Gender differences in mental health prevalence in autism

Using Photovoice Methods to Set Research Priorities With Autistic People With Experience of an Eating Disorder

OBJECTIVE(S)

Autism and Autistic traits are heightened in individuals with eating disorders (EDs), with Autistic people reporting poorer treatment outcomes and experiences. Despite this, mechanisms of this overlap remain poorly understood, perhaps due to an exclusion of lived experience perspectives in setting research agendas. The study therefore sought to identify research priorities for Autistic people with an eating disorder (ED) by using accessible and inclusive arts-based research methodologies.

METHODS

Research questions were explored using Photovoice, a creative research methodology involving the creation and discussion of images. 14 participants attended group workshops, in two of which they explored research priorities for Autistic people with an ED. Images and transcripts were analysed using an adapted Photovoice Question Matrix (production, content and meaning of the image) and thematic analysis. Participants had the opportunity to provide feedback on emerging themes before themes were finalised.

RESULTS

Five themes were identified that highlighted research priorities for Autistic people with an ED: (1) Impact of early experiences (with subthemes Internalizing of socio-cultural food and body narratives and generational cycles); (2) Function of the ED (with sub-themes ED as a regulatory strategy and ED as a social acceptance strategy); (3) Barriers and facilitators to ED recovery (with sub-themes Autistic traits as barriers, Autistic traits as facilitators and Help and harm of unravelling); (4) Understanding and accommodating for complexity (with sub-themes Co-occurring conditions and Intersectionality); and (5) Changing research culture (with sub-themes Inclusive and participatory research and Nonclinical support).

DISCUSSION

Study findings are contextualised within existing autism and ED research, highlighting avenues for future research and making recommendations for future research questions. By identifying community-driven research priorities, it is hoped that study findings will inspire novel, interdisciplinary and co-produced research that will serve as a meaningful evidence base towards improving the lives of Autistic people with an ED.

Longitudinal associations between autistic children's anxiety and social communication differences: The moderating role of executive function behaviours

Anxiety has been associated with social communication and interaction differences among autistic children. We sought to clarify the direction of these associations longitudinally, and test executive function as a moderator. Participants were autistic children (N = 157; 15% female, 85% male) engaged in a longitudinal study. Analyses focused on two timepoints during preadolescence (M ages 9.7 and 10.7 years). A cross-lagged panel model tested whether parent-reported anxiety at age 9 years predicted teacher-reported social communication and interaction differences at age 10 years, and vice versa. Next, multigroup analyses tested for similarity in cross-lagged pathways at different levels of teacher-reported metacognition and behavioural regulation (two facets of executive function). At each time point, respectively, 22% and 21% of children had anxiety exceeding a suggested clinical threshold. Longitudinal associations between parent-reported anxiety and teacher-reported social communication and interaction differences were not significant in the full sample. However, multigroup analyses found lower levels of parent-reported anxiety at age 9 years predicted greater teacher-reported social communication and interaction differences at age 10 years among participants with clinically elevated behavioural dysregulation. Findings indicate low levels of anxiety, coupled with behavioural dysregulation, may signify potential for increasing social communication and interaction differences observed by teachers among autistic children entering adolescence.Lay abstractAnxiety is a mental health concern affecting many autistic children, and has been linked to greater differences in social communication and interaction style. Executive functioning (i.e. the ability to direct and regulate attention and behaviour) plays an important role in autistic children's social-emotional development. We tested whether anxiety (reported by parents) predicts social communication and interaction differences (reported by teachers) over time or vice versa among autistic preadolescents. We also investigated whether the link between anxiety and social communication and interaction differed depending on children's EF abilities (reported by teachers). We found less parent-reported anxiety predicted more teacher-reported social communication and interaction differences a year later - but only for children who had heightened behavioural dysregulation (an aspect of executive functioning that includes impulse and emotion control). Our work suggests autistic preadolescents with behavioural dysregulation and limited anxiety may be at greater risk for social difficulties, and may need more support in this area. Executive functioning may be a useful mechanism to target in treatment for this group of children.

A Measurement Invariance Analysis of the Anxiety Scale for Autism-Adults in a Sample of Autistic and Non-Autistic Men and Women

The Anxiety Scale for Autism-Adults (ASA-A) captures the autistic anxiety experience, but we do not know whether it is structurally equivalent for men and women, or non-autistic people. Measurement invariance analysis considered gender and diagnostic status (342 cis-gender autistic men (N = 105) and women (N = 237), 316 cis-gender non-autistic men (N = 104) and women (N = 212)). Strict invariance was achieved between autistic men and women and between non-autistic men and women, but the ASA-A structure is quantitatively different in autistic compared to non-autistic adults. Therefore, this tool cannot be used to directly compare anxiety between these groups. Autistic women scored significantly higher on the ASA-A than autistic men and Uncertainty was the highest scoring factor for autistic participants. Future research should include alternative gender identities.

The Co-Occurrence of Autism and Avoidant/Restrictive Food Intake Disorder (ARFID): A Prevalence-Based Meta-Analysis

OBJECTIVE

Avoidant/restrictive food intake disorder (ARFID) is a feeding and eating disorder characterized by extensive avoidance and/or restriction of food. Existing research demonstrates that ARFID is over-represented in Autistic populations and vice-versa, with both groups exhibiting shared characteristics. This meta-analysis investigated the co-occurrence between ARFID and autism via determination of autism prevalence in ARFID populations, and ARFID prevalence in Autistic groups.

METHOD

This review systematically identified literature evaluating those with ARFID and Autistic individuals. Literature was searched for using SCOPUS, MEDLINE, and Web of Science. Selected publications included Autistic individuals and those with ARFID who either received a formal diagnosis of autism and/or ARFID or met clinical threshold cut-off scores on validated autism and/or ARFID questionnaires. Prevalence was reported in proportion-based values alongside 95% confidence intervals (CIs).

