Creating Accessible Survey Instruments for Use with Autistic Adults and People with Intellectual Disability: Lessons Learned and Recommendations

Sensory-movement underpinnings of lifelong neurodivergence: getting a grip on autism

While the autism diagnosis emphasizes "deficits" in social communication, the article advances that sensory-movement differences underpin autism through a review of the following sources of evidence. This account critically challenges "autistic regression", with evidence that sensory-movement features appear by birth as the earliest signs of autism and underlie the behavioral differences used for diagnosis, which may reflect adaptations to inherent differences and misunderstandings from others. Sensory and motor differences are salient to autistic people, but they often go underrecognized by others. They cause cascading effects in infancy on behavior and communication through differences in sensorimotor learning, automatic imitation, eye contact, sensory perception, and interests. The article then explains how sensory processing differences may influence reduced perceptual narrowing, which involves a bottom-up information processing style grounded in the surrounding environment. Furthermore, this bottom-up processing may grow from reduced sensory integration in feedback loops potentially involving the cerebellum of the brain. The article then moves into implications for the widespread consequences of these inherent differences on quality of life. The article closes with implications for autism as a construct (including underestimated empathy and pain), testing the theory, providing sensory-sensitive support and acceptance of autistic people, and applications to diverse autistic people. The theory may apply particularly well to autistic women and girls, autistic people with speech divergence, autistic people with ADHD, and autistic people with co-occurring sensory and motor-related neurodivergences. Throughout the article, the theory also provides clinical, neurological, and experiential evidence for sensory and motor differences as lifelong, challenging the notion of "losing" (an) autism (diagnosis) as instead reflecting (risky and not necessarily "successful") camouflaging.

Health economic evaluation of Autism Adapted Safety Plans: findings on feasibility of tools from a pilot randomised controlled trial

BACKGROUND

Autism Adapted Safety Plans (AASP) have been proposed to help prevent self-harm and suicidality among autistic adults. The introduction of such plans not only needs to be clinically effective but also cost-effective. The aim of this work was to establish how the cost-effectiveness of AASP could be assessed. Specifically, whether tools and techniques used to collect data for health economic evaluation of the intervention are feasible and acceptable to autistic people.

METHODS

A feasibility and external pilot randomised controlled trial of the AASP intervention was conducted. Autistic adults recruited from diverse locations in England and Wales were randomised to either: AASP and usual care, or usual care only. Health economics tools (bespoke and adapted) were developed and focus groups were undertaken with participants, including autistic adults (n = 15), their family members/carers (n = 5), and service providers (n = 10), to determine their acceptability and feasibility. Tools considered worth further exploration were interviewer administered to participants during the pilot trial at baseline and at 6 months. Interviewer notes were used to record any issues reported while completing the tools. Response rates on the questions and completeness of the tools, along with participant feedback in the interviewer notes was assessed.

RESULTS

Standard Gamble and Time-Trade Off approaches to measure health status were judged inappropriate to measure health outcomes with autistic adults experiencing suicidal ideation and with a history of self-harm. Contingent valuation and discrete choice experiments were also considered inappropriate, due to the heavy cognitive burden on respondents. The EQ-5D-5L/VAS, resource utilisation questionnaire and time-travel questionnaire were considered acceptable by participants. Response and completion rates (as a percentage of all returned questionnaires) for resource utilisation questionnaire (> 85%), time-travel questionnaire (> 79%), EQ-5D-5L (> 96%) and EQ-5D-VAS (> 87%) were good in general. Participants needed clear guidance and interviewer support to enable questionnaire completion.

CONCLUSIONS

It is feasible and acceptable to collect relevant data on resource utilisation, and costs of accessing care and the EQ-5D-5L in a future definitive trial. Clear guidance and interviewer support on how to complete the questionnaires and explanations of the importance of questions to the research would help autistic participants completing the health economic tools.

TRIAL REGISTRATION

ISRCTN70594445; Trial Registration Date: 06/07/2020.

Body appreciation mediates the association between satisfaction with autistic identity and flourishing in autistic adults

Underpinned by the neurodiversity paradigm, scholars are increasingly interested in relationships between positive autistic identity (i.e., feeling satisfaction and pride with being autistic) and states of flourishing (i.e., where numerous aspects of a person's life and well-being are good) in autistic people. However, possible mediational pathways between these constructs remain relatively under-researched. Here, we propose a conceptual model wherein positive autistic identity is associated with flourishing in autistic adults via positive body image. To test this model, we recruited an online sample of 384 autistic adults (189 women, 195 men; M = 34.66 years, SD = 10.77) from the United Kingdom. Participants were asked to complete measures of satisfaction with autistic identity, body appreciation, and flourishing, and provide their demographic information. Structural equation modelling showed that body appreciation mediated the association between satisfaction with autistic identity and flourishing. The mediational triangle remained significantly robust after controlling for participant demographics. Future research should consider promoting positive autistic identity as a means of developing more positive body image and capacities to flourish in autistic adults.

The Relationships, Employment, Autonomy, and Life Satisfaction (REALS) Measures for Autistic Adults and Adults With Other Intellectual and Developmental Disabilities: Psychometric Testing of the Self-Report and Proxy Versions

Research and clinical work demonstrate that adults with intellectual and developmental disabilities (IDDs; including autistic adults and adults with other IDDs) struggle with key outcomes in adult life, including social relationships, employment, autonomy, and life satisfaction. However, few validated measures exist to measure these outcomes in adults with IDDs. The Relationships, Employment, Autonomy, and Life Satisfaction (REALS) Measures were created using methods developed by the Patient-Reported Outcomes Measurement Information System (PROMIS) to assess these outcomes. Large item pools were generated for the four domains, and, in field testing, 875 adults with IDDs (90% autistic; 18.4% with intellectual disability or a non-autism IDD) and 911 proxy reporters (caregivers; 79% autistic; 48.3% with intellectual disability or a non-autism IDD) completed 108 and 74 items, respectively, using response options capturing frequency, level of support needed, and satisfaction. The structure and item content of the REALS Measures were determined through an iterative process using both classical test theory and item response theory analyses. The final versions include 19 self-report and 14 proxy-report measures, with a range of 3 to 14 items each. The measures have excellent psychometric properties, high precision, and acceptable respondent burden. Thus, they are applicable for service provision, clinical, and research arenas for autistic adults and adults with other IDDs, though additional testing in IDD is warranted and evidence supporting self-report use in IDD is more limited.

Centering Autistic Perspectives: Social Acceptability of Goals, Learning Contexts, and Procedures for Young Autistic Children

Despite the importance of centering autistic perspectives in educational decision-making for autistic children, few studies have directly assessed autistic perspectives on the social acceptability of early childhood practices. We conducted an online survey to recruit perspectives of autistic adults on a current, comprehensive range of educational practices typically employed with autistic children. We also extended the survey to caregivers and early childhood practitioners, to identify commonalities and discrepancies between shareholder groups. We conducted a descriptive survey study to assess social acceptability of goals, learning contexts, and procedures typically implemented with young autistic children. We received responses from 660 individuals, 226 of whom identified as autistic. For Likert scale and ranked items, we reported median rating and ranking for each item, by shareholder group. For open-ended questions, we conducted open and axial coding, to determine consistent themes within and across shareholder groups. Respondents reported (a) high acceptability for goals promoting self-determination and low social validity for goals promoting masking; (b) high acceptability for antecedent interventions and low social validity for some forms of extinction; (c) that appropriate learning environments are highly context dependent, varying with individual needs; and (d) that the child is the most important shareholder in educational decision-making. We make recommendations to practitioners in response to survey results, including (a) respecting autistic culture and characteristics in selecting goals; (b) considering social, emotional, and psychological needs in selecting procedures; and (c) individualizing goals, learning contexts, and procedures based on the child's perspectives and unique needs.

