research has found that camouflaging relates to poorer mental health. Given this, we must understand ways to reduce camouflaging. In this study, we looked at the links between camouflaging, autistic identity (a sense of affiliation with the autistic community), and disclosure (being openly autistic). We know from other research that identifying strongly with the autistic community may protect against mental health difficulties, so we wanted to explore the role autistic identity might play in camouflaging.What was the purpose of this study?: The purpose was to understand the relationships between camouflaging, autistic identity, and disclosure. We considered disclosure because someone could have a strong sense of autistic identity but might not be open about this to others. We tested the idea that someone with a strong autistic identity might be more openly autistic, and this then has a knock-on effect that links to less camouflaging.What did the researchers do?: One hundred and eighty autistic adults completed an online survey. They answered questions about camouflaging, autistic identity, and disclosure. They also answered questions about who they were (e.g., age, gender) and autistic characteristics. We analyzed everyone's answers using an analysis called "mediation analysis." This analysis enables us to test how disclosure influences any association between camouflaging and identity.What were the results of the study?: We found that higher autistic identity related to more disclosure, and this then linked to less camouflaging, that is, strong autistic identity can relate to less camouflaging when someone is more openly autistic. We also found that ignoring disclosure, autistic identity directly influenced camouflaging in the opposite way, that is, higher autistic identity contributed to more camouflaging if we do not take disclosure into account. This is known as "competitive mediation" and suggests a complex picture when it comes to identity, disclosure, and camouflaging.What do these findings add to what was already known?: As far as we know, no one has looked at these relationships before. We therefore add to camouflaging research and show that camouflaging might be reduced if autistic people identify strongly and they are able to be openly autistic.What are potential weaknesses in the study?: Participants were recruited online, which means the sample may be biased, and the findings will not apply to all autistic people. We measured disclosure using one question, which could be a problem because individuals might have interpreted the question in different ways. The "competitive mediation" suggests that there are other variables impacting on relationship between identity and camouflaging, which we did not capture.How will these findings help autistic adults now or in the future?: This study indicates that strong autistic identity and being openly autistic could reduce camouflaging, which we know to have negative effects on mental health. However, to enable disclosure, these findings demonstrate the need for safe spaces where autistic people can explore their identity and be openly autistic, without fear of discrimination.

"I'm Proud to be a Little Bit Different": The Effects of Autistic Individuals' Perceptions of Autism and Autism Social Identity on Their Collective Self-esteem

This study aimed to identify the attributes that autistic people perceive as positively and negatively impacting on their identity and wellbeing. In Study 1, we recruited 140 autistic participants for an online survey. Participants completed autism social identification and collective self-esteem measures and listed attributes they associated with autism. In Study 2, we conducted focus groups with 15 autistic people to explore how positively they perceived the attributes of autism. Participants then discussed the autism attributes in relation to their own experiences and identity. We found a positive relationship between the number of positive attributes participants associated with autism, and their collective self-esteem, to the extent that they identified with other autistic people.

Is Autism Inborn And Lifelong For Everyone?

Autism or autism spectrum disorder (ASD) is described as a lifelong condition with core behavioural symptoms appearing during infancy or early childhood. Genetic and other effects occurring during the earliest times of life are thought to play a significant contributory role to the presentation of autism, denoting that autism is typically seen as an innate or inborn condition. Such descriptions have, and continue to, define autism research and clinical practice. Inspection of the existing research literature, however, suggests that within the vast heterogeneity of autism, not everyone experiences autism in such a prescribed way. Various reports have observed the presentation of "acquired autism" following a period of typical development. Other findings have documented an abatement of clinically relevant autistic features and related comorbid pathology for some. Such reports offer important insights into the heterogeneity and complexity of autism.