RESULTS

This meta-analysis identified 21 studies (kARFID = 18 papers; kAutism = 3 papers) comprising of n = 7442 participants (nARFID = 1708; nAutism = 5734). Prevalence of autism diagnoses was 16.27% in those with ARFID (95% CI = 8.64%-28.53%), and ARFID prevalence in Autistic groups was 11.41% (95% CI = 2.89%-35.76%). Gender and ethnicity served as significant sources of heterogeneity in ARFID papers. There was insufficient data to provide comparator values or prevalence across study population and distinct underpinning drivers of ARFID.

DISCUSSION

Meta-analytic findings highlight significant rates of co-occurrence between autism and ARFID, suggesting that in clinical settings, it may be beneficial to consider screening Autistic individuals for ARFID and vice-versa. Future research should further investigate co-occurrence across ARFID profiles, gender, and ethnicity.

Avoidant/restrictive food intake disorder (ARFID) symptoms in gender diverse adults and their relation to autistic traits, ADHD traits, and sensory sensitivities

BACKGROUND

There is emerging evidence to suggest gender diverse people are overrepresented in avoidant/restrictive food intake disorder (ARFID) samples. However, the mechanisms underlying elevated risk for ARFID in this group are currently unknown. Gender diversity and neurodivergence commonly co-occur, with elevated sensory sensitivities reported to be a shared experience common across autism, attention deficit hyperactivity disorder (ADHD), and ARFID. We aimed to examine the unique contribution of sensory sensitivities, including hypo- and hyper-sensitivity, in predicting ARFID symptoms in gender diverse adults, whilst controlling for autistic and ADHD traits.

METHODS

Gender diverse adults (N = 182; 142 assigned female at birth; M age = 28.6 years) in the UK participated in an online survey. We examined correlations between their self-reported ARFID symptoms, sensory sensitivities, autistic traits (not including sensory sensitivities), and ADHD traits whilst controlling for weight and shape concerns. We then used hierarchical multiple regression to investigate the unique contribution of sensory sensitivities to ARFID symptoms whilst controlling for the other neurodivergent traits.

RESULTS

In our gender diverse sample, higher levels of ARFID symptoms were associated with higher levels of sensory sensitivities, autistic traits, and ADHD traits, after controlling for weight and shape concerns. Furthermore, sensory sensitivities, specifically hyper-sensitivity, uniquely predicted levels of ARFID symptoms once we accounted for autistic and ADHD traits.

CONCLUSIONS

When considering neurodivergence, sensory hyper-sensitivities may be particularly relevant to ARFID symptomatology in gender diverse adults. Future research should explore associations between ARFID presentations and sensory sensitivities in large samples of gender diverse adults, to enable separate analyses by gender identity.

Understanding autistic youths' menstrual product preferences and caregivers' product choices

LAY ABSTRACT

There is little research exploring the menstrual product preferences of autistic youth, especially those who recently started their period. Study authors surveyed caregivers' choice of menstrual products for their autistic children. They provided popular menstrual materials to autistic youth to try, then asked them which product(s) they preferred, did not try, and why they did not try it. Caregivers selected sensory impact as the most important feature they consider when choosing a menstrual product for their child, and youth participants preferred to use period underwear. Therefore, autistic youth may benefit from purchasing and using period underwear, and caregivers, clinicians, and companies should consider the impact of menstrual product features, like sensory sensitivities, on young autistic menstruators and how best to support them.

A Mixed Method Systematic Review Into the Impact of ED Treatment in Autistic People and Those With High Autistic Traits

OBJECTIVE

Our understanding of the impact of eating disorders (ED) treatment in Autistic people remains elusive. Research has begun to explore ED treatment outcomes and experiences in this population, however current understandings are poorly integrated. The current review therefore sought to explore the impact of ED treatment on Autistic people and those with higher Autistic traits.

METHOD

A convergent, segregated approach was used, independently evaluating quantitative then qualitative studies before integrating findings into a coherent narrative synthesis.

RESULTS

Autistic people and people with higher Autistic traits report poorer experiences of treatment and may be at increased risk of inpatient admission and prolonged inpatient treatment, possibly explained by difficulties with treatment timeframes and a lack of autism-informed support. Both groups reported similar improvements in ED symptoms and BMI. Higher rates of psychosocial difficulties pre-and post-treatment were reported in those with higher Autistic traits, and emotion-focused interventions were felt to be particularly relevant to Autistic presentations of EDs. Concerns were reported as to how well aligned group-based programs and cognitive-based interventions are for Autistic individuals and those reporting higher Autistic traits.

DISCUSSION

Future research in diagnosed autism samples is urgently needed to develop a more robust understanding of Autistic outcomes and experiences. Review findings demonstrate the need for increased understanding of ED presentations and the possible need for treatment adaptations, for Autistic people or those with higher Autistic traits.

Patterns and correlates of two-year changes in depressive symptoms for autistic adults

Background

Autistic adults are at elevated risk for depression. However, longitudinal data on the trajectory of depressive symptoms and its associated factors in autistic adults are scarce.

Methods

A community sample of 315 autistic adults participated in a two-year longitudinal study from the beginning of (March 2020) to the recovery from the COVID-19 pandemic (March 2022). They provided five waves of data on self-reported depressive symptoms and sociodemographic and life circumstances information.

Results

Multilevel model results showed that autistic adults reported large between-individual variability in self-reported depressive symptoms, and on average, they experienced an increase (i.e., worsening) in self-reported depressive symptoms over the two years of the study. Autistic adults with a depression history and lower annual household income reported higher levels of depressive symptoms. More importantly, autistic adults reported lower depressive symptoms when they were engaged in work or school, and those who had higher levels of depressive symptoms at the start of the study were more reactive to changes in work or school participation.

Conclusions

Findings from the current study have implications for potential venues of depression treatment in autistic adults around promoting employment/education, providing symptom monitoring, and addressing mental health disparities for those with lower incomes.

Internet-Delivered Psychoeducation (SCOPE) for Transition-Aged Autistic Youth: Pragmatic Randomized Controlled Trial

BACKGROUND

Psychoeducation is a recommended first-line intervention for transition-aged autistic youth, but it has not been previously evaluated in an internet-delivered format. SCOPE (Spectrum Computerized Psychoeducation) is an 8-week individual, internet-delivered, therapist-supported psychoeducative intervention.