The Suicide Assessment Kit-Modified Interview: Development and preliminary validation of a modified clinical interview for the assessment of suicidal thoughts and behavior in autistic adults

The increased prevalence of suicide among autistic people highlights the need for validated clinical suicide screening and assessment instruments that are accessible and meet the unique language and communication needs of this population. We describe the preliminary preregistered psychometric validation of the Suicide Assessment Kit-Modified Interview, in a sample of 98 autistic adults (58% women, 34% men, 7% nonbinary; MAGE = 41.65, SD = 12.96). A four-item negative affect score derived from the Suicide Assessment Kit-Modified Interview demonstrated adequate reliability (ω = 0.796, BCa 95% confidence interval = [0.706, 0.857]), as well as good convergent validity with related measures. Ordinal Suicide Assessment Kit-Modified Interview "categories" (1-5) demonstrated divergent validity (rs = -0.067 to 0.081) and good convergent validity, strongly correlating with mental health (rs = 0.446 to 0.744) and suicide assessment instruments (rs = 0.576 to 0.696). Suicide Assessment Kit-Modified Interview categories showed strong ability to predict participants identified by clinicians as "above low risk" of future suicide attempt (area under the curve = 0.887, posterior Mdn = 0.889, 95% credible interval = [0.810, 0.954], PAUC > 0.8 = 0.976). Suicide Assessment Kit-Modified Interview classifications > "Category 3" provided an observed sensitivity of 0.750 (Mdn = 0.810, [0.669, 0.948], PSe > 0.8 = 0.544) and an observed specificity of 0.895 (Mdn = 0.899, [0.833, 0.956], PSp > 0.8 = 0.995) for "above low risk" status. Our findings indicate that the Suicide Assessment Kit-Modified Interview is a psychometrically strong clinical assessment tool for suicidal behavior that can be validly administered to autistic adults without intellectual disability.Lay AbstractPeople with a diagnosis of autism are at increased risk of death by suicide. There is a need for clinical instruments that are adapted to the needs of autistic people. In this study, we modified and evaluated a clinical suicide interview (Suicide Assessment Kit-Modified Interview) for use with autistic people who do not have an intellectual disability. Autistic people helped us to modify the original version of the instrument by improving the questions, providing explanations for difficult terms or concepts, and recommending that we use different rating scales. Our results support the use of Suicide Assessment Kit-Modified Interview for assessing autistic adults without intellectual disability for suicidal thoughts and behavior. In the future, we will test how well Suicide Assessment Kit-Modified Interview works in clinical settings and with different clinical populations.

Attitudes of autistic adults toward genetic testing for autism

Genetic testing for autism has been a controversial topic within the autistic community. Opinions regarding the benefits, risks, and limitations of genetic testing often differ between autistic people, researchers, and healthcare providers. The present study sought to understand the beliefs, attitudes, and intentions to pursue genetic testing of autistic adults and compare perspectives of autistic people who have had genetic testing with those who have not. An international sample of 173 autistic adults (19 [11%] who had previously undergone autism-related genetic testing) completed an online survey with questions assessing beliefs, attitudes, and intentions to pursue genetic testing. Beliefs and attitudes about genetic testing varied widely across the sample. Autistic individuals who had received prior genetic testing had much more positive beliefs about autism-related genetic testing (d = 0.87, 95% CI [0.37, 1.36]) and attitudes toward genetic testing (d = 1.14, 95% CI [0.66, 1.61]) compared to those who had not received such testing, although there were no meaningful differences between those same groups regarding beliefs about genetic testing unrelated to autism (d = 0.02, 95% CI [-0.45, 0.49], p = 0.93). Intention to genetically test oneself or one's (hypothetical) children was also significantly predicted by autism-specific beliefs, attitudes, and prior genetic testing status. A large majority of the sample (78.6%) also agreed that autistic individuals would benefit from contact with a genetic counselor in certain situations. These findings suggest that the autistic community does not have a singular view of genetic testing, and for those Autistic individuals who are interested in pursuing genetic testing for themselves or a family member, genetic counselors have the potential to play a key role in clinical care.

Developing a Measure of Key Adult Outcomes in Adults with Developmental Disabilities: Conceptual Model and Item Generation of the REALS (Relationships, Employment, Autonomy, and Life Satisfaction)

Employment, social relationships, and autonomy are priorities to people with intellectual and developmental disabilities (IDDs). However, few validated measures exist to systematically assess these key adult outcomes in this population. This research includes first steps to develop self- and proxy report measures of life outcomes for adults with IDDs-the Relationships, Employment, Autonomy, and Life Satisfaction (REALS). A literature search identified existing adult outcome measures, and comparison of their domains informed initial conceptual model development. External consultants revised the model, and items were generated. Autistic adults (n = 15), adults with other IDDs (n = 7), caregivers of autistic adults (n = 13), and caregivers of adults with other IDDs (n = 10) completed in-depth cognitive interviews to assess comprehension of items and response categories, factors influencing how participants respond to items, and the inclusiveness of the item pool. A final conceptual model was generated with three subdomains (social relationships, employment, and autonomy), including assessment of life satisfaction within each domain. Cognitive interviews revealed that response set restructuring and item-level revisions were needed to capture the complexity of adult life and make the measure more accessible across a range of abilities. This study developed a conceptual model of relationships, work, and autonomy specific to adults with IDDs. Future work will involve collecting data from 800 + self-reporters with IDDs and 800 + caregivers of adults with IDDs to conduct psychometric analyses. Improving measurement in this area is critical to better understanding the needs of adults with IDDs and improving services available to them.

Operationalizing the ICF Core Sets for Autism and ADHD: A Multiple-Methods Feasibility Study

The International Classification of Functioning, Disability and Health (ICF) is the World Health Organization's (WHO) standard for assessing individual functioning. Over the last decade, the ICF has been made more accessible for autism and ADHD through the development and validation of tailored shorter ICF versions for these diagnoses, ICF Core Sets. To further enhance their applicability in research and practice, these Core Sets have been operationalized and implemented on an online platform, the ICF CoreSets platform. Here, we describe the iterative development process of the CoreSets platform. This multiple-methods study examines user feedback on the operationalization of the Core Sets and the feasibility of the CoreSets platform as a functional assessment for autism and ADHD. We collected a total of 678 assessments from the CoreSets platform. Individuals diagnosed with autism and/or ADHD, their relatives, participants from the general population, and professionals completed and provided feedback on the usability of the CoreSets platform. Qualitative feedback via interviews and focus groups were also collected. Qualitative data were analysed via content analysis, while quantitative data were examined using univariate and descriptive techniques. Findings show that the ICF CoreSets platform is feasible and user-friendly, but areas for improvement were also indicated, leading to additional refinement of the operationalization and platform. The operationalization of the ICF Core Sets and their implementation in the CoreSets platform appears adequate for use in research and practice, particularly after revisions indicated by future users, and is now ready for psychometric standardization.

A "Round, Bruising Sort of Pain": Autistic Girls' Social Camouflaging in Inclusive High School Settings

Although autistic females often "camouflage" their autism, few studies examine the degree to which adolescent females demonstrate these behaviors in inclusive school settings. We examined: (a) the nature, extent, and underlying motivation of camouflaging in high school; (b) the extent to which autistic girls' characteristics related to camouflaging settings, people, benefits, costs, and school supports; and (c) how girls' open-ended descriptions agreed with closed-ended camouflaging ratings. Using quantitative and qualitative analyses, this study examined the extent, domains, costs, and benefits of autistic females' school-based camouflaging. Thirty-one autistic female adolescents, all included in general education classrooms, answered rating and interview questions. Autistic females camouflaged most often in general education classrooms and with teachers and neurotypical peers that they did not know well; least often at home or with neurodivergent friends. Later age of diagnosis was associated with more camouflaging and camouflaging costs. Qualitative analyses revealed four themes: autistic identity; negative peer experiences; negative consequences of camouflaging; and value of neurodivergent friends. Some qualitative findings converged with quantitative findings, others diverged. Implications are discussed for research and practice for supporting autistic females in general education school settings.

The Feasibility of Occupation-Based Coaching for Autistic Children and Primary Caregivers

Autistic children participate less and have fewer opportunities to develop participation skills than nonautistic peers. The extent to which occupation-based coaching (OBC), a metacognitive strategy training intervention, affects participation in school-age autistic children is unknown. We conducted a single-group pretest-posttest design to evaluate the feasibility and preliminary effect of telehealth OBC for autistic children (n = 13) and primary caregivers (n = 12). Participants completed eight telehealth OBC sessions to address activity-based goals; they completed child, caregiver, and family outcomes pre- and post-intervention. Recruitment, retention, caregiver measure completion, and intervention adherence rates exceeded feasibility benchmarks. OBC had large effects on child performance (Hedge's g = 1.65) and satisfaction (Hedge's g = 1.89), a moderate effect on child sleep disturbance (Hedge's g = 0.60), and small effects on child participation (Hedge's g = 0.23) and family quality of life (Hedge's g = 0.26). Further research in a large-scale study is warranted with changes to better support child measure completion and enhance the study protocol.