OBJECTIVE

This study aimed to investigate the effectiveness of SCOPE through a 3-armed randomized controlled trial. The intervention aims to increase participants' understanding of autism and, in doing so, increase their quality of life (QoL).

METHODS

SCOPE was codeveloped with clinicians and autistic young adults. It contains 8 autism-related modules, each with (1) text describing the module topic, (2) four video vignettes with recurring characters who describe their lives and perspectives on the module topic, (3) a list of neurotypical characteristics related to the module's topic, and (4) self-reflection using 3 or 4 questions about the module topic, answered by multiple-choice bullets and voluntary open-ended written comments. Participants were randomized (2:1:1) to SCOPE, an active control (web-based self-study), or treatment as usual (TAU). The primary outcome was participants' autism knowledge, assessed using the Autism Spectrum Disorder Quiz, and secondary outcomes included acceptance of diagnosis, QoL, and symptoms of mental health problems. All outcomes were assessed at the baseline, postintervention, and 3-month follow-up time points, using mixed-effects models to assess change in outcome measures across time points.

RESULTS

Between 2014 and 2020, a total of 141 participants were randomized to 1 of the 3 treatment arms. The SCOPE participants had significantly greater autism knowledge gains at the posttreatment time point compared to TAU participants with a moderate effect size (d=0.47; P=.05); gains were maintained at the 3-month follow-up (d=0.46; P=.05). The self-study participants also had increased knowledge gains compared to TAU participants at the posttreatment time point with a moderate effect size (d=0.60; P=.03) but did not maintain these gains at the 3-month follow-up, and their autism knowledge scores returned to baseline (mean change score: -0.13, 95% CI -1.20 to 0.94; P=.81). In addition, SCOPE participants reported improved QoL at the postintervention (d=0.37, P=.02) and 3-month follow-up time points (d=0.60; P=.001), compared to the combined controls. The gained autism knowledge was not mirrored by changes in symptoms of anxiety or depression.

CONCLUSIONS

Effective internet-delivered interventions may facilitate first-line service access to individuals who are unable or unwilling to use traditional health care interventions or who live in geographically remote locations. Additionally, an intervention such as SCOPE could impart and sustain the knowledge gained through psychoeducation in transition-aged autistic youth. For future research, qualitative studies could further our understanding of the lived experiences of intervention participation and outcomes after internet-delivered psychoeducation.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03665363; https://clinicaltrials.gov/study/NCT03665363.

Time is of the essence: Age at autism diagnosis, sex assigned at birth, and psychopathology

LAY ABSTRACT

Previous research has shown that girls/women are diagnosed later than boys/men with autism. Individuals who are diagnosed later in life, especially girls/women, have greater anxious and depressive symptoms. Previous research has been limited due to narrow inclusionary criteria for enrollment in studies. The present study uses two samples-one clinic-based, large "real-world" sample and another research-based sample with strict criteria for autism diagnosis-to understand the relationships between diagnostic age, sex assigned at birth, and symptoms of anxiety/depression. In both samples, those who were diagnosed later had greater anxious/depressive symptoms, and anxiety was not predicted by sex. In the clinic-based but not research-based sample, those assigned female at birth were diagnosed later than those assigned male at birth. In the clinic-based sample only, individuals assigned female at birth and who were later diagnosed experienced greater symptoms of anxiety/depression compared to those assigned male who benefited from earlier diagnostic timing. Within the research-based sample, those assigned female at birth had greater depressive symptoms than those assigned male. These findings highlight the importance of timely identification of autism, especially for girls/women who are often diagnosed later. Community-based samples are needed to better understand real-world sex-based and diagnostic age-based disparities in mental health.

Gender, assigned sex at birth, and gender diversity: Windows into diagnostic timing disparities in autism

LAY ABSTRACT

Later autism diagnosis is associated with risk for mental health problems. Understanding factors related to later autism diagnosis may help reduce mental health risks for autistic people. One characteristic associated with later autism diagnosis is female sex. However, studies often do not distinguish sex assigned at birth and gender identity. Gender diversity may be more common in autistic relative to neurotypical people, and autism is more common in gender-diverse populations. We studied age at autism diagnosis by sex assigned at birth, gender identity, and gender diversity (gender-diverse vs cisgender) status, separately. We studied three separate autistic samples, each of which differed in how they were diagnosed and how they were recruited. The samples included 193 persons (8.0-18.0 years) from a research-recruited academic medical center sample; 1,550 people (1.3-25.4 years) from a clinic-based sample; and 244 people (18.2-30.0 years) from a community-enriched sample. We found significant differences in the clinic-based and community-enriched samples. People assigned female sex at birth were diagnosed with autism significantly later than people assigned male at birth. People of female gender were diagnosed significantly later than people of male gender. Gender-diverse people were diagnosed significantly later than cisgender people. Sex assigned at birth, gender identity, and gender diversity may each show unique relationships with age of autism diagnosis. Differences in how autistic people are diagnosed and recruited are important to consider in studies that examine sex assigned at birth or gender identity. More research into autism diagnosis in adulthood is needed.

Camouflaging, not sensory processing or autistic identity, predicts eating disorder symptoms in autistic adults

LAY ABSTRACT

This study aimed to explore the impact of Autistic identity (i.e. feeling like you belong to the Autistic community), sensory profiles (e.g. being over or under responsive to sensations) and camouflaging behaviours (i.e. masking) on eating disorder symptoms in Autistic adults. 180 Autistic people were recruited from the community and NHS. The Autistic people completed online questionnaires measuring Autistic identity, sensory profiles, camouflaging behaviours, autistic traits and eating disorder symptoms. The analysis showed that higher levels of camouflaging behaviour predicted higher levels of eating disorder symptoms. Sensory profiles were related to but did not predict eating disorder symptoms and there was no relationship between level of Autistic identity and eating disorder symptoms. This shows that camouflaging is the most important predictor of eating disorder symptoms in Autistic people, and warrants further exploration.

Gender differences in the association between inter-generational interaction and depressive symptoms among Chinese older adults

BACKGROUND

Inter-generational interaction is a carrier of Chinese traditional culture, and it can exert important influence on the depressive symptoms on Chinese older adults. The study aims to analyze gender differences in the association between inter-generational interaction and depressive symptoms among Chinese older adults and explore factors contributing to the differences.

METHOD

Data from China Family Panel Studies in 2020 were used. Depressive symptoms were assessed using the 8-item Center for Epidemiologic Studies Depression Scale. The latent class analysis was applied to identify patterns of inter-generational interaction of older adults (aged 60 and above). Before the comparison between older man and older woman, we used Coarsened Exact Matching to control confounding factors and improve causal inferences. Multiple linear regression was conducted to explore the association between inter-generational interaction and depression symptoms. Oaxaca-blinder decomposition method was used to analyze the gender difference and the sources.

RESULT

Our study identified three types of inter-generational interaction: detached, nearby but discordant and two-way tight-knit. Analysis indicated that most of older man (54.39%) and older woman (49.78%) were in the type of nearby but discordant. Older man and older woman who in detached type had higher depression scores than other types, and the depression score of two-way tight-knit type accounted for 12.42 and 13.77 respectively. Our findings demonstrated that two-way tight-knit type (-11.89%) significantly decreased the gender differences in the depression symptoms. Other major contributors also included living without spouse (20.56%), primary school and junior middle school (15.95%), higher middle school and above (9.50%) and no illness for two weeks (47.70%).

CONCLUSION

Our study highlighted three patterns of inter-generational interaction, and most of older man and older woman were in the pattern of nearby but discordant. In addition, the two-way tight-knit pattern significantly can decrease gender differences in depression symptoms. The contributors should be taken into account in more targeted intervention strategies for narrowing gender differences in the depression symptoms, which could achieve a gender dividend in the era of China's aging population.

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

Background

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

Methods

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

Results

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

Conclusion

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

Barriers and facilitators to ethical co-production with Autistic people with an eating disorder

BACKGROUND

Co-production is the collaboration between researchers and the lived experience community in designing, conducting and sharing research. The importance of co-production is increasingly advocated in both the autism and eating disorder fields. Despite this, there remains a lack of clarity at how to define, apply and conduct ethical co-production. Understanding common challenges and what we can do to overcome these challenges are integral to ensuring ethical and meaningful research with Autistic people with an eating disorder. The current study therefore explored: What are the barriers and facilitators to ethical co-production with Autistic people with an ED?

METHODS

Five workshops were conducted with 30 collaborators exploring barriers and facilitators to ethical co-production. Synchronous (online workshops) and asynchronous (offline discussion forum) data was analysed using thematic analysis. Themes were co-produced by a neurotypical and Autistic researcher with lived/living experience of an eating disorder.

RESULTS

Four themes were identified that explored barriers to ethical co-production: unequal partnerships, the inaccessibility of research, excluded by diagnoses and communication differences. Three themes were identified with regards to facilitators of ethical co-production: shared power (with sub-themes relationships, not roles and creative compensation), clarity and transparency and autism-affirming approaches.

DISCUSSION

Conducting ethical co-production with Autistic people with eating disorders has the potential to generate meaningful research that can be translated into improving the lives of the Autistic and eating disorder community. To achieve this, co-production teams should strive towards shared power and long-term relationships, adapting for communication differences and preferences and operating firmly within an autism-affirming framework. It is hoped that study findings will inspire collaboration, discussion and novel, translatable research.

Testing the social motivation theory of autism: the role of co-occurring anxiety

BACKGROUND

The Social Motivation Theory proposes that social reward processing differences underlie autism. However, low social motivation has also been linked to higher anxiety. Given the co-occurrence between autism and anxiety, it is possible that anxiety drives the association between social motivation and autistic characteristics. This study tests the mechanisms underlying the association between social motivation and autistic traits.

METHODS

Participants were 165 adolescents (71 male), aged 10-16 years, from the Mapping profiles of cognition, motivation and attention in childhood (C-MAPS) study, enriched for autistic traits (70 participants with an autism diagnosis, 37 male). Participants completed a battery of online experimental tasks, including a Choose-a-Movie social motivation task and social cognition measures (theory of mind; emotion recognition), alongside parent-reported child anxiety and autistic traits.

RESULTS

Higher social motivation was significantly associated with lower autistic traits (β = -.26, p < .001). Controlling for social cognition did not change the association between social motivation and autistic traits. Controlling for anxiety did significantly reduce the strength of the association (unstandardized coefficient change: p = .003), although social motivation remained associated with autistic traits (β = -.16, p = .004). Post hoc analyses demonstrated differential sex-effects: The association between social motivation and autistic traits was significant only in the females (β = -.38, p < .001), as was the attenuation by anxiety (unstandardized coefficient change: p < .001).

CONCLUSIONS

The association between social motivation and autistic traits could be partially attributed to co-occurring anxiety. Sex-specific effects found in females may be due to environmental factors such as increased social demands in adolescent female relationships. Results are consistent with self-report by autistic individuals who do not identify as having reduced social motivation.

Social self-efficacy and mental well-being in autistic adults: Exploring the role of social identity

LAY ABSTRACT

In the past, research has suggested that autistic people are not able to communicate well with non-autistic people because of autistic people's communication difficulties. However, newer theories question this conclusion. It is now thought that the communication difficulties may be because autistic and non-autistic people both struggle to understand each other. This study explores how these differences in shared understanding relate to autistic people's mental well-being, confidence in social situations and social identities (groups that we belong to and that influence how we see ourselves). We created an online survey taken by 512 autistic adults, which included questions about their confidence being social with people from different groups (such as other autistic people or people they share a hobby with), about the social groups they felt they belong to and about their mental well-being. First, participants reported higher social confidence when interacting with members of a social group they belonged to. Second, being confident during these interactions was linked to higher mental well-being. Finally, the groups participants belonged to did not influence the link between social confidence and mental well-being. These findings are important as they help us better understand autistic people's experiences of social interactions and what contributes to good and poor mental well-being in autistic people. They also help us to think further about how to improve autistic people's well-being.