Oxytocin in autism: Rethinking treatment and research through a neurodivergent perspective

This perspective piece addresses critical challenges in oxytocin-based interventions for autism, drawing on neurodivergent perspectives to highlight key issues in research relevance and inclusivity. Although oxytocin has been posited to modulate social and routinized behaviors in autistic individuals, empirical findings on its efficacy remain inconsistent. We argue that these behavioral targets may reflect neurotypical biases, often disregarding autistic individuals' perspectives, thereby limiting intervention acceptability and efficacy. Past research has frequently excluded marginalized autistic populations, including individuals with intellectual disabilities or gender-diverse identities, exacerbating generalizability issues. This piece advocates for a reorientation of research objectives in autism, proposing a shift from modifying core autistic behaviors towards enhancing quality of life through participatory research. By integrating autistic perspectives into study design and outcome selection, researchers move away from deficit-oriented frameworks and instead prioritize socially valid outcomes, such as reducing anxiety and improving adaptive functioning. Further, the perspective piece critiques the reliance on animal models, which often lack translational validity due to autism's complex social and communicative dimensions. In closing, we underscore the importance of inclusive, reproducible autism research practices that align with the lived experiences and priorities of autistic individuals. Embracing participatory research, alongside rigorous methodological adjustments, can foster advancements that effectively support the well-being of the autistic community.

Health care transition for autistic adolescents and young adults: A pilot rural and urban comparison survey study

LAY ABSTRACT

Autistic adolescents and young adults in rural areas face significant challenges in health care transition compared to their urban counterparts. Health care transition, the process of moving from pediatric to adult health care, is crucial for the long-term health outcomes of adolescents and young adults. Previous research indicates rural adolescents and young adults often have greater unmet medical and financial needs, affecting their transition experiences, but there was no study focusing on rural autistic adolescents and young adults' health care transition experiences. This pilot study provides a comparative analysis of the health care transition experiences of rural and urban autistic adolescents and young adults. Ninety-six urban and 84 rural participants (14-25 years old) participated in the study. Their average age was 19.67 years. Just over half of the participants had completed the transition to adult care, typically reporting finishing this process at around 18 years old. A majority had limited discussions with their doctors about transitioning, and those who had discussions often started these conversations late. It also reveals that the responses completed by or with parents of autistic adolescents and young adults tend to indicate that the adolescents and young adults would not make future medical decisions or are uncertain about it. The findings underscore the necessity for targeted support for autistic adolescents and young adults during their health care transition process, regardless of their residence. There is a clear need for targeted health care transition interventions for adolescents and young adults, parents, and health care providers to ensure autistic adolescents and young adults and their families receive adequate support during the health care transition process.

A Spectrum of Understanding: A Qualitative Exploration of Autistic Adults' Understandings and Perceptions of Friendship(s)

Background

Previous research has often documented that friendship is an area of difficulty for autistic people, however this may be caused by a neurotypical understanding of friendship. The current study aimed at adopting a more inclusive account of friendship, involving an autistic participant group representing a range of genders and communication preferences while exploring the following question-What are autistic adults' perceptions of friendships?

Method

Participants (n = 20) were interviewed using their preferred method of communication (speaking and non-speaking) during 2021-2022.

Results

The results showed that three main themes emerged under an overarching theme of A Spectrum of Understanding: Identity with Others, Sharing Value, and Shared Presence. The inclusive approaches used in the current study allowed under-researched autistic groups such as non-speaking autistic people and autistic people who identify as non-binary to participate in meaningful research.

Conclusions

The study offers a new perspective on the Double Empathy theory, suggesting it may be helpful to conceptualize it as a continuum of neuro-cultural learning rather than a distinctive binary centered on an autistic-allistic misunderstanding. Increased understanding of friendships in autistic groups will help to increase awareness of social belonging and support that can protect against poor mental health outcomes.

Measuring Healthcare Experiences Among People With Intellectual Disability: A Rapid Evidence Synthesis of Tools and Methods

OBJECTIVES

Patient-reported experience measures (PREMs) collect essential data for service and system-wide quality improvement and performance monitoring toward value-based care. However, the experiences of people with intellectual disability, who have high healthcare utilization couple with poorer outcomes, are often omitted from system-wide PREMs and service-wide PREMs data. The use of PREMs instruments for data collection among people with intellectual disability has not been explored. This review aimed to identify and synthesize measurement tools and approaches that have been used to gather patient-reported experience data from people with intellectual disability.

METHODS

Rapid evidence assessment was used, in which comprehensive search strategies were applied to electronic databases and gray literature. Narrative synthesis was used with the included articles to address the review aim.

RESULTS

A total of 48 documents were included; 26 peer-reviewed journal articles and 22 articles from gray literature. Patient-reported experiences have been gathered from people with intellectual disabilities in relation to specific services or encounters, predominantly using qualitative methods. To date, there is an absence of targeted service- or system-wide surveys. Existing clinic- and condition-specific instruments provide insight for broader application.

CONCLUSIONS

Patient experience assessment among people with intellectual disability requires consideration of (1) how individuals are identified and approached, (2) the content, design and structure of measurement instruments, and (3) the process by which data are collected, and (4) how it may be applied to create change. Despite the collection of patient experience data from people with intellectual disability, there is little research available about how this information is later used to support health service improvement. Applying PREMs for quality improvement is critical to realize the improvements to healthcare provision required for people with intellectual disability toward equitable care quality.

Measuring eating disorders in Autistic people: a proposal for future research

While diagnostic pathways for identifying Autism in eating disorder (ED) populations have been developed, the field continues to lack validated psychometric tools to measure EDs for use in the Autistic population. Many commonly used measures for EDs potentially lack validity and reliability in the Autistic population limiting theoretical and practical advancements in the field. This paper outlines current conflicts in autism and ED research and how these can be addressed through psychometric methodology. We discuss: (1) the lack of differentiation between ED pathology and Autistic eating behaviours, as well as the limited inclusion of autism-specific mechanisms in existing tools; (2) the subsequent theoretical and practical implications for researchers, clinicians, and Autistic people; and (3) future directions for psychometric research. Scholars are encouraged to employ participatory designs with autistic people before carefully considering which analytical strategies are used in the Autistic population.

PROs for RARE: protocol for development of a core patient reported outcome set for individuals with genetic intellectual disability

INTRODUCTION

Rare genetic neurodevelopmental disorders and intellectual disability (ID), collectively called genetic ID (GID), can profoundly impact daily functioning and overall well-being of affected individuals. To improve our understanding of the impact of GID and advancing both care and research, measuring relevant patient reported outcomes (PROs) is crucial. Currently, various PROs are measured for GID. Given the shared comorbidities across disorders, we aim to develop a generic core PRO set for children and adults with GID.

METHODS AND RESULTS

Developing the generic core PRO set entails the following steps: 1) providing an overview of potentially relevant PROs by scoping reviews and qualitative research; 2) integrating and conceptualizing these PROs (i.e., describing the content of the PROs in detail) into a pilot generic core PRO set; and 3) prioritizing relevant PROs by a European Delphi survey and consensus meetings.

CONCLUSIONS

This protocol presents the steps for developing a generic core PRO set for children and adults with GID. The next step involves selecting suitable patient reported outcome measures (PROMs) to adequately measure these PROs: the generic core PROM set. This generic core PROM set needs validation in the GID population, and eventually implementation in care and research, facilitating the aggregation and analysis of PRO data and guaranteeing continuous integration of the patient perspective in both care and research.

Community Member Views on Autism Intervention: Effects of Closeness to Autistic People with Intellectual Disabilities And Nonspeaking Autistic People

Background

Controversy regarding the neurodiversity movement (NDM), the social and medical models of disability, autism intervention goals, and causal attributions of disability contributes to divides in the autistic and autism communities. The present study investigates the views of autistic and non-autistic autistic and autism community members on these topics. We explored whether these views are shaped by having close relationships to autistic people with intellectual disabilities (ID) and nonspeaking autistic (NSA) people.