Perspectives of autistic adolescent girls and women on the determinants of their mental health and social and emotional well-being: A systematic review and thematic synthesis of lived experience

LAY ABSTRACT

Difficulties with mental health and low levels of well-being are more common among autistic girls and women than non-autistic people, but we do not fully understand why. Research does not focus enough on what autistic girls and women could tell us about this. This review aims to summarise the studies where autistic girls and women explain things that affect their mental health and well-being to help us understand how to prevent these difficulties from developing. Three research databases were searched to find possibly relevant studies. There were 877 studies found, which two researchers screened according to particular criteria. They found 52 studies that could be included in this review. One researcher evaluated the quality of these studies and extracted the key information from them. This review summarises the views of 973 autistic girls and women aged between 13 and 70+. The findings from the 52 studies were analysed, and we found many factors that affect the mental health and well-being of autistic girls and women. These factors fall into two categories: (1) difficulties living in a world not designed for autistic people and (2) the impact of stigma due to being autistic.

Improving Diagnostic Procedures in Autism for Girls and Women: A Narrative Review

Biases exist in the diagnostic process for autism spectrum disorder (henceforth "autism"), which result in some girls and women being diagnosed later or missed entirely. Current diagnostic tools may not capture the full range of behavioural presentations of autism, leading to under-identification. This review explores why these biases may occur, and how diagnostic procedures could be adapted to better identify autistic girls and women. We recommend that diagnostic assessments are adjusted to capture a broader range of behavioural exemplars of autism; that camouflaging of autistic traits is taken into account; and that care is taken to ensure co-occurring mental health conditions do not overshadow autism diagnosis. We offer recommendations, building on gold-standard diagnostic guidelines, for how diagnostic procedures can be improved for girls and women.

Autism Traits and Cognitive Performance: Mediating Roles of Sleep Disturbance, Anxiety and Depression

Theories about autism spectrum disorder (ASD) have addressed cognitive deficits however few have examined how comorbid diagnoses, including sleep disturbance, anxiety and depression contribute to the underlying deficits. We investigated potential mediations of common ASD comorbidities in the relationship between sub-clinical autism traits and cognitive performance using an international community sample. Cognitive tasks assessed working memory [executive functioning (EF) theory], mental state attribution [theory of mind (ToM)], and global/local visual processing [weak central coherence (WCC) theory]. Structural equation modelling (SEM) demonstrated sleep disturbance and anxiety mediated the relationship of autism traits on measures of EF, but not WCC and ToM. This suggests that treating the symptoms of sleep disturbance and anxiety may lead to improvements in working memory.

The Predictive Relationship Between Sensory Reactivity and Depressive Symptoms in Young Autistic Children with Few to No Words

Depression and sensory reactivity are both common in autism. However, there is little understanding of the predictive relationship between these factors, or the nature of this relationship in autistic children who speak few to no words. This study set out to explore the longitudinal relationship between sensory reactivity and depressive symptoms in 33 young autistic children who speak few to no words. We found positive correlations between depressive symptoms and hyper-reactivity and sensory seeking at both timepoints, and across timepoints. We further found a bidirectional predictive relationship between depressive symptoms and sensory seeking. These results implicate sensory seeking in the development of depressive symptoms in young autistic children who use few to no words. Our findings have important implications for preventative mental health interventions, especially for those with a developmental language delay.

Longitudinal Analysis of Mental Health in Autistic University Students Across an Academic Year

BACKGROUND

Autistic people have worse mental health (MH) than non-autistic people. This proof-of-concept study explored feasibility of longitudinal research with autistic university students, focusing on their MH and coping styles across an academic year.

METHODS

Twenty-two students took part at all timepoints. They completed four rounds of online MH questionnaires.

RESULTS

Over 80% of students were retained. They started the year with high levels of all MH issues, which remained stable across the year. Network Change analysis showed the connections between MH and coping style changed over time.

CONCLUSIONS

Autistic students are engaged participants who are likely to take part in longitudinal research. While MH levels were stable, it may be that coping styles are a useful target for intervention.

Association between autistic traits and binge drinking: Findings from Japan

PURPOSE

Substance misuse may be elevated in some individuals with autism spectrum disorder (ASD). As yet, however, little is known about the association between autistic traits (AT) and substance use/misuse in adults. This study examined the association between AT and binge drinking (BD) among individuals in Japan.

METHODS

Data were analyzed from 1452 individuals aged 18 and above collected during an online survey in February 2021. Self-reported information was obtained on BD assessed as consuming 5 or more (males) or 4 or more (females) drinks containing any kind of alcohol within a 2-h period. AT were assessed with the Japanese version of the Autism Spectrum Quotient - the AQ-J-10. Logistic regression analysis was used to examine associations.

RESULTS

The prevalence of past-month BD was significantly higher in individuals with AT compared to those without AT (42.7% > 27.6%). In a fully adjusted analysis that controlled for mental health (anxiety, depression) and attention-deficit/hyperactivity disorder symptoms, individuals with AT had significantly higher odds for BD once a week or more often (OR: 1.54, 95%CI: 1.04-2.29). AT were also associated with significantly higher odds for BD among women (OR: 2.27, 95%CI: 1.08-4.76), and those aged 18-34 (OR: 2.37, 95%CI: 1.09-5.18) and aged 60 and above (OR: 2.15, 95%CI: 1.02-4.53).

CONCLUSION

Individuals with AT have higher odds for BD. Increased efforts to detect alcohol use/misuse in adults with AT and AT in adults misusing alcohol may be efficacious in efforts to manage symptoms and eliminate harmful alcohol misuse.

'Living in a world that's not about us': The impact of everyday life on the health and wellbeing of autistic women and gender diverse people

BACKGROUND

Autistic women and gender diverse people have specific needs related to their physical and mental health. They also experience more barriers to accessing services. While there are autobiographical accounts of the 'invisible' challenges that autistic women and gender diverse people face day-to-day, there has been limited research that explores how these experiences impact health and wellbeing.

OBJECTIVES

This study aimed to understand the everyday experiences of autistic women and gender diverse people, and their impact on health and wellbeing.