Methods

A total of 504 autistic and autism community members (278 autistic, 226 non-autistic) completed an online survey about theoretical models and intervention goals. Participants reported whether they had one or more close relationships with NSA people, autistic people with ID, neither, or both.

Results

Overall, there was considerable consensus regarding desired intervention goals: normalization goals were generally opposed, while participants generally supported well-being, societal reform, supportive environment, and adaptive skill goals. While autistic participants reported less support for normalization and adaptive skills goals than non-autistic participants, they expressed somewhat more enthusiasm for societal reform and supportive environments than non-autistic people. Autistic people supported the NDM more and the medical model less than non-autistic people. Those close to autistic people with ID gave higher ratings to adaptive skill goals. On average, participants not close to autistic people with ID saw the challenges of those without ID as being slightly more due to environmental/social factors than the challenges of those with ID; there was no such statistical difference among those close to autistic people with ID.

Conclusion

Further research investigating community views, with the inclusion of more autistic people with ID and NSA people themselves, is needed, but the results of this study suggest that the broader autistic and autism communities see NDM-consistent intervention goals as appropriate for all autistic people, including NSA people and those with ID. As autism interventions have often pursued unpopular normalization goals, this suggests directions for reform.

Adoption of new transportation assistive technologies by people with mild intellectual disabilities

PURPOSE

Although numerous technology-based assistive devices are available for use by people with intellectual disabilities, device adoption rates of are often low. The current research examined reasons for non-adoption among two samples of people with mild intellectual disabilities focusing on transportation: an area of great concern for individuals with intellectual disabilities. The influences on adoption or non-adoption of the perceived benefits of assistive devices were assessed together with the effects of device complexity, transportation self-efficacy, desire for self-determination regarding transport, technophobia, and the desire to be seen to "fit in" with wider society when wearing a device.

MATERIALS AND METHODS

Interviews were conducted with 44 people attending a support venue in southwest London. Outcomes to the interviews were employed in the formation of a questionnaire distributed to a wider national sample of people with mild intellectual disabilities. Interview and survey questions were created using Tourangeau's investigation method. Responses to the survey were subjected to a logistic regression analysis.

RESULTS AND CONCLUSION

Technophobia, transportation self-efficacy and desires for self-determination and to "fit-in" exerted powerful impacts on device adoption. Campaigns and activities designed to increase adoption rates need to recognise these important influences.

Evaluating measures to assess loneliness in autistic adults

LAY ABSTRACT

There has been increasing interest in research on loneliness in autistic adults. Much of this research has involved giving autistic adults widely-used questionnaires that are thought to measure how lonely people are. However, these questionnaires have been developed for the general public. We do not know whether these questionnaires accurately measure how lonely autistic adults are. We asked 203 autistic adults to complete an online survey that included two widely-used loneliness questionnaires: (1) the University of California, Los Angeles (UCLA) Loneliness Scale Version 3 and (2) the Social and Emotional Loneliness Scale for Adults (SELSA). We also asked participants to rate how lonely they were from 1 (often/always) to 5 (never). Participants were then asked to give their views on the questionnaires (e.g. what they thought was good, and what they thought was not so good about them). We found that the scores on the UCLA scale and the SELSA aligned with participants' ratings of how lonely they were, which suggests that these two questionnaires accurately measure loneliness in autistic people. However, our participants also identified several ways to improve the questionnaires. This included (1) better distinguishing the characteristics/experiences of loneliness from those of being autistic; (2) better reflecting how loneliness may change at different times and in different contexts and (3) making the phrasing of the questions clearer. Overall, our autistic participants tended to prefer the UCLA scale to the SELSA. Therefore, we present some recommendations about how the UCLA scale could be changed to be more suitable for autistic people.

'Who, When, How to Share': Pilot study of a new disclosure decision-making programme for autistic adults

LAY ABSTRACT

'Who, When, How to Share' is a new programme that aims to support autistic adults in making decisions around sharing their autistic identity with others. The programme involves working through a self-help guide independently over 3 weeks with optional peer support. We wanted to find out if autistic adults would join the programme and find it useful. Thirty-two autistic adults took part in the programme and 19 of them completed it. Most participants who completed the programme liked the programme and found it helpful, but some felt that they needed more time and support to complete it. They suggested that the programme would be more accessible if it was more interactive, such as including videos and other ways to gain feedback on their progress. Surveys filled in by participants before and after the programme suggested that they became more confident and less stressed about sharing their autistic identity with others, but some felt they still needed to build more confidence in order to handle negative attitudes from others. More work is needed to improve and test the programme further.

Approaches to improving mental healthcare for autistic people: systematic review

BACKGROUND

Autistic people have a high likelihood of developing mental health difficulties but a low chance of receiving effective mental healthcare. Therefore, there is a need to identify and examine strategies to improve mental healthcare for autistic people.

AIMS

To identify strategies that have been implemented to improve access, experiences of care and mental health outcomes for autistic adults, and to examine evidence on their acceptability, feasibility and effectiveness.

METHOD

A co-produced systematic review was conducted. MEDLINE, PsycINFO, CINHAL, medRxiv and PsyArXiv were searched. We included all study designs reporting acceptability or feasibility outcomes and empirical quantitative study designs reporting effectiveness outcomes. Data were synthesised using a narrative approach.

RESULTS

A total of 30 articles were identified. These included 16 studies of adapted mental health interventions, eight studies of service improvements and six studies of bespoke mental health interventions developed for autistic people. There was no conclusive evidence on effectiveness. However, most bespoke and adapted approaches appeared to be feasible and acceptable. Identified adaptations appeared to be acceptable and feasible, including increasing knowledge and detection of autism, providing environmental adjustments and communication accommodations, accommodating individual differences and modifying the structure and content of interventions.

CONCLUSION

Many identified strategies are feasible and acceptable, and can be readily implemented in services with the potential to make mental healthcare more suitable for autistic people, but important research gaps remain. Future research should address these and investigate a co-produced package of service improvement measures.

Approaches to improving mental health care for autistic children and young people: a systematic review and meta-analysis

Autistic children and young people (CYP) experience mental health difficulties but face many barriers to accessing and benefiting from mental health care. There is a need to explore strategies in mental health care for autistic CYP to guide clinical practice and future research and support their mental health needs. Our aim was to identify strategies used to improve mental health care for autistic CYP and examine evidence on their acceptability, feasibility, and effectiveness. A systematic review and meta-analysis were carried out. All study designs reporting acceptability/feasibility outcomes and empirical quantitative studies reporting effectiveness outcomes for strategies tested within mental health care were eligible. We conducted a narrative synthesis and separate meta-analyses by informant (self, parent, and clinician). Fifty-seven papers were included, with most investigating cognitive behavioral therapy (CBT)-based interventions for anxiety and several exploring service-level strategies, such as autism screening tools, clinician training, and adaptations regarding organization of services. Most papers described caregiver involvement in therapy and reported adaptations to communication and intervention content; a few reported environmental adjustments. In the meta-analyses, parent- and clinician-reported outcomes, but not self-reported outcomes, showed with moderate certainty that CBT for anxiety was an effective treatment compared to any comparison condition in reducing anxiety symptoms in autistic individuals. The certainty of evidence for effectiveness, synthesized narratively, ranged from low to moderate. Evidence for feasibility and acceptability tended to be positive. Many identified strategies are simple, reasonable adjustments that can be implemented in services to enhance mental health care for autistic individuals. Notable research gaps persist, however.

Item Understanding of Common Quality of Life Measures for use with Autistic Adults

Quality of life (QOL) and life satisfaction are important research priorities for autistic adults. As such, we saw a need to evaluate individual items of commonly used subjective QOL scales to understand how they are interpreted and perceived by autistic adults. This study used cognitive interviews and repeated sampling to evaluate the accessibility, test-retest reliability and internal consistency of several common QOL measures in a sample of young autistic adults (n = 20; aged 19-32). Cognitive interviews suggested that the Satisfaction with Life Scale was well understood and demonstrated excellent internal consistency and test-retest reliability. While the WHOQoL-BREF and WHOQoL Disability Modules had adequate reliability, cognitive interviews suggested that additional instructions and examples would further enhance their accessibility for use with autistic adults.