DESIGN

Qualitative methods were used to elicit rich information about the unique experiences of autistic women and gender diverse people.

METHODS

We conducted semi-structured interviews with 31 autistic adults. The data were analysed using reflexive thematic analysis.

RESULTS

We identified 3 themes and 10 subthemes. Our first theme described 'all the stuff that you have to do to get through life', including managing domestic tasks, parenting, unique health needs and co-occurring physical conditions. The second theme outlined the impact of 'living in a world that's not about us', describing how navigating the neurotypical world, managing gender role expectations and trying to fit impacts on mental health. Our third theme outlined the positive impacts of 'shedding all the layers and being myself', including the importance of formal identification, exploring autistic identity and community, and including autistic people in research to support them to 'have a good life on their own terms'.

CONCLUSION

This study emphasized the importance of shifting the responsibility of health and wellbeing from the individual, and the importance of interpersonal, community, cultural, policy and societal factors in ensuring positive health outcomes for autistic women and gender diverse people. It also highlighted areas that enable autistic women and gender diverse people to flourish, including autistic community connectedness, positive relationships and autistic-affirming support from health professionals.

Sex Differences in Mental Health Problems and Psychiatric Hospitalization in Autistic Young Adults

Importance

Psychiatric disorders are common among autistic children and adults. Little is known about sex differences in psychiatric disorders and hospitalization in early adulthood.

Objective

To examine sex differences in psychiatric diagnoses and hospitalizations in autistic compared with nonautistic young adults.

Design, Setting, and Participants

This population-based cohort study assessed all individuals born in Sweden between 1985 and 1997. A total of 1 335 753 individuals, including 20 841 autistic individuals (7129 [34.2%] female individuals), were followed up from age 16 through 24 years between 2001 and 2013. Analysis took place between June 2021 and August 2022.

Exposures

Autism was defined as having received at least 1 clinical diagnosis of autism based on the International Classification of Diseases.

Main Outcomes and Measures

The cumulative incidence of 11 psychiatric diagnoses up until age 25 years was estimated, and birth year-standardized risk difference was used to compare autistic female and male individuals directly. Sex-specific birth year-adjusted hazard ratios (HRs) with 95% CIs were calculated using Cox regression. Analyses were repeated for inpatient diagnoses to assess psychiatric hospitalization.

Results

Of 1 335 753 individuals included in this study, 650 314 (48.7%) were assigned female at birth. Autism was clinically diagnosed in 20 841 individuals (1.6%; 7129 [34.2%] female) with a mean (SD) age of 16.1 (5.1) years (17.0 [4.8] years in female individuals and 15.7 [5.2] years in male individuals) for the first recorded autism diagnosis. For most disorders, autistic female individuals were at higher risk for psychiatric diagnoses and hospitalizations. By age 25 years, 77 of 100 autistic female individuals and 62 of 100 autistic male individuals received at least 1 psychiatric diagnosis. Statistically significant standardized risk differences were observed between autistic female and male individuals for any psychiatric disorder (-0.18; 95% CI, -0.26 to -0.10) and specifically for anxiety, depressive, and sleep disorders. Risk differences were larger among autistic than nonautistic individuals. Compared with nonautistic same-sex individuals, autistic female individuals (HR range [95% CI], 3.17 [2.50-4.04.]-20.78 [18.48-23.37]) and male individuals (HR range [95% CI], 2.98 [2.75-3.23]-18.52 [17.07-20.08]) were both at increased risk for all psychiatric diagnoses. Any psychiatric hospitalization was statistically significantly more common in autistic female individuals (32 of 100) compared with autistic male individuals (19 of 100). However, both autistic female and male individuals had a higher relative risk for psychiatric hospitalization compared with nonautistic female and male individuals for all disorders (female individuals: HR range [95% CI], 5.55 [4.63-6.66]-26.30 [21.50-32.16]; male individuals: HR range [95% CI], 3.79 [3.22-4.45]-29.36 [24.04-35.87]).

Conclusions and Relevance

These findings highlight the need for profound mental health services among autistic young adults. Autistic female individuals, who experience more psychiatric difficulties at different levels of care, require increased clinical surveillance and support.

The indirect effect of self-compassion in the association between autistic traits and anxiety/depression: A cross-sectional study in autistic and non-autistic adults

This study followed a pre-registered analysis plan with the aim to investigate whether autistic traits and self-compassion are correlated in autistic adults, and to test an indirect effect of autistic traits on anxiety/depression via self-compassion. We present the findings of an online survey of 456 participants ( n = 228 autistic adults, n = 228 non-autistic adults) who completed the Autism Spectrum Quotient (AQ), the Self-Compassion Scale (SCS) and the Hospital Anxiety and Depression Scale (HADS). Lower self-compassion was reported by autistic participants compared to non-autistic participants, and a negative correlation was found between autistic traits and self-compassion in both groups. Furthermore, an indirect association between autistic traits and anxiety/depression via self-compassion was observed in both samples. Considering that many autistic people experience co-occurring anxiety and depression, and that self-compassion is a skill that can be cultivated with practice, the findings of this study suggest that self-compassion may be a modifiable factor that could improve the mental health of this population.

Lay abstract

Previous research on non-autistic adults suggests self-compassion may serve to reduce mental health problems and promote psychological well-being. Correlations between autistic traits and self-compassion have been observed in non-clinical populations. In this study, we were interested in extending previous research by exploring relationships between autistic traits, self-compassion and anxiety/depression in autistic adults without intellectual disability. The findings revealed that on average autistic people reported lower self-compassion than non-autistic people. Once we accounted for levels of self-compassion in our statistical model, this resulted in a complete loss of statistical significance in the relationships between autistic traits and anxiety/depression. Self-compassion may be a useful target for clinical intervention in autistic adults with co-occurring mental health difficulties.

Loneliness in Autism and Its Association with Anxiety and Depression: A Systematic Review with Meta-Analyses

Objectives

This systematic review aimed to quantify differences in loneliness levels between autistic and neurotypical samples and investigate the association between loneliness and mental health in autistic individuals.

Methods

Three meta-analyses were conducted. Studies were methodologically appraised using established tools.

Results

Overall, 39 studies were included. The majority of these achieved moderate methodological quality ratings. The primary meta-analysis (N = 23) found autistic samples reported higher loneliness compared with neurotypical samples (Hedges’ g = .89). The meta-analyses on the associations between loneliness and anxiety (N = 14) and depression (N = 11) in autistic samples found significant pooled correlations (r = .29 and r = .48, respectively).

Conclusions

This review highlights numerous limitations within current autism and loneliness research. Nevertheless, loneliness in autism merits targeted clinical and research attention.

Eating Problems in Autistic Females and Males: A Co-twin Control Study

This study investigated the association between autism and self-reported eating problems and the influence of gender on the association, in a sample of adolescent and adult twins (N = 192). Autistic traits and autism diagnosis were associated with both total and specific eating problems, including selective eating and sensory sensitivity during mealtimes. Interaction effects indicated a stronger association between autistic traits and total eating problems in females, as well as more difficulties with eating in social contexts among autistic females. In within-pair analyses, where unmeasured confounders including genes and shared environment are implicitly controlled for, the association was lost within monozygotic pairs, which might further indicate a genetic influence on the relationship between autism and eating problems.

Associations between childhood autistic traits and adolescent eating disorder behaviours are partially mediated by fussy eating

Objective

Previous literature shows an increased risk for eating disorders in autistic individuals. This study tested whether fussy eating contributes to the association between childhood autistic traits and adolescent eating disorder behaviours.

Method

Using data from the Avon Longitudinal Study of Parents and Children, we estimated the intercept and slope of parent‐rated autistic traits and fussy eating between 7 and 14 years (N = 8982) and their association with self‐reported eating disorder behaviours at age 14 years, including the indirect path from autistic traits to eating disorder behaviours via fussy eating. Analyses were adjusted for child sex, maternal age at delivery, maternal body mass index and maternal education.

Results

Analyses found a small indirect pathway from autistic traits intercept to eating disorder behaviours via fussy eating slope (b = 0.017, 95% CI = 0.002–0.032, p = 0.026), with higher levels of autistic traits at age 7 years being associated with a shallower decline in fussy eating, which in turn was associated with greater eating disorder behaviours.

Conclusion

Findings point towards fussy eating as a potential link between childhood autistic traits and later disordered eating. Addressing fussy eating patterns before they become entrenched may decrease risk for eating disorders later in development.

There is evidence that high levels of autistic traits are associated with an increased likelihood of experiencing an eating disorder.

The current study sought to test whether the link between autism and eating disorders could in part be explained by variation in fussy eating.

In a large prospective cohort study, we found a significant indirect effect of fussy eating, such that higher childhood autistic traits were associated with a shallower decline in fussy eating between childhood and adolescence, which in turn was associated with higher levels of eating disorder behaviours in adolescence.

Neuroticism Drives Associations Between Repetitive Behaviors and Depression in Autistic Adults

Depression is more prevalent among autistic adults than neurotypical adults, yet risk factors are incompletely understood in this population. Some research groups have focused on relationships between negative repetitive thinking and depression in the autistic population, which may explain elevated prevalence rates in line with general population findings on rumination and internalizing disorders. Little is known about associations between depression and more prototypical repetitive cognitions and/or behaviors characteristic of autism (i.e., insistence on sameness [IS] and repetitive sensorimotor [RSM] behaviors). Therefore, the present study aimed to examine associations between IS, RSM behaviors, and depressive symptoms in 762 autistic adults, and whether observed effects are confounded by additional factors (e.g., demographic factors, trait neuroticism). To test if greater IS scores were associated with greater depressive symptoms on the BDI-II, a Bayesian linear regression was conducted with BDI-II scores (dependent variable) regressed on age, gender, educational level, RSM scores, and IS scores (independent variables). To test the effects of neuroticism on observed relationships, a second regression was conducted that included all predictors from the baseline model and neuroticism. Standardized regression coefficients were tested against an interval null hypothesis of [-0.1, 0.1] to assess for practical significance. Results indicated that IS exhibited a moderate positive relationship with depressive symptoms, while RSM behaviors provided only a slight increase in predictive ability. However in the second model, neuroticism exhibited a strong positive relationship with depressive symptoms, completely attenuating the effect of IS. Associations between RSM behaviors and depressive symptoms did not meet our criteria for practical significance, particularly when neuroticism was added to the model. Neither RSM nor IS moderated the effect of neuroticism on depression. The findings from this study add to the literature on risk factors in the pathway to depression in autism, and suggest opportunities for clinical translation to screening and intervention efforts. Screening for IS in autistic individuals is a common diagnostic practice in clinical and research settings that may be leveraged to also identify those at higher risk for depression, and increasing flexibility in daily life may promote emotional regulation and distress tolerance.

The Quest for Acceptance: A Blog-Based Study of Autistic Women's Experiences and Well-Being During Autism Identification and Diagnosis

Background

Although studies have found that autism is underdiagnosed in women and that autistic women have poorer well-being outcomes than men, less is known about autistic women's experiences with self-identification or diagnosis or how they feel such experiences affect their mental health.

Methods

We explored autistic women's experiences of coming to recognize and understand themselves as autistic. We used data collected from blogs written by autistic women about their diagnostic or self-identification experiences. We were particularly interested in well-being, and how this contributed to, was affected by, and interacted with the identification and diagnostic process. We used thematic analysis to explore and document experiences described in blogs from 20 blogsites (representing the views of 23 autistic women).

Results

Acceptance was a central issue. We developed themes of self-understanding and self-acceptance, being understood and accepted by others (including peers, clinicians, and others in the autism community), and the exhaustion resulting from trying to be accepted and be understood. These issues arose both when going through the diagnostic process, and after receiving a formal diagnosis.

Conclusions

Diagnosis and identification may have both positive and negative effects on autistic women's well-being, with women often describing difficulties after diagnosis as stemming from facing male stereotypes of autism. We consider the implications of our findings for clinicians, researchers, and those who work with autistic women.