Measuring self and informant perspectives of Restricted and Repetitive Behaviours (RRBs): psychometric evaluation of the Repetitive Behaviours Questionnaire-3 (RBQ-3) in adult clinical practice and research settgs

BACKGROUND

Brief questionnaires that comprehensively capture key restricted and repetitive behaviours (RRBs) across different informants have potential to support autism diagnostic services. We tested the psychometric properties of the 20-item Repetitive Behaviours Questionnaire-3 (RBQ-3), a questionnaire that includes self-report and informant-report versions enabling use across the lifespan.

METHOD

In Study 1, adults referred to a specialised adult autism diagnostic service (N = 110) completed the RBQ-3 self-report version, and a relative or long-term friend completed the RBQ-3 informant-report version. Clinicians completed the abbreviated version of the Diagnostic Interview for Social and Communication Disorders (DISCO-Abbreviated) with the same adults as part of the diagnostic process. For half of the assessments, clinicians were blind to the RBQ-3 ratings. We tested internal consistency, cross-informant reliability and convergent validity of the RBQ-3. In Study 2, a follow-up online study with autistic (N = 151) and non-autistic (N = 151) adults, we further tested internal consistency of the RBQ-3 self-report version. We also tested group differences and response patterns in this sample.

RESULTS

Study 1 showed good to excellent internal consistency for both self- and informant-report versions of the RBQ-3 (total score, α = 0.90, ω = 0.90, subscales, α = 0.76-0.89, ω = 0.77-0.88). Study 1 also showed cross-informant reliability as the RBQ-3 self-report scores significantly correlated with RBQ-3 informant-report scores for the total score (rs = 0.71) and subscales (rs= 0.69-0.72). Convergent validity was found for both self and informant versions of the RBQ-3, which significantly correlated with DISCO-Abbreviated RRB domain scores (rs = 0.45-0.54). Moreover, the RBQ-3 scores showed significantly weaker association with DISCO -Abbreviated scores for the Social Communication domain, demonstrating divergent validity. Importantly, these patterns of validity were found even when clinicians were blind to RBQ-3 items. In Study 2, for both autistic and non-autistic groups, internal consistency was found for the total score (α = 0.82-0.89, ω = 0.81-0.81) and for subscales (α = 0.68-0.85, ω = 0.69-0.85). A group difference was found between groups.

LIMITATIONS

Due to the characteristics and scope of the specialist autism diagnostic service, further testing is needed to include representative samples of age (including children) and intellectual ability, and those with a non-autistic diagnostic outcome.

CONCLUSIONS

The RBQ-3 is a questionnaire of RRBs that can be used across the lifespan. The current study tested its psychometric properties with autistic adults without intellectual disability and supported its utility for both clinical diagnostic and research settings.

Autistic adults' views on the design and processes within randomised controlled trials: The APRiCoT study

LAY ABSTRACT

Large randomised controlled trials are used to test healthcare treatments. Yet there are no large randomised controlled trials on effective treatments for common mental health issues affecting autistic adults. The purpose of this study was to learn what autistic adults think about randomised controlled trials in preparation for a randomised controlled trial testing a medication for anxiety. This means we wanted to know their opinions about the way randomised controlled trials are done, such as how people are chosen to be in the study and how the study is carried out. We did this by talking to 49 autistic adults individually and asking them questions. We found that most of the people we talked to were okay with the way randomised controlled trials are done. They thought it was fair and they liked that it was based on evidence. However, some autistic people might find it hard to take part in randomised controlled trials. Some people did not like the uncertainty of not knowing what treatment they would receive in a randomised controlled trial. Others felt too vulnerable and may have had bad experiences with healthcare in the past. We found that it is important to involve autistic people early on and at every stage when designing a clinical trial. Care about how clear and precise the study communication is will build trust and improve access to research. Our study indicates that it is possible to conduct large randomised controlled trials with and for autistic people. This can ultimately contribute to the improvement of healthcare outcomes for this population.

Using the Three-Minute Speech Sample to Examine the Parent-Adolescent Relationship in Autistic Youth: A Qualitative Analysis

PURPOSE

This qualitative study examines autistic adolescents' perception of the quality of their relationship with their parent using the Three Minute Speech Sample.

METHODS

Twenty autistic youth (13-17 years; 83% male) spoke, uninterrupted, for three minutes about their thoughts and feelings regarding their mothers. Audio-recorded speech samples were transcribed and coded for emergent themes.

RESULTS

Adolescents highlighted emotional support and acceptance in the context of their relationship, support mothers provide for mental health, love and caring, efforts to build the relationship through shared activities, and areas of adolescent-parent conflict.

CONCLUSION

The TMSS is a low cost, low burden method by which autistic adolescents can comfortably and effectively self-report the quality of their relationship with their parent/caregiver.

Psychometric evaluation of a revised version of the body appreciation scale-2 for autistic adults (BAS-2A)

Emerging evidence points to unique conceptualisations of positive body image in autistic individuals. However, there are no existing measures of positive body image that have been developed or validated for use with autistic adults. To rectify this, we developed a revised version of the BAS-2 - the BAS-2A - and examined its factorial validity and psychometric properties in a sample of autistic adults from the United Kingdom. Based on the results of exploratory factor analysis and scale purification, we extracted a 12-item, unidimensional model of BAS-2A scores in a first split-subsample (n = 273). Confirmatory factor analysis supported the unidimensional model of BAS-2A scores in a second split-subsample (n = 277). BAS-2A scores presented adequate composite reliability, measurement invariance across gender identity, and patterns of construct validity. For both women and men, BAS-2A scores correlated positively with self-esteem, well-being, quality of life, and adaptive coping, and inversely with dietary restraint, weight/shape overvaluation, body dissatisfaction, and depression. Finally, BAS-2A scores demonstrated incremental validity, predicting self-esteem over-and-above body dissatisfaction. However, temporal stability of the BAS-2A over three weeks was not supported. These results support the BAS-2A as a psychometrically robust measure of body appreciation for use in autistic adults from the United Kingdom.

A Comparison of Autistic and Non-Autistic College Students' Perceived Challenges and Engagement in Self-Advocacy

PURPOSE

Autistic students experience lower college graduation rates than their peers, affecting future opportunities. Self-advocacy is crucial for successful adaptation in postsecondary settings and is documented as a challenge for autistic students. The purpose of the study was to examine autistic college students' engagement in self-advocacy and specific college-related challenges as compared to their neurodivergent and neurotypical peers.

METHOD

This study used a cross-sectional survey design to compare perceptions related to self-advocacy and college-related challenges across three groups of students: autistic students, students with a disability other than autism, and nondisabled students. Descriptive and inferential statistics were used to compare survey responses across groups.

RESULTS

Differences in the groups' perceptions of their engagement in overall self-advocacy and specific self-advocacy strategies were evident. Autistic students rated themselves significantly lower on self-advocacy than did students with other disabilities. When compared to their nondisabled peers, the autistic students and those with other disabilities were less likely to report comfort interacting in the classroom, including less interest in group work, and more difficulty interacting with unfamiliar peers. In addition, the autistic students were more likely to report difficulty recognizing the need for academic assistance when compared to both peer groups. Autistic students also reported greater social challenges in the college setting than their nondisabled peers, and both neurodivergent groups of students reported significantly more challenges, overall, navigating the college setting than did their nondisabled peers.

CONCLUSIONS

Findings highlight the need for systematic, individualized self-advocacy supports for autistic and other neurodivergent college students. In addition, findings show the need to educate peers and professors about autism and self-advocacy to foster a welcoming college environment. Finally, findings suggest the need for increased social support and opportunities for social integration within postsecondary settings. Speech-language pathologists play a critical role in implementing these next steps.

Measurement matters: A commentary on the state of the science on patient reported outcome measures (PROMs) in autism research

High quality science relies upon psychometrically valid and reliable measurement, yet very few Patient Reported Outcome Measures (PROMs) have been developed or thoroughly validated for use with autistic individuals. The present commentary summarizes the current state of autism PROM science, based on discussion at the Special Interest Group (SIG) at the 2022 International Society for Autism Research (INSAR) Annual Meeting and collective expertise of the authors. First, we identify current issues in autism PROM research including content and construct operationalization, informant-structure, measure accessibility, and measure validation and generalization. We then enumerate barriers to conducting and disseminating this research, such as a lack of guidance, concerns regarding funding and time, lack of accessible training and professionals with psychometric skills, difficulties collecting large representative samples, and challenges with dissemination. Lastly, we offer future priorities and resources to improve PROMs in autism research including a need to continue to evaluate and develop PROMs for autistic people using robust methods, to prioritize diverse and representative samples, to expand the breadth of psychometric properties and techniques, and to consider developing field specific guidelines. We remain extremely optimistic about the future directions of this area of autism research. This work is well positioned to have an immense, positive impact on our scientific understanding of autism and the everyday lives of autistic people and their families.

Examining cognitive accessibility of the VIA Inventory of Strengths for adults with intellectual disability

BACKGROUND

We evaluated cognitive accessibility of the VIA Inventory of Strengths Youth short form with adults with intellectual disability for use in strengths-based practice.

METHODS

We conducted cognitive testing with adults with intellectual disability (n = 33; M age = 36.2; range: 20.4-64.2). Data were coded for the extent to which (1) items were interpreted correctly; (2) participants endorsed items as describing themselves. We calculated descriptive statistics to evaluate item interpretation and response scale use.

RESULTS

On average, 59% of participants interpreted items correctly, 20% misinterpreted items, 14% had mixed interpretations. Positive item endorsement was most associated with the response 'Very much like me' (77%); mixed endorsement was most associated with 'Somewhat like me' (39%); and negative endorsement of items was most associated with 'Not at all like me' (54%).

CONCLUSIONS

Revisions are necessary for several items to improve accessibility for adults with intellectual disability and should be made in collaboration with this population.

"There's No Separating My View of My Body from My Autism": A qualitative study of positive body image in autistic individuals

While scholars have investigated positive body image across diverse populations, extant theory largely excludes those with differing socio-cognitive experiences, such as autistic individuals. Using constructivist grounded theory, this study sought to develop a grounded theory of positive body image in autistic individuals. One-to-one interviews with photo-elicitation were conducted with 20 autistic adults (7 women, 8 men, 5 non-binary/agender; aged 18-53 years) from the United Kingdom. Through a process of open, axial, and focused coding, a grounded theory was developed around a core category of positive body image in autistic adults and was found to comprise six themes: body connection, body acceptance, appreciating body functionality and neurodivergent strengths, having a body-positive protective filter, taking care of the body, and body and appearance neutrality. Our findings suggest that some aspects of positive body image in autistic individuals are consistent with those found in neurotypical adults. However, positive body image in autistic individuals further encompasses both the sensory (i.e., how the body is felt) and aesthetic (i.e., how the body is seen) body. These findings may stimulate research aimed at improving positive body image in autistic populations.

Identification of suicide risk in a pediatric psychiatric emergency setting: Comparing the Ask Suicide-screening Questions and the Kiddie-Computerized Adaptive Test-Suicide Scale

While the emergency department (ED) is an important setting for identifying youth with psychiatric symptoms and connecting them to services, the demands of the ED make efficient and accurate measurement essential in the implementation of mental health screening. The Kiddie-Computerized Adaptive Test (K-CAT) scales, a new electronically administered measure that offers quick and comprehensive assessment across several mental health domains, may be particularly useful in this setting. Given current recommendations for youth suicide risk screening in EDs, this study compared the K-CAT-Suicide Scale (K-CAT-SS) and the Ask Suicide-screening Questions (ASQ), a widely used measure in EDs, in a sample of participants presenting to a pediatric, psychiatric emergency setting. The measures agreed on the presence of suicide risk in over 85% of cases (κ=0.59), and the characteristics of youth who screened at risk on both were similar. Cases of disagreement were more often male and more often had educational accommodations. They had lower symptom levels of and were less often diagnosed with internalizing disorders and were less often identified as high risk by ED psychiatrists and psychologists. Examination of item endorsement patterns in cases of disagreement revealed important areas of future study, including the role of caregiver report in suicide risk screening, item comprehension concerns, and the validity of assessing youth with neurodevelopmental disabilities. While additional research would be beneficial into its psychometrics when deployed in real-world settings, the K-CAT-SS should be considered a viable alternative for suicide risk screening in EDs.

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.

Lower Completion of Depression Screening and Higher Positivity Among Autistic Adolescents Across a Large Pediatric Primary Care Network

OBJECTIVE

To examine rates of depression screening and positivity among autistic adolescents where electronic depression screening is administered universally; to compare rates between autistic and nonautistic youth; and to explore sociodemographic and clinical factors associated with screening completion and results.

METHODS

We conducted a retrospective cohort study comparing 12-17-year-old autistic and nonautistic adolescents presenting for well-child care in a large pediatric primary care network between November 2017 and January 2019 (N = 60,181). Sociodemographic and clinical data, including PHQ-9-M completion status and results, were extracted digitally from the electronic health record and compared between autistic and nonautistic youth. Logistic regression explored the relationship between sociodemographic and clinical factors and screen completion and results, stratified by autism diagnosis.

RESULTS

Autistic adolescents were significantly less likely to have a completed depression screen compared to nonautistic adolescents [67.0% vs 78.9%, odds ratio (OR) = 0.54, P < .01]. Among those with a completed screen, a higher percentage of autistic youths screened positive for depression (39.1% vs 22.8%; OR = 2.18, P < .01,) and suicidal ideation/behavior (13.4% vs 6.8%; OR = 2.13, P < .01). Factors associated with screening completion and positivity differed between autistic and nonautistic groups.

CONCLUSIONS

Autistic adolescents were less likely to have a completed depression screen when presenting for well-child care. However, when screened, they were more likely to endorse depression and suicide risk. This suggests disparities in depression screening and risk among autistic youth compared to nonautistic youth. Additional research should evaluate the source of these disparities, explore barriers to screening, and examine longitudinal outcomes of positive results among this population.

Confirming the nature of autistic burnout

LAY ABSTRACT

Autistic burnout is something autistic people have been talking about for a while (see #AutBurnout and #AutisticBurnout on social media). Recently, researchers published two different definitions of autistic burnout. We wanted to test these definitions. We wanted to confirm the duration and frequency of autistic burnout. That is, how long and how often do people get autistic burnout? We surveyed 141 autistic adults who had autistic burnout. We used descriptive statistics, content analysis and reflexive thematic analysis to analyse the survey responses. Autistic adults strongly agreed with the definition published by Higgins et al. How long and how often people get autistic burnout was not clear. Participants told us they have both short and long episodes. Participants told us that autistic burnout leads to exhaustion. They needed to withdraw from being with other people. They needed to stay away from autism unfriendly places. Many had been misdiagnosed as having depression, anxiety, bipolar disorder, borderline personality disorder or other conditions. We need increased awareness of autistic burnout. Autistic people need more help. More research is needed, we need to have bigger studies to understand autistic burnout.

Lockdown Experiences and Views on Future Research Participation of Autistic Adults in the UK During the First 6 Months of the COVID-19 Pandemic

Background

The COVID-19 pandemic resulted in large-scale public health restrictions and lockdowns across many countries. There is an increasing literature on the varied impact of such lockdowns in autistic adults. However, there is very little research on how the pandemic and related public health measures may impact the willingness of autistic people in engaging and taking part in research. The aim of this qualitative study was to explore autistic adults' experiences of the COVID-19 lockdown and how the pandemic may affect future research participation.

Methods

We conducted in-depth interviews with 31 autistic adults between March and July 2020. Transcripts were analyzed thematically within a critical realism framework.

Results

Participants identified positive aspects of lockdown such as enjoying the lack of social pressures and using their well-developed skills for dealing with uncertainty. Autistic people also shared challenges of adjusting to lockdown, for example, rapid change in daily routines. While hopeful about the freedom gained from easing restrictions, participants were concerned about the inconsistent communication and application of rules during the transition out of lockdown. This may have exacerbated already rising mental health issues among autistic people. The participants viewed research participation and engagement with increased relevance during the pandemic and welcomed efforts to conduct research using online methods of communication.

Conclusion

The COVID-19 lockdown had a varied effect in the lives and routines of autistic people. However, health care providers and researchers need to be mindful of rising mental health issues in the aftermath of the pandemic, especially for people who were already vulnerable. The response to the pandemic may have offered opportunities for innovation in research processes enabling more autistic people to engage with research and making studies more inclusive.

"Simultaneously Vague and Oddly Specific": Understanding Autistic People's Experiences of Decision Making and Research Questionnaires

Background

Autism researchers often use questionnaires to gather the views and experiences of autistic people. However, questionnaires may not always be designed in accessible ways. In addition, answering questions within a questionnaire involves decision making, which some autistic people have reported finding difficult. Therefore, this exploratory study aimed to enhance our understanding of autistic people's experiences of decision making, and to analyze their feedback on questionnaire measures to further understand decision making within the research context.