Autistic Mothers of Autistic Children: A Preliminary Study in an Under-Researched Area

Background

Much research exists on the mental health and well-being of parents of autistic children; however, parents who are themselves autistic have received little attention in the literature. We aimed to compare parenting stress and family outcomes in mothers who do, and do not, identify as being autistic.

Methods

We matched 20 mothers who identified as being autistic to 20 mothers who do not identify as being autistic on variables associated with parental well-being: child externalizing behaviors, score on the Social Communication Questionnaire, child adaptive functioning, family income, and child and maternal age. All mothers had at least one autistic child. Outcome variables were family outcomes (Family Outcome Survey-Revised) and parenting stress (Parent Stress Index 4-Short Form). Paired t-tests were used to compare scores between the two samples.

Results

There were no statistical differences in achievement of family outcomes between the autistic and nonautistic mothers. The small effect size on Family Outcome 4 may suggest that autistic mothers develop stronger support networks, but as a statistical comparison for this item nonsignificant, this should be interpreted with caution. Autistic and nonautistic mothers reported equally high levels of parenting stress.

Conclusions

Further research with larger samples is required to explore this under-researched area. Such research would be of value to understand any interaction between parental and child autism characteristics, well-being, and parenting. This could then inform development of supports, which can be tailored for each child's family.

Lay summary

Why was this research done?: Despite decades of research exploring the well-being and mental health of parents of autistic children, the experience of autistic adults with autistic children has not been researched in detail. In fact, we could find less than five research studies on the topic.What was the purpose of the study?: We wanted to do some preliminary work in the area and look at whether parent well-being or family outcomes are similar or different between autistic and nonautistic mothers of autistic children.What did the researchers do?: We are part of a team of researchers working on a larger study on a different topic. As part of this study, we asked parents about their own experiences and well-being, which included questions on whether or not the parents identify as autistic. This meant that within this larger study, there were the data to look at parent and family outcomes and see if they differ depending on whether or not the mothers themselves identified as being autistic.To do this, we went to the large data set and first identified the mothers who identified as being autistic; this was 20 mothers. Then, one of the researchers (M.S.) carefully matched the 20 autistic mothers to 20 mothers who did not identify as autistic (nonautistic mothers) on a number of areas that previous research has linked with parent and family well-being and outcomes. Trying to make the two groups as similar as possible in the areas shown to impact parent and family outcomes means that we can be more confident that any differences between the two groups are due to the one thing that is purposeful: whether or not the mothers were autistic.What were the results of the study?: We found that in general, parent well-being and family outcomes did not differ between the two groups.What were the potential weaknesses of the study?: The small sample size and the lack of detailed knowledge around parental relationship status and ethnicity mean that it is not possible to assume that these results represent the wider population. We also cannot be sure that mothers who identified as nonautistic were definitely not autistic (i.e., they may have been autistic but as yet undiagnosed).How will these findings help autistic adults now or in the future?: We hope that this study will be a platform to inspire future research in this area, using different research methods (interviews, questionnaires) to learn from the lived experience of autistic mothers. This can provide a way for nonautistic parents, researchers, and professionals to learn from the experience and skills of autistic mothers and potentially inform future practice.

Assessment and Treatment of Anxiety in Children with Autism Spectrum Disorder in School Settings: A Systematic Review and Meta-Analysis

Anxiety is the most common mental health problem that occurs with Autism Spectrum Disorder (ASD), and due to creating a more inclusive learning environment, children with ASD are placed in general education classrooms. Thus, addressing anxiety problems for children with ASD in school settings become critically important. This systematic review and meta-analysis investigated the current qualities of studies and the effects of school-based interventions for reducing anxiety in children with ASD. The study included six studies with a total of 165 participants. A random-effect meta-analysis yielded a moderate overall effect (g =  - 0.58, 95% CI [- 0.96, - 0.20], z =  - 3.01, p < .05) with no significant heterogeneity, Q (5) = 7.31, p = 0.20. Findings of the systematic review indicated that school-based interventions for anxiety problems are still in the early stages, and studies showed significant issues with adaptations of current clinical-based interventions and anxiety measurements to use in school settings for children with ASD. Interpretation of these findings and implications are discussed.

The presentation, recognition and diagnosis of autism in women and girls

Purpose

Autistic women and girls have received comparatively less attention within clinical practice and research. Research suggests women tend to be diagnosed later than men, and are more likely to experience misdiagnosis.

Design/methodology/approach

This paper aims to report a narrative literature review that examines research on the presentation, recognition, and diagnosis of autistic women and girls.

Findings

Findings suggest that autistic females present differently to males and highlight low recognition of the female presentation of autism among the general public, in social spheres, educational, clinical and forensic settings. This lack of recognition appears to affect the likelihood of females being referred for diagnosis, the reliability of diagnostic assessments and subsequent access to support.

Originality/value

Recommendations for clinical practice focus on initiatives to increase awareness of the female presentation of autism, improving the diagnostic process for females, increasing female representation within autism training and for future research to support these goals.

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.

'I have more control over my life': A qualitative exploration of challenges, opportunities, and support needs among autistic university students

BACKGROUND

Autistic people are known to experience more mental health issues than non-autistic people, and the same is true among university students. These difficulties can have long-term consequences, such as dropping out of university and unemployment. Understanding the challenges autistic students face can help institutions to better support this group, while allowing celebration of the opportunities higher education offers.

METHODS

12 autistic university students took part in semi-structured interviews about their mental health, the impact of university on their mental health, and their experiences of support while in higher education. Interviews were subject to thematic analysis.

RESULTS

Three key themes were identified from autistic student accounts: Relationships, Independence, and Support. While each of these encompassed positive and negative elements, Relationships were described as tying everything together - when these were supportive, things went well, but when they were characterized by stigmatizing attitudes, students experienced much greater difficulties at university.

CONCLUSIONS

Autistic students can and do thrive at university, as shown by many of our participants. However, all faced significant challenges with their mental health at times, and experienced varying levels of support. Improving autism knowledge among staff, with emphasis on enabling better relationships, would make a significant difference to the autistic student experience.