Methods

One hundred seventeen participants completed an online questionnaire. In the questionnaire, they answered an open question about what affected their ability to make decisions. They then completed four questionnaire measures and after each one provided feedback. We used content analysis to categorize participants' qualitative answers.

Results

Participants discussed how their internal state, other people, the quality and quantity of information, pressure on choosing a response, external distractions, and lack of time all affected their decision making. Feedback on the questionnaires highlighted how questions needed context, often questions themselves were unclear and difficult to understand, that there were issues with Likert scales, and how measures could have questionable validity for autistic people.

Conclusions

Autism researchers need to consider how they can make their research as accessible as possible for autistic people. Our study highlights how decision making is not a straight-forward process, and researchers have a role in ensuring they give their participants clear and contextualized information. Involving autistic people in the design of research is a potential way of improving the quality of research.

Is camouflaging autistic traits associated with defeat, entrapment, and lifetime suicidal thoughts? Expanding the Integrated Motivational Volitional Model of Suicide

INTRODUCTION

The current study explored whether camouflaging autistic traits is associated with defeat and entrapment and lifetime suicidal thoughts, as predicted by the Integrated Volitional Model of Suicide (IMV model).

METHODS

180 UK undergraduate students (76.7% female 18-67 years) completed a cross-sectional online survey from February 5 to March 23, 2020, including self-report measures of defeat and entrapment (SDES), autistic traits (AQ-10), depression (PHQ-9), anxiety (GAD-7), camouflaging autistic traits (CAT-Q), and lifetime suicidal thoughts and behaviors (SBQ-R item 1).

RESULTS

After controlling for age, gender, current depression, and anxiety symptoms, autistic traits accounted for significantly more of the variance in defeat and entrapment (1.1%), and camouflaging accounted for a further 3.2% of the variance. The association between autistic traits and lifetime suicidality was significantly mediated by camouflaging, defeat, and entrapment. After controlling for age, gender, current depression, and anxiety symptoms, defeat and entrapment (but not camouflaging) accounted for significantly more variance in lifetime suicidal thoughts. The interaction between camouflaging, defeat and entrapment predicted significantly less variance in lifetime suicidal thoughts than either variable alone.

CONCLUSION

Results suggest that camouflaging autistic traits is a transdiagnostic risk factor for lifetime suicidality, relevant to the defeat and entrapment constructs of the IMV model.

Community-guided measurement-based care for autistic youth and adults receiving psychotherapy: A conceptual overview and pilot implementation study of MBC-AUT

LAY ABSTRACT

Autistic youth and adults are more likely to experience psychiatric symptoms (e.g. depression, anxiety) and to use psychiatric services than non-autistic people, yet research on evidence-based approaches to enhance psychiatric care for autistic people is limited. Measurement-based care is an evidence-based approach to psychotherapy that improves outcomes for clients, clinicians, and organizations by routinely administering and evaluating measures to clients. Despite this, research on measurement-based care systems for autistic clients is sparse. To address this gap, we developed an autism-adapted measurement-based care (MBC-AUT) system for and with autistic people and pilot tested the system in an outpatient psychiatry clinic to investigate the preliminary feasibility, acceptability, benefits, and barriers to this system for clients and clinicians. Findings suggested that the MBC-AUT system was a feasible and acceptable system for the first 18 autistic youth, their caregivers, and autistic adults to use the system. In semi-structured interviews, clients and clinicians discussed the benefits of the MBC-AUT system to various therapeutic processes, as well as several important barriers to the use of the system. We offer potential solutions to address these barriers and to reduce client and clinician burden, and propose future directions for this line of research to increase access to more autistic people. As autistic clients continue to seek psychological services amid social landscapes of increasing complexity (e.g. COVID-19 pandemic), efforts to enhance the delivery of psychotherapy for this population are critical.

Examining early learners' perceptions of inclusion: adaptation of the student version of the perceptions of inclusion questionnaire for first- and second-grade students (PIQ-EARLY)

Promoting the emotional and social development of students with and without special needs is a central goal of implementing inclusive education in the school system. The entry into school, and thus into the formal education system, is accompanied by emotions and changes in self-image and social relationships. For assessing emotional inclusion, social inclusion, and academic self-concept, the Perceptions of Inclusion Questionnaire (PIQ) is a widely used instrument. To date, the paper-pencil questionnaire has been used from third through ninth grades but has not yet been used with younger ages. This paper presents an adapted version of the PIQ for first- and second-grade students, which was used on two measurement time occasions (T1, N = 407, M_Age = 7.2; T2, N = 613, M_Age = 7.6). Information on students' reading and listening comprehension was collected from the class teachers to verify whether the adapted questionnaire can be used for all students with different levels of language competencies. Measurement invariance was demonstrated to be at least scalar for all groups considered in the analyses. Students with higher rankings of reading and listening comprehension skills reported significant higher levels of emotional inclusion and academic self-concept while there were no significant differences in social inclusion. The findings suggest that the PIQ-EARLY is a suitable instrument for assessing self-perceived inclusion in first- and second-grade students. The results also highlight the importance of students' language competencies for adjustment to school in early school years.

A systematic review and meta-analysis of suicidality in autistic and possibly autistic people without co-occurring intellectual disability

BACKGROUND

Suicidality is highly prevalent in autistic people without co-occurring intellectual disabilities, and high autistic traits are found in adults who have attempted suicide. However, prevalence rates for both autistic and possibly autistic people have not been synthesised meta-analytically.

AIMS

To (1) calculate pooled prevalence estimates of suicidality in autistic people and possibly autistic people without co-occurring intellectual disability; (2) evaluate the influence of participant and study level characteristics on heterogeneity; and (3) determine the quality of evidence.

METHODS

Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines were followed. PsycINFO, Embase, MEDLINE and Web of Science were systematically searched from 1992 to January 25, 2022. Empirical quantitative studies reporting prevalence of suicidal ideation, suicide plans, or suicide attempts and behaviours were considered for inclusion. Random effects models were used to estimate pooled prevalence of each suicidality outcome with 95% confidence intervals. Heterogeneity was explored using sensitivity and moderator analyses.

RESULTS

Data from 48,186 autistic and possibly autistic participants in 36 primary studies were meta-analysed. Pooled prevalence of suicidal ideation was 34.2% (95% CI 27.9-40.5), suicide plans 21.9% (13.4-30.4), and suicidal attempts and behaviours 24.3% (18.9-29.6). High levels of heterogeneity (I² > 75) were observed in all three analyses. Estimates did not differ between autistic or possibly autistic samples. Geographical location (p = 0.005), transgender or gender non-conforming samples (p < 0.001) and type of report (p < 0.001) significantly moderated suicidal ideation, whereas age group (p = 0.001) and measure of suicidality (p = 0.001) significantly moderated suicide plans. There was a significant association between the proportion of male participants and prevalence of suicide plans, with a decrease in the proportion of males for every unit change of suicide plan prevalence (p = 0.013). No variables were found to moderate estimates of suicide attempts and behaviours.

CONCLUSIONS

The results confirm suicidality is highly prevalent in both autistic and possibly autistic people without co-occurring intellectual disability and highlights potential moderators. Possibly autistic individuals require more attention in clinical and research considerations going forward to further understand and prevent suicide in both groups.

Centering the Inner Experience of Autism: Development of the Self-Assessment of Autistic Traits

Current tools for identifying autism are critiqued for their lack of specificity and sensitivity, especially in autistic people who are older, have higher verbal ability or significant compensatory skills, and are not cisgender boys. This may reflect the following: the historical focus of autism research on White (cisgender) male, upper and middle class children; limited interest in the inner, lived experience of autism; and the predominance of a deficit-based model of autism. We report here on the first attempt of which we are aware to develop a clinical self-report measure of autistic traits as described by autistic people. We believe this is an advance in methodology because prior work in the development of autistic trait/diagnostic measures has prioritized the perspectives of nonautistic clinicians and scientists. The measure was developed under the leadership of two autistic researchers and constructed by leveraging descriptions of autism by autistic people to generate items designed to encompass the range of the autistic experience, using strength-based, accessible language. The team utilized iterative feedback from a panel of autistic experts to refine and enhance the measure, called the Self Assessment of Autistic Traits (SAAT). It is intended for people 16 years or older and uses a format that is designed to increase its accessibility and acceptability for autistic respondents. Future work will report on the preliminary psychometrics of the SAAT, with a long-term goal of advancing our understanding of the inner autistic experience and enhancing the clinical and scientific assessment of autism.

Web search to access health information by adults with intellectual disability

Purpose

This study explored the current and desired use of web-search, particularly for health information, by adults with intellectual disability.

Design/methodology/approach

The authors surveyed 39 participants who were in supported employment or attending day centers in Australia. The survey, delivered through structured interviews, increased participation with data in a form of the participants' narratives. The responses were analyzed through a form of thematic analysis.

Findings

This study's results present the participants' daily health information interests, approaches to finding information and expectations for self-sufficiency. Participants' interest was in information to stay healthy rather than purely clinical information. The participants were keen to use online information in, accessible as well as entertaining and engaging formats. Supporting others close to the participants was the prominent intention of participants' health information access. Participants showed aspirations for an autonomous life by wanting to learn how to search.

Research limitations/implications

The findings of this study provide some avenues for consumer health information access to be respectful and inclusive of users with intellectual disability, both from an accessible design perspective as well as from a learning and support standpoint.

Originality/value

This study complements other human–computer interaction (HCI) studies which observe how adults with intellectual disability can be supported to engage with web search; this study offers the adults' verbalized perspectives on how adults wish to interact with web searching for health information, nuanced by adults' existing abilities and support needs.

Evaluating the online delivery of an autistic-led programme to support newly diagnosed or identified autistic adults

Background & aims

Exploring Being Autistic is an autistic-led group-based programme providing psychoeducation and peer support to newly identified/diagnosed autistic adults. In 2020, due to social distancing measures implemented following the coronavirus pandemic, Exploring Being Autistic was adapted for online delivery. Here, we aimed to replicate previous research into the in-person delivery of Exploring Being Autistic, to determine whether similar results were obtained when the programme was delivered online. Further, we aimed to identify the unique opportunities and challenges that online delivery afforded.

Methods

We used a community-based participatory research (CBPR) approach, whereby the autistic developer and facilitator of Exploring Being Autistic worked collaboratively with a team of academic researchers throughout the research process. Together, we evaluated two iterations of the online Exploring Being Autistic programme, involving 16 attendees. Attendees completed questionnaires before, during and after the programme. Attendees were also invited to participate in two post-programme (group or individual) interviews: one following the completion of the programme (time one) and another 6-8 months later (time two). Attendees were included in the research if they completed at least one questionnaire or interview. Data were analysed qualitatively, using reflexive thematic analysis.

Results

Experiences of participating in the programme tended to be positive. Participants appreciated the autistic-led nature of the programme, found unity in the diversity of the group, and developed a positive and practical outlook as a result of the programme. Further analyses of our data revealed mixed views regarding the online delivery of the programme. Opportunities of online delivery were noted, such as this mode of participation reducing cognitive load, enabling the programme to be accessible to more participants, and fostering meaningful social connections among participants. However, technology and practical issues were felt to cause barriers, and some human aspects of participation were felt to be 'lost in translation' (e.g., in breakout groups).

Conclusions

The online delivery of the Exploring Being Autistic programme yielded similar results to previous, in-person evaluations of the programme. While we identified positive aspects of online delivery, this mode did not entirely suit everyone's needs.

Implications

From the current findings, we can make several recommendations to develop online support for autistic people. First, flexibility is key. To make support accessible and inclusive to a broad range of autistic people, the option for attendees to engage in-person, online or in hybrid formats should be considered. Second, if delivering support online, the use of breakout rooms should be carefully considered. While participants appreciated the opportunity to meet different people, some participants found the unpredictability and lack of scaffolding associated with breakout rooms challenging. To mitigate these challenges, groups could be pre-determined and shared with the attendees in advance (although consideration should be given to how the groups 'fit' together, and whether groupings should be changed at set intervals). Gentle warnings should also be given to those in breakout rooms, to alert them of the need to re-join the main group. Finally, support with technological aspects relating to engagement should be prioritised.

Does Language Matter? Identity-First Versus Person-First Language Use in Autism Research: A Response to Vivanti

In response to Vivanti's 'Ask The Editor…' paper [Journal of Autism and Developmental Disorders, 50(2), 691-693], we argue that the use of language in autism research has material consequences for autistic people including stigmatisation, dehumanisation, and violence. Further, that the debate in the use of person-first language versus identity-first language should centre first and foremost on the needs, autonomy, and rights of autistic people, so in to preserve their rights to self-determination. Lastly, we provide directions for future research.

Intersectional Stigma for Autistic People at Work: A Compound Adverse Impact Effect on Labor Force Participation and Experiences of Belonging

Background

Little research addresses the experiences of autistic people at work, yet employment prospects remain bleak. The extant literature takes a largely remedial perspective and does not focus on harnessing this population's considerable talents. In global organizational practice, several programs purposefully target autistic people for their abilities. However, preliminary evidence suggests that such programs are inadvertently attracting mainly White males, to the exclusion of other demographics. Therefore, stigma surrounding autism at work remains, creating potential compound adverse impacts by marginalizing identities, including gender, race, ethnicity, sexuality, and socioeconomic status. We explored the intersection of autism with other marginalizing identities in the context of work. The research focused on labor force participation for autistic people and, for those in employment, perceptions of exclusion and inclusion. We compared the aforementioned variables by gender identity, racial identity, sexuality, socioeconomic background, and geographic origin.

Methods

We undertook a global cross-sectional survey, advertised through various social media platforms and promoted directly to relevant organizations. The survey included a range of validated measures as well as demographic information. We analyzed the data with frequencies, cross tabulations, chi-square tests, and non-parametric, group-wise comparisons.

Results

We found preliminary evidence of reduced rates of employment participation by race and geographic location. Females and non-binary people had lower perceptions of inclusion and belonging at work. The perception of accommodation provision had a strong association with inclusion and belonging; more so than incidental provision of flexibility in environment and scheduling not framed as a specific accommodation.

Conclusions

The findings highlight the relational aspects of accommodation and a more universal inclusion perspective. We urge practitioners and researchers to monitor employment participation and levels of inclusion/exclusion using intersectional demographic identification. We appeal for cross-cultural collaboration with academic institutions outside the anglosphere to improve our knowledge of global programs and their impact.

Shining a light on disability and health communication

Examining health inequities in the context of communication related to health and health care is important for creating health equity. There has been an increasing number of studies conducting health communication research to address inequities, but research that has prioritized people with disabilities remains limited. Over the past year, there has been a growing focus on disability and health research, including peer-reviewed papers in this volume. The health communication field can build on this momentum to continue to focus on disability in topics related to health information, misinformation, health literacy, interpersonal communication, media campaigns, media representation, digital health, communication technologies, and more.

The role of emotion dysregulation and intolerance of uncertainty in autism: Transdiagnostic factors influencing co-occurring conditions

BACKGROUND

Individuals with autism spectrum disorders (ASD) are more likely to have co-occurring psychiatric conditions such as depression and anxiety. Transdiagnostic constructs such as intolerance of uncertainty (IU) and emotion dysregulation (ED) have both been shown to be individually associated with depression and anxiety in those with ASD.

AIMS

The current study examined the relationship between IU and ED, depression, and anxiety in an ED treatment-seeking sample and examined whether ED acts as a mediator between IU-depression and IU-anxiety.

METHODS AND PROCEDURES

We examined baseline scores for 78 adolescents and young adults (12-21 years old) who were participating in an ED treatment. We assessed for correlations between IU, Reactivity and Dysphoria, anxiety, and depression symptoms, and then conducted mediation analyses to determine whether Reactivity and Dysphoria functioned as a mediator in IU- anxiety and IU- depression relationships.

OUTCOMES AND RESULTS

Concordant with prior research, ED, IU, anxiety, and depression scores were correlated. Both Reactivity and Dysphoria were found to mediate both IU-depression and IU-anxiety.

CONCLUSIONS AND IMPLICATIONS

Findings suggest that ED contributes to how IU affects psychopathology. Furthermore, both IU and ED may be pertinent treatment targets for individuals with depression or anxiety and ASD.